Insufficient Nursing Staff Leading to Unsafe Transfers, Falls, and Delayed Incontinence Care
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff with appropriate competencies and skill sets to meet resident needs on 34 of 84 reviewed shifts, despite a facility assessment requiring at least two direct care staff and one nurse per shift. Timecard review showed that on multiple specified dates and shifts between early January and early February, only one direct care staff member was on duty, even though the facility had residents requiring mechanical lifts and two-person transfers. Interviews with leadership acknowledged that the facility was short staffed due to staff quitting, difficulty hiring in a rural area, and inability to compete with larger facilities and hospitals, and that resident care suffered because of being short staffed. One resident with a left femur fracture, severe cognitive impairment (BIMS score 00), and a care plan requiring two-person maximum assistance and two-person mechanical lift transfers was inappropriately transferred by a single NA without a mechanical lift. The NA reported she was the only aide working, knew the resident required a mechanical lift and two staff, but transferred him alone because no help was available and stated she routinely transferred him this way. Another resident with heart failure, kidney disease, severe cognitive impairment (BIMS score 07), and a care plan identifying high fall risk and the need for prompt response to call lights fell after using the call light for toileting assistance, waiting, then attempting to go to the restroom alone. Her call light was observed activated with no staff present in the hall or at the nurses’ station; she reported she always had to wait a while for staff to answer her call light and that she had fallen before. Timecards showed only one direct care staff was on shift at the time of this fall. A third resident with colon cancer, muscle weakness, and moderate cognitive impairment (BIMS score 09), who used a walker and wheelchair and required one-person assistance for transfers, had multiple falls over a short period, including two falls on the same day that led to hospitalization for rib fractures and pleural effusion. Progress notes described falls occurring while the resident attempted to get on the commode and when she was found on the floor between the bathroom and her room, with documentation of weakness and difficulty standing. The incident log showed numerous falls, and the care plan identified high fall risk related to weakness, but there were no updates to fall interventions since several months prior. Timecards indicated only one direct care staff was on duty during the falls that occurred that day. Another resident with depression, anxiety, severe cognitive impairment (BIMS score 01), partial/moderate assistance needs for transfers, and occasional incontinence waited approximately two hours to be changed after an incontinent episode. She was repeatedly told by the only aide on shift that the aide was too busy, was observed crying and still unchanged in the hall and dining room, and later had her request to an RN ignored before finally being changed about two hours after her initial request. The aide stated she had been working alone more often since other staff had quit, had difficulty getting everything done when working alone, and that being short staffed could lead to residents not getting needed care and could be considered neglect. Leadership interviews further linked these events to insufficient staffing. The AIT confirmed that on one of the key days only one aide was working because another did not show up, and acknowledged that it was not safe to have only one NA on the floor and that a resident should not have been transferred without a mechanical lift. The AIT stated her expectation was that residents be taken care of by whatever means necessary, while also acknowledging that policies and procedures were not always realistically followed. The ADON reported that the facility had been short staffed due to staff not wanting to work, staff quitting, and hiring challenges, and stated that resident care suffers because of being short staffed. The MD stated he was not aware the facility had been using so many uncertified aides and that the facility should have been using agency staff to ensure residents received care from qualified staff. These observations, interviews, and record reviews formed the basis for the Immediate Jeopardy determination related to insufficient nursing staff and resulting resident care failures.
Removal Plan
- Define direct care staff as any trained individual who demonstrates competency per the facility aide competency checklist (including NA enrolled in CNA training employed less than 120 days, CNA, LVN, or RN providing direct care).
- Ensure there are two direct care staff on the floor at all times in addition to one LVN/RN charge nurse; maintain a total of one LVN/RN and two direct care staff in the building at all times if there are any mechanical lift residents.
- Assess staffing requirements weekly based on census and resident needs; ensure two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.
- Ensure all agency or temporary direct care staff have documented training prior to working a shift by checking credentials via the agency portal and obtaining sister-facility CNA credentials prior to shifts.
