F0725

E

Insufficient Nursing and CNA Staffing Leading to Delayed Medications and ADL Care

Chicago, Illinois Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on the first floor to meet residents’ ADL needs in a timely manner and to administer medications as ordered. On the day of survey, the staffing coordinator stated that the first floor should be staffed with two nurses when there are 32 or more residents and three to four CNAs when the census is 40. The daily census for the first floor showed 40 residents, yet the daily assignment sheet listed only one nurse assigned to the unit. Observations confirmed that only one LPN was working on the first floor, and initially only two CNAs were present due to a CNA call-out, with a third CNA brought in later in the morning.

The LPN assigned to the first floor reported that she was the only nurse scheduled for the 7AM–7PM shift and that she had to manage two medication carts. She stated she had not started passing 9AM medications by 10:50 AM and was still passing 9AM medications after noon, acknowledging that the medications were late due to staffing. Another LPN from the second floor came down after completing her own 9AM medication pass to assist with remaining medications and Accu-Chek readings for diabetic residents on the first floor. The Director of Nursing confirmed that medications are expected to be administered within one hour before or after the scheduled time and that insufficient staffing could cause delays in care, including medication administration.

CNAs on the first floor described having to care for 40 residents with only two CNAs at the start of the shift, each responsible for about 20 residents, which they stated was not realistic compared to the usual 11–12 residents per CNA. They reported prioritizing breakfast service, including passing trays, feeding dependent residents, and collecting dirty trays, which delayed routine care such as two-hour checks, incontinence care, and showers. One CNA stated she still needed to provide a shower that would have been completed earlier if fully staffed. Residents corroborated delays in ADL care: one resident, with diagnoses including hemiplegia following cerebral infarction, cerebral palsy, neuromuscular bladder dysfunction, and documented need for substantial/maximal assistance with ADLs, reported that she was usually gotten out of bed before breakfast but remained in bed late in the day and attributed this to having only two CNAs instead of three. Another resident, with quadriplegia, extensive mobility and self-care limitations, and substantial/maximal assistance needs, stated he requested to get out of bed at 9:30 AM but was told staff could not assist due to only two CNAs working; he was not gotten out of bed until after lunch around 12:30 PM. The facility administrator reported there was no written staffing policy.