F0725

F

Failure to Provide Sufficient Nursing Staff for Timely Resident Care

Springfield, Illinois Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on a daily basis to meet residents’ needs and to ensure timely care. The DON reported a standard staffing pattern for nurses and CNAs on each shift, but multiple interviews and observations showed that actual staffing was frequently inadequate, with CNAs caring for up to 16 residents each and nurses responsible for as many as 32 residents. Staff, including CNAs, a CNA supervisor, and an LPN, consistently stated that staffing was “terrible,” “horrible,” and “always” short, especially on certain halls and shifts, and that they were unable to respond promptly to call lights or complete needed care. The CNA supervisor stated she was given a fixed number of CNAs per shift and could not increase staffing unless census increased and it was approved, and the administrator stated there was no staffing policy and that they followed federal guidelines.

Residents reported and surveyors observed delays in care and unmet needs directly related to insufficient staffing. One cognitively intact resident who was intermittently incontinent stated that call light response times varied depending on who was working and that nights and weekends were usually short-staffed. Another cognitively intact resident reported requesting a stool softener in the morning and not receiving it until evening because the CNA had to locate a nurse. A cognitively intact resident who required a full-body mechanical lift reported that staff sometimes transferred her with only one person because there were not enough staff. Another resident’s oxygen tank was found empty; the LPN stated the resident had been back in his room “a while” and had not been reported as low on oxygen, and explained that CNAs had 16 residents each and she had 32, contributing to such issues.

Surveyors also observed prolonged delays in response to call lights and assistance with toileting and transfers. One cognitively intact resident waited approximately an hour from the time she first activated her call light requesting a bedpan until two CNAs using a full-body mechanical lift finally transferred her to bed and placed her on a bedpan; during this time, her call light was answered once only to be told she must wait for a CNA to return from break, and staff were occupied assisting other residents requiring two-person lift transfers. On another occasion, both CNAs and a nurse were in one resident’s room for 30–45 minutes, leaving other residents waiting to be taken to the dining room and at least one call light unanswered for an unknown period. Staff reported that many residents on the 300- and 400-halls required two-person or full-body mechanical lift transfers and close observation for behaviors, and that with only two CNAs on a hall they could not be “everywhere” or get to all residents when needed. Resident council minutes documented ongoing concerns about call light response times, shower schedules, medications, and timeliness of service, further evidencing persistent staffing-related problems.