- Require two direct care nursing staff on each rotation.
- Utilize staffing agency and aides from the sister facility if the facility does not have enough qualified staff.
- Complete the facility assessment weekly to assess acuity and needs for direct care nursing staffing requirements.
- IDT will review the facility assessment policy for guidance on acuity levels and staffing needs.
- Follow the facility assessment to determine staffing needs.
- Assess Residents #5, #3, #2, and #16 for any further injury, emotional distress, or pain.
- Conduct an immediate review of staffing patterns to evaluate gaps in coverage and staffing needs.
- Contact temporary staffing agencies to meet staffing requirements.
- Use aides from the sister facility to cover staffing gaps until staffing agency assignments are filled.
- Implement temporary agency staffing to ensure two direct care staffing coverage.
- Request a copy of aide certification from the staffing agency.
- Conduct certification checks on all aides arriving from the sister facility.
- Charge nurse will verbally educate any agency and sister-facility staff during shift report (before starting) on call lights, mechanical lift, and abuse/neglect.
- Charge nurse will require verbal return instruction from agency/sister-facility staff before they start the shift to determine competency.
- Adjust the schedule to prevent only one direct care staff at any time, using temp agencies and sister-facility CNAs.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insufficient nursing staff were present on a unit when a resident who required 2-person assist for ambulation and toileting was found walking from the bathroom to bed alone after waiting for help. At the time, only an LPN and a clerk were observed on the unit, while other NA staff had already punched out and the second nurse was charting on another unit.
Insufficient CNA Staffing and Delayed Resident Care: Residents and staff reported that CNA coverage was inadequate on evenings, nights, and weekends, leading to delayed call light response and unmet care needs. A resident with impaired mobility and another with CVA-related deficits reported long waits for assistance, while a CNA stated she was the only CNA on a hall overnight and had not been able to check many rooms. The Administrator and CNA Supervisor acknowledged staffing shortages, especially on nights and weekends, and resident council and grievance records also documented concerns about short staffing.
Insufficient nursing staffing led to delayed and incomplete resident care. The facility scheduled fewer CNAs than required by its assessment, often leaving only 5 to 6 CNAs on day shift instead of 8, and staff were told to cancel shifts when census dropped. Residents reported long waits for toileting and assistance, including being left in feces and waiting during meals for help, while CNAs described working alone, delayed call light response, missed or delayed ADL care, and difficulty completing 2-person transfers and mechanical lifts.
Delayed response to activated call lights was identified for a resident with intact cognition who required assistance with toileting, transfers, and ambulation and had care plan interventions for impaired mobility, safety, weakness from TIA, and fall risk. The resident reported staff often shut off the call light without providing help, and alarm records showed multiple response times over 15 minutes, including several lasting more than 30 minutes and up to nearly an hour. Staff and the DON acknowledged that response times had exceeded the expected timeframe, and the facility policy required staff to respond to engaged call lights in a timely manner.
A resident with a PEG tube, dysphagia, dementia, epilepsy, and other neurologic conditions had scheduled meds ordered through the tube, but the eMAR showed no meds documented for an entire evening med pass. The RN/UM said she worked a double shift because of a nursing call-out and forgot to document the meds as given, and the DON acknowledged the missed documentation.
Insufficient nursing staffing and delayed call light response were identified after residents reported waits of 30 minutes to 2 hours for assistance, including one resident left in the bathroom for 45 minutes and another with a 55-minute wait after activating a call light. The CNA scheduler said staffing was based on a corporate PPD target of 2.85 hours per resident rather than acuity, and records showed multiple weekend shifts with CNA, UM, and RN call-offs or no-shows. Residents also reported staff sitting in the lounge, not responding to lights, and unmet toileting and care needs.
