F0725

E

Prolonged Incontinence and Delayed ADL Care Due to Insufficient Nursing Staff

Chicago, Illinois Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ ADL and incontinence care needs in a timely manner, resulting in prolonged periods in soiled briefs and unmet requests for assistance. On multiple occasions, residents and family members reported that staffing was inadequate and that residents waited a long time, sometimes hours, for incontinence care. One family member stated that on a holiday evening there was only one nurse covering approximately fifty residents on a floor after another nurse called off, and that there had been several times when the resident’s under brief was entirely wet and soiled with feces stuck to her body. This family member reported that staffing issues were ongoing and ultimately moved the resident to another facility.

On one survey day, a resident on the third floor was observed with a strong fecal odor in the room shortly after activating the call light and reporting a bowel movement after breakfast. The resident stated that staffing was terrible and that he often waited a long time, sometimes hours, to be changed and cleaned up. The surveyor observed that a CNA entered the room, turned off the call light, exited without providing care, and the resident turned the call light back on. Surveillance of the room from 9:00 AM to 11:50 AM showed that incontinence care was not initiated until approximately 11:50 AM, meaning the resident remained soiled with feces for about three hours. The CNA later stated she had told the resident she would return but forgot because she was very busy with her assigned residents and that there were only two CNAs on the floor for approximately forty or more residents.

Another resident was heard yelling for help, stating she was wet and had been wet for a long time. The surveyor turned on the call light, and an LPN entered, turned off the light, left the room, and returned to the nursing station. When asked later, the resident reported she was still wet and that the staff member had said she would be back. The LPN stated the resident needed to be cleaned up and that she had told one of the aides but could not recall which one, explaining she had an admission coming and needed to get report, and that staffing had been an issue for a while. The resident did not receive incontinence care until a CNA who had been off the unit escorting another resident to a medical appointment returned and was asked by the surveyor to provide care, resulting in the resident remaining wet for about two hours.

Staff interviews and staffing records showed that on the day of survey the vent unit had only one nurse and two CNAs instead of the expected two nurses and three CNAs, and CNAs reported that most residents on that unit were bedbound and total assist, making it difficult to care for everyone properly when short staffed. Residents on the third floor and other units reported that there were not enough CNAs or nurses, that they had to wait a long time for assistance, and that short staffing was common, especially on weekends and holidays. The nurse scheduler described expected staffing levels for each floor and shift and confirmed that on a prior holiday three nurses had called off and replacements could not be found, resulting in only one nurse on the second floor for a 7:00 AM–7:00 PM shift and one nurse covering both the vent unit and the west unit for part of a shift. A nurse who worked that day stated she was the only nurse on the second floor, that there were normally two nurses, that she notified the former DON, and that she resigned shortly afterward due to unsafe staffing.

The administrator acknowledged being notified of nurse call-offs on the holiday and stated that attempts to contact the DON, ADONs, staff nurses, and an agency did not result in additional coverage, and that staff worked short that day. The acting DON, who assumed the role after these events, stated that residents should not wait three hours for assistance, that the second floor should have two nurses, and that the vent unit and west unit each needed their own nurse to provide adequate care. Multiple staff members and residents reported ongoing staffing issues, including insufficient CNAs and nurses, increased workloads, delayed response to call lights, and delays in changing residents after bowel movements. The facility did not have a staffing policy, despite a facility assessment statement indicating that extra and relief staffing would be provided by sister facilities and corporate employees, and federal regulations require sufficient nursing staff with appropriate competencies and skill sets to meet residents’ needs on a 24-hour basis.