F0725

D

Insufficient CNA Staffing Leads to Untimely Incontinence Care and Undocumented Double Brief Use

Hackensack, New Jersey Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to ensure timely and appropriate incontinence care, as evidenced by staffing levels and the condition of an incontinent resident. On one morning, the Nursing Home Resident Care Staffing Report showed a census of 118 residents on the 7 AM–3 PM shift with a CNA-to-resident ratio of 1:14.8. On the 5th floor, there were 28 residents and only two CNAs assigned. When interviewed, a CNA on that unit stated she had about 14 residents, described the assignment as hard, and reported she was not finished with morning care. On another day, the posted staffing report showed a census of 117 with 10 CNAs on the 7 AM–3 PM shift, for a ratio of 1 CNA to 11.7 residents. The facility’s own leadership later acknowledged that staffing concerns and at times not meeting New Jersey minimum staffing ratios were known issues.

During an incontinence round on the 5th floor, the RN/Unit Manager confirmed that a resident was incontinent of both bladder and bowel and obtained the resident’s permission to check the incontinence brief. The RN/Unit Manager and surveyor observed that the resident was wearing double incontinence briefs that were wet with urine. The RN/Unit Manager also found that the resident’s pads, folded linen, and cloth-type chuck under the resident were wet beyond the pads, and there was a noticeable urine odor. The RN/Unit Manager stated she was unaware that the resident had requested double briefs and indicated that double briefs were not allowed unless specifically requested by the resident and included in the care plan. She further stated she was unsure whether this preference was in the care plan. The surveyor was unable to interview the CNA assigned to the resident at that time.

Record review for this resident showed diagnoses including type 2 diabetes mellitus without complications, COPD unspecified, need for assistance with personal care, and difficulty in walking. The care plan identified a focus on potential impairment to skin integrity with an intervention to assist with toileting needs, but there was no care plan entry documenting a preference for double incontinence briefs or any documented evidence that the resident had requested them. The most recent quarterly MDS showed the resident was cognitively intact (BIMS 15/15), always incontinent of bladder and bowel, and dependent for toileting hygiene and toilet transfer, with no documented skin impairment. Review of CNA electronic documentation for toileting hygiene from 1/10/26 to 1/22/26 showed the task was checked off every shift as completed with the resident dependent and requiring assistance of two or more helpers. However, on 1/23/26, only one shift at 12:17 AM documented toileting hygiene, and there was no documentation by the 7 AM–3 PM shift or any evidence of incontinence care after 12:17 AM that day, despite the resident being listed on the facility’s list of incontinent residents and only two CNAs being scheduled on the 5th floor for that shift.