Insufficient nursing staff on unit
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of every resident and to have a licensed nurse in charge on each shift. During an observation on 7/7/26 from 6:54 a.m. through 7:02 a.m., only LPN Employee E10 and the 2A clerk were observed on the nursing unit, while the resident room bathroom call light for Resident R239 was illuminated. At 7:03 a.m., Resident R239 was observed ambulating from the bathroom to bed by herself and stated she got tired of waiting for help. LPN Employee E10 then went to assist her because there were no other staff on the unit. Resident R239's plan of care identified that she required assistance of two staff for ambulation and toileting. Review of 11 p.m. to 7 a.m. staff punch-out times showed one NA punched out at 6:48 a.m., one NA punched out at 6:58 a.m., and two others punched out with the supervisor at 7:00 a.m.; the first NA for the 7 a.m. to 3 p.m. shift was observed on the unit at 7:02 a.m. During interview, the Nursing Supervisor stated the second nurse for the 2A unit was on 2B charting and no other staff were on the unit. The Nursing Home Administrator later confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident R239.
Insufficient CNA Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs in a timely manner and failed to have enough CNA coverage on evenings, nights, and weekends. The report states the facility had 108 residents and could not provide a staffing policy. Interviews with the Administrator and CNA Supervisor confirmed that nights and weekends were the hardest shifts to fill, that staff shortages were common, and that administrative staff were being used to help cover evening hours when CNA shifts were not fully staffed due to call-ins or no-shows. The CNA Supervisor also stated that optimal staffing on the 200 hall would be two CNAs on all shifts because many residents required two-person assistance with mechanical lifts. Several residents described delayed responses to call lights and assistance needs. One resident with diagnoses including acute respiratory failure, diabetes mellitus, anemia, anxiety disorder, and cognitive communication deficit stated the call light system was not working and that she had been given a whistle to use instead; she reported prolonged waits for staff response, especially after dinner and overnight, and said she had had incontinence episodes while waiting. Another resident with cerebral infarction, hemiplegia, major depressive disorder, and cognitive communication deficit stated she waited longer in the evening and overnight when using the call light, and that weekends seemed to have less staff available. A family member present during that interview stated staff worked hard but did not have enough help, especially on second shift and weekends. A third resident with anemia, muscle weakness, and need for assistance with personal care stated her call light system did not work and she had been given a dinner bell to use when needing assistance. She reported waiting 30 minutes or more for help with her incontinence brief during evening and overnight hours. A CNA working the night shift stated she was the only CNA assigned to the 200 hall at that time, that only 5 CNAs total were working nights including the supervisor, and that she had only checked 4 rooms since arriving before 2:00 AM, with 8 rooms or 11 residents still not checked on her hall. Resident council minutes also documented concerns that there were not enough CNAs on weekends, and a grievance form documented a resident complaint about not receiving a shower due to short staffing.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff in accordance with its facility assessment and residents’ care needs. The assessment called for 1 RN, 2 LPNs, and 8 CNAs on day shift; 3 LPNs and 8 CNAs on evening shift; and 3 CNAs plus 2 additional staff on night shift. However, the nursing schedule from June 2026 through July 3, 2026, showed no days with 8 CNAs assigned to the day or evening shift, with day shift typically staffed by only 5 to 6 CNAs. On one day, a note next to two staff names stated, “If all show, go home,” leaving only 5 CNAs on the floor. On another day, one CNA called off and was not replaced, leaving 3 CNAs for the 100-400 units and 1 CNA for the villa. Residents and staff described delays in care and difficulty meeting basic needs because of the staffing levels. One resident, who had multiple diagnoses including multiple sclerosis, trigeminal neuralgia, convulsions, malnutrition, COPD, hypotension, and epilepsy, was dependent on staff for ADLs and reported being left in feces for 45 minutes because no one was available to assist. The resident also reported that during meal times, call lights were not answered until meals were finished because aides were feeding residents and no one else was available. Another resident, who was dependent on staff for ADLs and had diagnoses including hemiplegia, chronic pain, depression, and falls, stated that the facility was short-staffed and that CNAs were stressed and unable to perform their jobs as they should. Multiple CNAs and the DON confirmed the staffing shortages and the effect on resident care. CNAs reported working alone in the villa, being told no additional CNA would be assigned until census exceeded 18, waiting for help with two-person transfers and mechanical lifts, delayed call light response times of up to 25 minutes, and residents being left soaked in urine overnight because there was not enough staff. The DON stated he wanted additional nurses and CNAs but was told to cancel staff when census dropped. The facility’s fall list also showed an increase in unwitnessed falls from 3 in May 2026 to 15 in June 2026.