F0725

D

Failure to Maintain Sufficient Nursing and Direct Care Staffing to Meet Resident Needs

Beloit, Wisconsin Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs in accordance with its own Facility Assessment and staffing policy. The Facility Assessment dated July 2025 specifies a staffing plan of 4 licensed nurses on the day shift, 2–4 licensed nurses on the evening shift, and 2 licensed nurses on the night shift, with direct care staff ratios of 1:16–18 on day and evening shifts and 1:20 on night shift. Review of staffing schedules from late December through early January showed multiple shifts where the number of licensed nurses and direct care staff fell below these stated ratios. On several dates, there was only 1 licensed nurse on night shift for a census of approximately 80–84 residents, resulting in nurse-to-resident ratios as high as 1:84, and direct care staff ratios as high as 1:28 during portions of the night.

From 12/23/25 through 1/6/26, the surveyor identified repeated instances of inadequate staffing compared to the facility’s own assessment. Examples include: on 12/24/25, the day shift had 3 licensed nurses with a 1:28 ratio instead of 4, and the night shift had 1 licensed nurse with a 1:84 ratio and only 3 direct care staff with a 1:28 ratio from 10:00 PM to 5:00 AM. On 12/25/25, the day shift again had 3 licensed nurses (1:28), the evening shift had 2 licensed nurses (1:42), and the night shift had 1 licensed nurse (1:84). Similar shortfalls occurred on 12/26/25, 12/29/25, 12/30/25, 12/31/25, 1/2/26, 1/3/26, and 1/4/26, with periods where only 1 licensed nurse covered the entire building and direct care staff numbers did not meet the 1:16–18 or 1:20 ratios. On some days, the facility could not provide the required staffing postings for census confirmation.

Two cognitively intact residents reported care concerns consistent with these staffing shortages. One resident, with diagnoses including aftercare following joint replacement, radial nerve injury, vascular dementia, morbid obesity, adult failure to thrive, muscle weakness, and chronic congestive heart failure, stated that staff leave her on the commode too long and that she must sometimes wait an hour for her call light to be answered to use the bathroom, describing the waiting as getting “out of line.” Another resident, with acute on chronic congestive heart failure, disorientation, morbid obesity, muscle weakness, difficulty in walking, and adult failure to thrive, reported that there is often only one CNA for a hall of 24–25 residents, that this happens “all the time,” and that she has to wait a long time. Staff interviews further reflected staffing strain: one CNA stated it is hard to complete all tasks on her shift and acknowledged general short staffing, while the scheduler/CNA described relying on full-time/part-time set schedules, pool staff, and staff coming in early or staying late to fill gaps, and confirmed that staffing should follow the facility assessment. The DON stated that a 1:40 nurse-to-resident ratio for PM and NOC shifts was considered safe due to ancillary staff, acknowledged that night shift sometimes has only one nurse on duty, and confirmed that staffing is an ongoing concern discussed at QAPI meetings, even though no ancillary staff were actually scheduled on the reviewed schedules.