F0725

F

Insufficient Nursing and CNA Staffing Leading to Unmet Care, Hygiene, and Monitoring Needs

Homewood, Illinois Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff and related services to meet residents’ assessed needs, as reflected in multiple observations of unmet care needs, poor hygiene, and inadequate monitoring. On the 2nd floor, a resident with wounds and an indwelling urinary catheter was observed lying on a low air loss mattress set to static mode instead of alternate mode, with the LPN unable to explain or adjust the setting. The same resident had large white clumps of food on his chest and reported having eaten grits, yet the LPN did not clean the resident or change his soiled shirt. The resident’s catheter tubing and urine bag were cloudy with purulent material and heavy sediment, the bag was undated, and the LPN had not notified the physician and could not determine when the catheter or bag had last been changed. Another resident on the same floor had a shirt covered in white debris, long untrimmed facial hair and nails, and an indwelling catheter bag ordered to be changed as clinically appropriate, but there was no documentation of bag changes.

Additional observations showed environmental neglect and lack of timely care. One resident’s privacy curtain was partially detached from the track, and the resident reported having notified staff about it about a week earlier without repair. A 2nd floor shower room was found with soiled sinks and countertop containing white residue, dried orange substance, and food debris; a large pile of soiled toilet paper with a brown smeared substance on the floor; broken ceramic tiles around the shower drain; a missing shower head; a wet, used washcloth hanging from a shower chair; and a razor left on the tub, despite staff acknowledging residents should not use razors unsupervised. Another resident was observed lying on a bare mattress with the fitted sheet at the foot of the bed and a modified call light dangling out of reach; the LPN attributed the missing sheet to the resident’s movement and left the room without replacing the sheet or positioning the call light. A different resident’s incontinence brief appeared saturated, and after confirming the brief was wet, the LPN re-taped it and left, stating someone would be sent to change the resident. The same resident’s enteral feeding (Jevity 1.5 Cal) had been hung with a documented start time many hours earlier, but only a small volume had infused compared to the ordered rate, and the LPN could not explain the discrepancy.

Other residents reported delays and omissions in basic care and restorative services. Two residents were seated at a table with a large brown spill, likely coffee, that required scrubbing to remove and left a stain. One resident with flaccid right upper extremity was served lunch at the bedside and left to self-feed; when the resident attempted to eat carrots with a spoon, food fell off the plate due to difficulty using only one hand, and no assistance was provided. Another resident reported sitting in urine for extended periods at night, stating night staff typically changed residents only twice during the shift and expressing concern that there were not enough staff. A resident on the 100/200 unit reported not receiving scheduled showers on the days they were told they were scheduled, and another resident stated she had been waiting to be changed since after lunch, remained wet with a bowel movement, and said this happened frequently; she also reported being supposed to receive restorative care for left-sided weakness but not receiving it. A further resident stated she sometimes sat in urine and feces for hours before being changed and reported that on night shift there was only one CNA for both the 100 and 200 units, with one CNA being pulled to another unit when short.

Staffing patterns and facility practices contributed directly to these deficiencies. On the 2nd floor, an LPN reported there were two nurses for the 500/600 and 700/800 units and five CNAs on day shift, but the daily assignment sheet showed only four CNAs assigned to the 500/600 units after one was crossed off. On the 100/200 units, an RN was observed as the only nurse passing medications for 25 residents with two CNAs, and later confirmed no additional nurse had arrived despite the schedule listing a second nurse; the DON confirmed there was only one nurse on those units and stated that having one nurse for 25 residents was their normal scheduling unless the unit was full. The DON also stated the facility had only two restorative aides and no restorative nurse, and was unsure if restorative care was being provided to a resident who reported not receiving it. The staffing coordinator described standard staffing based on census, with one nurse and two CNAs on the 100/200 units and one nurse and two CNAs on the 700 unit for all shifts, and acknowledged never scheduling more than one nurse on the 100/200 units and being unaware that one CNA was pulled from those units on night shift. The facility assessment, however, documented higher overall numbers of licensed nurses and nurse aides per day and specific nurse and CNA ratios (1:20 for nurses on post-acute units, 1:25 on long-term care units, and 1:12 for CNAs on all shifts), and the schedules and interviews showed the facility was not staffing according to its own facility assessment and staffing policy.