F0725

E

Inadequate Nurse and CNA Staffing Leading to Delayed Medications and Care

Chicago, Illinois Survey Completed on 03-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate nursing staff to ensure resident needs were met in a timely manner and medications were administered as ordered. On multiple occasions, nurse and CNA staffing on various floors and shifts fell below the facility’s usual staffing framework, resulting in delayed medication administration and delayed response to resident care needs. On one day shift, an LPN assigned to the first floor arrived around 10:14 AM to cover a 7-3 shift, causing some 9:00 AM medications on her assignment to be given after 10:00 AM. A registered nurse working that same day reported being the only nurse on the first floor at the start of the shift after another nurse called off, and stated that residents on the second set of rooms did not receive their 9:00 AM medications within the 8:00-10:00 AM window because of short staffing.

A resident with diagnoses including chronic upper respiratory disease, congenital tracheal malformation, type 2 diabetes mellitus, morbid obesity, peripheral vascular disease, seizure disorder, schizophrenia, bipolar disorder, and anxiety reported often not receiving medications as scheduled, sometimes three hours late, and described one day when no medications were received until early afternoon. This resident, who receives Gabapentin for bilateral lower leg pain and has an intact cognition per MDS, stated that on a Saturday when the unit was short staffed and there was an emergency with another resident, his Gabapentin was not given on time and his pain level was eight out of ten. The RN confirmed that this resident’s standing 9:00 AM Gabapentin dose was administered around 11:15 AM and documented in the eMAR, outside the stated 8:00-10:00 AM window for 9:00 AM medications.

The facility also failed to maintain adequate CNA staffing on several shifts. On one 7-3 shift with a census of 81 residents, only four CNAs worked on the second floor instead of the usual six, resulting in one CNA caring for approximately 19-20 residents, about half of whom required total care and three required a mechanical lift. That CNA reported prioritizing initial rounds, incontinence care, answering call lights, feeding residents, and passing out ice water, and stated that charting, nail care, shaving, and getting some residents who required a mechanical lift dressed or out of bed might not have been completed. Another resident with multiple comorbidities including partial traumatic amputation of the left lower leg, chronic venous hypertension with inflammation of both lower extremities, complex regional pain syndrome, dietary folate deficiency anemia, long-term insulin use, type 2 diabetes mellitus, long-term anticoagulant use, and chronic kidney disease, and who requires assistance with toileting, bathing, and transfers, reported that on a Saturday day shift there were only four CNAs working and that she had to wait a longer time for staff to respond to her call light and to be changed because staff were very busy.

Additional staffing shortfalls occurred on other units and shifts. On one 3-11 shift on the third floor, only two nurses worked instead of the expected three, and an LPN reported that although all residents eventually received their 5:00 PM medications, some were administered outside the 4:00-6:00 PM timeframe due to the reduced staffing and the higher acuity of the dementia unit. On a separate 11-7 shift on the third floor, three CNAs worked instead of the usual four, with one CNA caring for 24-25 residents on the dementia unit and reporting that residents who wander and are at risk for falls could not all be watched and that residents had to wait longer to be changed if wet or soiled. On another morning, an LPN assigned to approximately 24 residents on the second floor arrived at 9:35 AM for a shift where 9:00 AM medications were to be given between 8:00-10:00 AM; by 10:01 AM she still had not completed the medication pass for all assigned rooms and acknowledged she would not be able to finish before 10:00 AM. The Director of Nursing and an advanced practice nurse both stated that inadequate staffing can delay medication passes, nursing assessments, accuchecks, and timely ADL care, and that CNA-to-resident ratios such as 1:20 and nurse shortages on heavier units like the locked dementia floor are problematic. The administrator reported that the facility does not have a staffing policy.