F0725

F

Insufficient Nursing Staff and Missed Toileting Care Due to Frequent Call-Ins

South Holland, Illinois Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet resident needs and to staff in accordance with its own facility assessment. The facility census ranged from 109 to 113 residents during the review period, with the facility assessment identifying a need for 11 CNAs on day shift, 10 on evening shift, and 9 on night shift, and 4 licensed nurses on first and second shifts and 3 on third shift. Daily staffing sheets from late January to mid-February documented frequent call-ins and no-call/no-shows among CNAs and nurses, resulting in reduced CNA coverage on multiple night shifts, including nights when only 6–8 CNAs worked instead of the 9 CNAs specified in the staffing plan. The scheduler and DON acknowledged frequent call-ins that sometimes caused disruptions or delays in resident care when replacement staff could not be found.

A cognitively intact resident with multiple complex diagnoses, including lumbar spine fusion, inflammatory spondylopathy, type 2 diabetes with neuropathy, malnutrition, neuromuscular bladder dysfunction, obesity, COPD, and major depressive disorder, reported that there was not enough staff and described waiting 3–4 hours for assistance. This resident, who is dependent on staff for toileting, stated they had been left hanging in a Hoyer lift for over three hours in feces in October and frequently left in urine and feces for hours, including at the time of the interview. Point of Care (POC) documentation for this resident showed multiple dates and shifts where no toileting assistance was recorded. The same resident also reported hearing staff discuss another resident who allegedly fell from bed onto a radiator and sustained third-degree burns after not being checked on for hours, though the reporting resident did not witness the event and could not identify the resident involved.

Two additional cognitively intact residents, both dependent on staff for toileting or reporting incontinence care needs, stated that there were not enough aides, that they had to wait a long time for help, and that incontinence care was sometimes not provided. POC records for one of these residents showed multiple dates and shifts with no documented toileting assistance. Staff interviews corroborated concerns about insufficient staffing: a CNA stated they were usually short-staffed due to frequent call-ins, and an LPN reported being assigned to 42 residents alone and did not believe this was safe, especially given the number of residents with dementia. In contrast, the administrator and DON stated they believed staffing was sufficient overall and reported no staffing complaints, though they acknowledged call-ins occurred at least every other day and that care could be delayed when coverage could not be secured, resulting in more residents per staff member and delayed care.