Insufficient Nursing Staff Leading to Missed Incontinence Care and Delayed Medications
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ incontinence care and medication administration needs, resulting in missed or delayed care for multiple residents. One resident with a care plan identifying a stage 2 pressure sore on the left buttock and risk for further skin breakdown due to incontinence, impaired mobility, diabetes, and comorbidities reported not receiving incontinence care since getting out of bed in the morning. When a CNA provided care around midday, the resident was found wearing two incontinence briefs with a small amount of thick feces and blood in the brief, and excoriation of the buttocks, sacrum, scrotum, and a bleeding left abdominal fold. The CNA stated she routinely placed two briefs on this resident because she was responsible for many residents, could not always get back to him, and believed the extra brief would keep his clothes dry when he sat in a wet brief for extended periods. Another resident with a care plan for bowel and bladder incontinence, including an intervention to clean the perineal area with each incontinence episode, was observed during incontinence care wearing two briefs that were saturated with urine and stool, with a large, reddened scrotum. The CNA providing care stated the double briefs had been applied by the previous shift and acknowledged that residents should not wear two disposable briefs at the same time because it was bad for their skin. The DON later stated that residents should not have two briefs on unless this was a care-planned preference and that double-briefing could lead to skin breakdown and UTIs if not changed, while facility policy required residents to be checked periodically for incontinence and provided appropriate perineal/genital care. Multiple cognitively intact residents reported that medications, including routine and PRN pain medications, were often late and that nurses told them they were busy and would give medications when they could. Medication administration records showed repeated delays beyond the facility’s policy requirement that medications be administered within one hour of prescribed times. One resident council president reported complaints from residents about late medications, long call light response times, and insufficient staff; their MAR showed numerous medications scheduled for late afternoon and evening being given more than an hour late on several days. Other residents reported late blood glucose checks and insulin administration, with documentation showing insulin and other medications given one to several hours after scheduled times. One resident stated their blood glucose check was delayed because the nurse lacked testing strips and had to obtain them from another area, and that insulin ordered for early evening was not given until later at night. Additional residents described waiting more than two hours for medications and feeling there were not enough nurses to pass medications when needed. MAR reviews for several cognitively intact and severely cognitively impaired residents showed repeated late administration of ophthalmic medications, creams, oral medications, blood glucose monitoring, and insulin, often one to two hours after scheduled times. Resident council minutes over several months documented ongoing concerns about call light response times, inconsistent follow-up, and staff turning off call lights before providing requested assistance. Staff interviews revealed that one LPN was responsible for 32 residents on a floor that previously had 25 residents, and CNAs reported working with only two CNAs for 30 residents, including many with mechanical lifts, feeding needs, and dialysis schedules. The DON confirmed that the first floor, with about 30 residents, was staffed with two CNAs and one nurse on all shifts, despite the facility assessment and staffing policy stating staffing should be based on census and acuity to ensure sufficient staff to meet residents’ care needs.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insufficient nursing staff were present on a unit when a resident who required 2-person assist for ambulation and toileting was found walking from the bathroom to bed alone after waiting for help. At the time, only an LPN and a clerk were observed on the unit, while other NA staff had already punched out and the second nurse was charting on another unit.
Insufficient CNA Staffing and Delayed Resident Care: Residents and staff reported that CNA coverage was inadequate on evenings, nights, and weekends, leading to delayed call light response and unmet care needs. A resident with impaired mobility and another with CVA-related deficits reported long waits for assistance, while a CNA stated she was the only CNA on a hall overnight and had not been able to check many rooms. The Administrator and CNA Supervisor acknowledged staffing shortages, especially on nights and weekends, and resident council and grievance records also documented concerns about short staffing.
Insufficient nursing staffing led to delayed and incomplete resident care. The facility scheduled fewer CNAs than required by its assessment, often leaving only 5 to 6 CNAs on day shift instead of 8, and staff were told to cancel shifts when census dropped. Residents reported long waits for toileting and assistance, including being left in feces and waiting during meals for help, while CNAs described working alone, delayed call light response, missed or delayed ADL care, and difficulty completing 2-person transfers and mechanical lifts.
Delayed response to activated call lights was identified for a resident with intact cognition who required assistance with toileting, transfers, and ambulation and had care plan interventions for impaired mobility, safety, weakness from TIA, and fall risk. The resident reported staff often shut off the call light without providing help, and alarm records showed multiple response times over 15 minutes, including several lasting more than 30 minutes and up to nearly an hour. Staff and the DON acknowledged that response times had exceeded the expected timeframe, and the facility policy required staff to respond to engaged call lights in a timely manner.