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to consistently respond to activated call lights within a timely manner for one resident. Resident #47 had a BIMS score of 15 out of 15 and required partial/moderate assistance with toileting hygiene and toilet transfers. The resident’s care plan identified impaired mobility, safety concerns, functional performance deficits related to weakness from a transient ischemic attack, and risk for falls, with interventions directing staff to keep the call light within reach, encourage use of it for assistance, and provide prompt response to requests for help. During observation, Resident #47 stated the call light had been activated for several minutes and was shut off by staff without assistance being provided, and the resident reported this happened often. Staff F acknowledged shutting off the call light when unable to assist the resident to the bathroom. Review of the facility’s excess response alarms showed multiple call light response times for Resident #47 ranging from 16.7 minutes to 57.3 minutes. Staff interviews confirmed that an appropriate response time was under 15 minutes, and the DON acknowledged that call lights had exceeded 15 minutes at times. The facility policy stated all staff were to respond to an engaged call light to rule out an emergency situation and that resident needs such as transfers, toileting, and dressing were to be addressed in a timely manner.
Missing Medication Documentation After Short-Staffed Shift
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure that medications and treatments were properly documented for one resident. Resident #47 had diagnoses including late effects of cerebral infarction, aphasia following cerebral infarction, dysphagia, dementia, epilepsy, hypertension, and gastrostomy status. The resident’s MDS indicated the resident was rarely or never understood and had a tube feeding. Physician orders included multiple scheduled medications administered via PEG tube and enteral feeding orders. Review of the eMAR for the evening shift showed no medications documented as administered for the entire medication pass. The medical record did not contain a nursing progress note explaining that the resident was out of the facility, refused medications, or otherwise accounting for the missing documentation. The RN/UM stated she worked a double shift because of a nursing call-out and, while working as the med nurse, forgot to document that the medications had been administered during the evening shift. The DON acknowledged that the RN/UM had worked two consecutive shifts due to a call-out and forgot to document administering the resident’s medications during the evening med pass.
Insufficient Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and failed to ensure a licensed nurse was in charge on each shift. During a confidential resident group meeting, residents reported that call light response times were commonly about 30 minutes, could be as long as two hours, and that one resident had been left in the bathroom for 45 minutes before yelling for help. Residents also stated that the facility needed more staff and that staff called in too often. During interviews and record review, the surveyor learned that the facility used a corporate per-patient-day guideline of 2.85 hours per resident and did not use resident acuity in scheduling. The CNA/staff scheduler stated that management did not want staffing to go over or under that target and that she scheduled as close to it as possible. She also stated that weekend staffing was stacked to anticipate call-offs, and that residents had reported only one CNA on night shift, although she said clock-in records did not show that. She further stated that 3rd shift staff were in the lounge watching TV and not responding to call lights, and that the cameras did not work. Payroll and staffing records showed multiple weekend shifts with call-offs and short staffing across CNA, unit manager, and licensed nurse shifts, including several dates with multiple call-ins or no-shows on 1st, 2nd, and 3rd shifts. Residents reported long waits for call lights, unmet toileting needs, and staff not responding or returning after entering rooms. One resident’s concern form documented a 55-minute wait after a call light was activated, and another resident stated that staff did not respond for 30 minutes to 3 hours. The DON, regional clinical consultant, and NHA all acknowledged that PBJ staffing was submitted at the corporate level, and the NHA was aware of excessively low weekend staffing that had triggered in March 2026.
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