F0725

E

Insufficient Licensed Nurse Staffing Leading to Delayed Medications and Tube Feedings

Momence, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient licensed nursing staff to administer medications and gastrostomy tube feedings as ordered. On one survey day late in the morning, a cognitively intact resident remained in bed, restless, reporting that he had not received his morning medications and that on many nights his 9:00 PM medications were not given until around midnight, with morning medications often delayed until late morning. At the same time, an LPN passing medications showed an eMAR screen with 14 residents on the hall having overdue medications, confirming that the pink color indicated overdue doses. This LPN stated there was only one nurse on that side of the building when there were supposed to be two, and that he had worked the overnight 12‑hour shift as well.

Another RN reported she did not begin passing morning medications until around late morning because she had been working on the other side of the building with another new nurse, and she had been on duty since the previous night. Medication administration records showed that a resident’s 9:00 AM antihypertensive medications with blood pressure parameters were actually administered around midday. A resident dependent on gastrostomy tube feeding, with diagnoses including functional quadriplegia, dysphagia, and gastrostomy status, experienced significant weight loss from 114.2 pounds in November to 98.8 pounds in late December. The resident’s physician stated there was no medical reason for the weight loss and that if the resident was losing weight, it would only be from not being fed.

The ADON confirmed that the facility’s staffing plan required a minimum of three nurses on day shift and two on night shift, yet review of daily assignment sheets, staffing sheets, and time sheets showed multiple dates in November and December when only one nurse, or fewer than the planned minimum, were on duty for substantial portions of shifts. The ADON stated that not meeting minimum staffing affects care such as timely medication passes and tube feedings. Multiple alert and oriented residents reported that there were not enough nurses, that some nights there was no nurse on duty, and that they did not receive medications, including pain and sleep medications, sometimes having to yell or threaten to call 911. CNAs also reported there were not enough nurses, that some residents did not receive medications or G‑tube feedings and had to wait, and that they had notified leadership when only one nurse was on the floor and residents were waiting for medications and exhibiting behaviors, without receiving a response. The Administrator and DON acknowledged that the minimum number of nurses was not always met and that having only one nurse for the whole facility was unsafe, and that they were aware of at least one night when only one nurse was working.