F0725

D

Inadequate CNA Night-Shift Staffing Leading to Resident Fall

Glenwood, Illinois Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient CNA staffing on a night shift to meet resident needs in accordance with its own Facility Assessment Tool and Staffing Policy, resulting in a resident fall. On the night in question, the facility’s midnight census was 136 residents, and the facility was scheduled to have eight CNAs but had only five due to call-offs. The DON and Assistant Administrator stated that having five CNAs for a census of 136 should not impede resident care. However, the daily assignment sheet for that night documented that three CNAs on the A and B wings each had 25 residents, the CNA on Unit C had 33 residents, and the CNA on Unit D had 28 residents. The DON acknowledged that there was a resident incident/fall at 1:40 a.m. and that there was not an appropriate number of staff available to meet the needs of the residents.

A CNA who worked the 11:00 p.m. to 7:00 a.m. shift reported having 25 residents assigned and stated that CNAs needed more help to ensure proper nursing care was completed, and that some work was not completed. The facility’s Assessment Tool, last updated in August 2025, specified that staffing and resource needs should be based on a holistic approach considering resident acuity, ADLs, personal preferences, and psychosocial needs, and set direct care CNA ratios for post-acute units at 1:12 and LTC units at 1:18 on night shift. The facility’s Staffing Policy, reviewed in May 2025, stated that appropriate numbers of staff must be available to meet resident needs. Despite this, the nursing management team’s handling of call-offs resulted in staffing levels and CNA-to-resident assignments that did not align with the facility’s own assessment-based staffing parameters, contributing to the fall of one resident.