A resident with a PEG tube, dysphagia, dementia, epilepsy, and other neurologic conditions had scheduled meds ordered through the tube, but the eMAR showed no meds documented for an entire evening med pass. The RN/UM said she worked a double shift because of a nursing call-out and forgot to document the meds as given, and the DON acknowledged the missed documentation.
Insufficient nursing staffing and delayed call light response were identified after residents reported waits of 30 minutes to 2 hours for assistance, including one resident left in the bathroom for 45 minutes and another with a 55-minute wait after activating a call light. The CNA scheduler said staffing was based on a corporate PPD target of 2.85 hours per resident rather than acuity, and records showed multiple weekend shifts with CNA, UM, and RN call-offs or no-shows. Residents also reported staff sitting in the lounge, not responding to lights, and unmet toileting and care needs.
Insufficient nursing staff on unit
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of every resident and to have a licensed nurse in charge on each shift. During an observation on 7/7/26 from 6:54 a.m. through 7:02 a.m., only LPN Employee E10 and the 2A clerk were observed on the nursing unit, while the resident room bathroom call light for Resident R239 was illuminated. At 7:03 a.m., Resident R239 was observed ambulating from the bathroom to bed by herself and stated she got tired of waiting for help. LPN Employee E10 then went to assist her because there were no other staff on the unit. Resident R239's plan of care identified that she required assistance of two staff for ambulation and toileting. Review of 11 p.m. to 7 a.m. staff punch-out times showed one NA punched out at 6:48 a.m., one NA punched out at 6:58 a.m., and two others punched out with the supervisor at 7:00 a.m.; the first NA for the 7 a.m. to 3 p.m. shift was observed on the unit at 7:02 a.m. During interview, the Nursing Supervisor stated the second nurse for the 2A unit was on 2B charting and no other staff were on the unit. The Nursing Home Administrator later confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident R239.
Insufficient CNA Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs in a timely manner and failed to have enough CNA coverage on evenings, nights, and weekends. The report states the facility had 108 residents and could not provide a staffing policy. Interviews with the Administrator and CNA Supervisor confirmed that nights and weekends were the hardest shifts to fill, that staff shortages were common, and that administrative staff were being used to help cover evening hours when CNA shifts were not fully staffed due to call-ins or no-shows. The CNA Supervisor also stated that optimal staffing on the 200 hall would be two CNAs on all shifts because many residents required two-person assistance with mechanical lifts. Several residents described delayed responses to call lights and assistance needs. One resident with diagnoses including acute respiratory failure, diabetes mellitus, anemia, anxiety disorder, and cognitive communication deficit stated the call light system was not working and that she had been given a whistle to use instead; she reported prolonged waits for staff response, especially after dinner and overnight, and said she had had incontinence episodes while waiting. Another resident with cerebral infarction, hemiplegia, major depressive disorder, and cognitive communication deficit stated she waited longer in the evening and overnight when using the call light, and that weekends seemed to have less staff available. A family member present during that interview stated staff worked hard but did not have enough help, especially on second shift and weekends. A third resident with anemia, muscle weakness, and need for assistance with personal care stated her call light system did not work and she had been given a dinner bell to use when needing assistance. She reported waiting 30 minutes or more for help with her incontinence brief during evening and overnight hours. A CNA working the night shift stated she was the only CNA assigned to the 200 hall at that time, that only 5 CNAs total were working nights including the supervisor, and that she had only checked 4 rooms since arriving before 2:00 AM, with 8 rooms or 11 residents still not checked on her hall. Resident council minutes also documented concerns that there were not enough CNAs on weekends, and a grievance form documented a resident complaint about not receiving a shower due to short staffing.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff in accordance with its facility assessment and residents’ care needs. The assessment called for 1 RN, 2 LPNs, and 8 CNAs on day shift; 3 LPNs and 8 CNAs on evening shift; and 3 CNAs plus 2 additional staff on night shift. However, the nursing schedule from June 2026 through July 3, 2026, showed no days with 8 CNAs assigned to the day or evening shift, with day shift typically staffed by only 5 to 6 CNAs. On one day, a note next to two staff names stated, “If all show, go home,” leaving only 5 CNAs on the floor. On another day, one CNA called off and was not replaced, leaving 3 CNAs for the 100-400 units and 1 CNA for the villa. Residents and staff described delays in care and difficulty meeting basic needs because of the staffing levels. One resident, who had multiple diagnoses including multiple sclerosis, trigeminal neuralgia, convulsions, malnutrition, COPD, hypotension, and epilepsy, was dependent on staff for ADLs and reported being left in feces for 45 minutes because no one was available to assist. The resident also reported