F0725

E

Insufficient Nursing Staff Leading to Missed Showers and Delayed Call-Light Responses

Cranberry Township, Pennsylvania Survey Completed on 01-31-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient and competent nursing staff to meet residents’ needs, resulting in missed care, delayed responses to call lights, and unmet basic care needs across multiple timeframes and care areas. Facility policy on sufficient and competent nursing staffing states that the facility will provide enough nursing staff with appropriate skills and competency to deliver care and services in accordance with resident care plans and the facility assessment. However, review of Payroll Based Journal data for one quarter showed excessively low weekend staffing, and resident council minutes from two meetings documented multiple residents’ concerns about long wait times for call lights to be answered. Grievance and concern forms also documented complaints that one staff member was covering half a floor, that it took two to two and a half hours to get a resident on a bedpan, and that this had happened repeatedly.

Additional concerns from residents and resident representatives described cold meals and inadequate assistance with showers due to insufficient staffing. Resident council documentation and group resident interviews indicated that staffing adequacy varied by day and shift, and that residents who required a Hoyer lift often did not receive showers on days when staffing was low because two staff were needed to operate the lift. Several residents reported missing scheduled showers for this reason, and multiple residents reported waiting between 30 minutes and two hours for assistance on various shifts. Staff interviews with NAs, an RN, and an LPN corroborated these concerns, with staff stating that when staffing was low, showers were not completed, tray passing was delayed, residents could not always be gotten out of bed, and call lights had to wait.

Specific resident records and observations further demonstrated the impact of insufficient staffing. One resident with diagnoses including hypertension, GERD, and multiple sclerosis was scheduled for showers twice weekly but reported frequently missing showers, and documentation showed missed showers on three specified dates, which the DON confirmed. Another resident with atrial fibrillation, hypertension, and pancreatic cancer had a care plan requiring prompt response to call lights; observation showed this resident’s call light active for 17 minutes for pain medication, with the final activation time reaching 22 minutes. A resident with hypertension, aphasia, and hypokalemia, scheduled for showers twice weekly at a set time, missed multiple scheduled showers, and reported that staff attributed missed showers to lack of staffing. Another resident with aphasia, depression, and lack of coordination, scheduled for showers twice weekly on day shift, also missed a scheduled shower and indicated they did not receive showers as scheduled. A further resident with atrial fibrillation, hypertension, and renal failure, care-planned for prompt call light response, had a call light active for 25 minutes for assistance with an indwelling Foley catheter, with the final activation time at 26 minutes, which was confirmed by an RN. The DON acknowledged that the facility failed to have sufficient nursing staff to provide necessary nursing and related services during the identified periods and for the identified residents.