F0725

E

Insufficient CNA Staffing Leading to Missed Showers, Delayed Toileting, and Incomplete Restorative Care

La Grange, Illinois Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient CNA staffing to meet residents’ daily care needs, including bathing, transfers, toileting, restorative services, and timely call light response. Multiple cognitively intact residents reported missed or altered showers and prolonged waits for assistance. One resident, who is dependent on staff for transfers and requires substantial/maximal assistance for tub/shower transfers per her MDS, reported not receiving her scheduled shower and instead remaining in bed while staff supervised residents in the TV room. The CNA assigned to her confirmed providing only a quick bed bath and not documenting the shower because there was “too much to do” and that using a mechanical lift for showers was difficult when working short-staffed and responsible for three showers.

Other residents described similar impacts from inadequate staffing. One resident stated that a CNA had 15 residents to care for, so she tried not to ask for help and stayed in bed; she reported turning on her call light to request a bedpan and waiting about 50 minutes without response, ultimately soiling herself, and also being late to dialysis because the night CNA was behind with other residents. Another resident, who is cognitively impaired and requires substantial assistance with bathing and is on a restorative program, did not receive his scheduled shower and instead received a bed bath because the CNA could not complete all assigned showers while also feeding five residents and monitoring the TV room. Additional residents who require mechanical lifts for transfers reported not receiving scheduled showers, remaining in bed for extended periods, and not being gotten up for church on time. Several residents on restorative programs reported receiving restorative therapy only once weekly instead of the planned two or three times because restorative aides were being pulled to work as CNAs on the units.

Staff interviews and facility documentation further demonstrated systemic understaffing and the diversion of restorative staff to CNA duties. CNAs, LPNs, and restorative aides consistently reported that staffing on certain floors was “horrible,” that they were “working short for weeks,” and that with only three to four CNAs per shift they could not complete showers, answer call lights timely, or safely manage numerous mechanical lift transfers. Restorative aides and the restorative nurse stated that restorative aides were pulled to the floor at least two to three days per week, resulting in residents not walking, restorative exercises not being done, and restorative charting not being completed. The scheduler reported staffing patterns of three nurses and four to five CNAs per floor for a building census of 151 residents, while facility records showed 75 residents required mechanical lifts and 70 residents were supposed to be on restorative programs. The Facility Assessment Tool noted that bathing and sleeping preferences were to be considered in staffing, but the section for listing needed FTEs for licensed nurses and CNAs was left blank, and staff reported that assignments did not adequately account for residents’ acuity and care needs.