that during meal times, call lights were not answered until meals were finished because aides were feeding residents and no one else was available. Another resident, who was dependent on staff for ADLs and had diagnoses including hemiplegia, chronic pain, depression, and falls, stated that the facility was short-staffed and that CNAs were stressed and unable to perform their jobs as they should. Multiple CNAs and the DON confirmed the staffing shortages and the effect on resident care. CNAs reported working alone in the villa, being told no additional CNA would be assigned until census exceeded 18, waiting for help with two-person transfers and mechanical lifts, delayed call light response times of up to 25 minutes, and residents being left soaked in urine overnight because there was not enough staff. The DON stated he wanted additional nurses and CNAs but was told to cancel staff when census dropped. The facility’s fall list also showed an increase in unwitnessed falls from 3 in May 2026 to 15 in June 2026.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to consistently respond to activated call lights within a timely manner for one resident. Resident #47 had a BIMS score of 15 out of 15 and required partial/moderate assistance with toileting hygiene and toilet transfers. The resident’s care plan identified impaired mobility, safety concerns, functional performance deficits related to weakness from a transient ischemic attack, and risk for falls, with interventions directing staff to keep the call light within reach, encourage use of it for assistance, and provide prompt response to requests for help. During observation, Resident #47 stated the call light had been activated for several minutes and was shut off by staff without assistance being provided, and the resident reported this happened often. Staff F acknowledged shutting off the call light when unable to assist the resident to the bathroom. Review of the facility’s excess response alarms showed multiple call light response times for Resident #47 ranging from 16.7 minutes to 57.3 minutes. Staff interviews confirmed that an appropriate response time was under 15 minutes, and the DON acknowledged that call lights had exceeded 15 minutes at times. The facility policy stated all staff were to respond to an engaged call light to rule out an emergency situation and that resident needs such as transfers, toileting, and dressing were to be addressed in a timely manner.
Missing Medication Documentation After Short-Staffed Shift
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure that medications and treatments were properly documented for one resident. Resident #47 had diagnoses including late effects of cerebral infarction, aphasia following cerebral infarction, dysphagia, dementia, epilepsy, hypertension, and gastrostomy status. The resident’s MDS indicated the resident was rarely or never understood and had a tube feeding. Physician orders included multiple scheduled medications administered via PEG tube and enteral feeding orders. Review of the eMAR for the evening shift showed no medications documented as administered for the entire medication pass. The medical record did not contain a nursing progress note explaining that the resident was out of the facility, refused medications, or otherwise accounting for the missing documentation. The RN/UM stated she worked a double shift because of a nursing call-out and, while working as the med nurse, forgot to document that the medications had been administered during the evening shift. The DON acknowledged that the RN/UM had worked two consecutive shifts due to a call-out and forgot to document administering the resident’s medications during the evening med pass.
Insufficient Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and failed to ensure a licensed nurse was in charge on each shift. During a confidential resident group meeting, residents reported that call light response times were commonly about 30 minutes, could be as long as two hours, and that one resident had been left in the bathroom for 45 minutes before yelling for help. Residents also stated that the facility needed more staff and that staff called in too often. During interviews and record review, the surveyor learned that the facility used a corporate per-patient-day guideline of 2.85 hours per resident and did not use resident acuity in scheduling. The CNA/staff scheduler stated that management did not want staffing to go over or under that target and that she scheduled as close to it as possible. She also stated that weekend staffing was stacked to anticipate call-offs, and that residents had reported only one CNA on night shift, although she said clock-in records did not show that. She further stated that 3rd shift staff were in the lounge watching TV and not responding to call lights, and that the cameras did not work. Payroll and staffing records showed multiple weekend shifts with call-offs and short staffing across CNA, unit manager, and licensed nurse shifts, including several dates with multiple call-ins or no-shows on 1st, 2nd, and 3rd shifts. Residents reported long waits for call lights, unmet toileting needs, and staff not responding or returning after entering rooms. One resident’s concern form documented a 55-minute wait after a call light was activated, and another resident stated that staff did not respond for 30 minutes to 3 hours. The DON, regional clinical consultant, and NHA all acknowledged that PBJ staffing was submitted at the corporate level, and the NHA was aware of excessively low weekend staffing that had triggered in March 2026.
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