F0725

F

Insufficient Licensed Nursing Staff and Unmet Staffing Calculator Requirements

Peoria, Illinois Survey Completed on 09-03-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient licensed nursing staff to meet residents’ needs and to follow its own staffing policy and staffing calculator requirements. The facility’s Staffing Policy dated 4/30/25 states that minimum numbers of nursing staff must be established and maintained based on census and resident acuity. The facility’s staffing calculator for multiple dates in August 2025 documented that four nurses (32 licensed nursing hours) were required on day shift, three nurses (24 licensed nursing hours) on evening shift, and two nurses (16 licensed nursing hours) on night shift. However, timecard reports for 8/5/25 through 8/24/25 showed that on several dates the actual licensed nursing hours fell below these calculated requirements. For example, on some days only one nurse worked the day shift, one to one-and-a-half nurses worked the evening shift, and one nurse worked the night shift, instead of the higher numbers required by the staffing calculator.

The Director of Nursing confirmed multiple staffing shortages on specific dates and stated that staffing is an issue and that she was not aware the staffing calculator required four nurses on days, three on evenings, and two on nights. A registered nurse reported that she did not chart on her residents on one of the cited dates because things were too busy and there was not enough staff. The DON also stated that nurses complain about staffing numbers, report they cannot get things done, and that the MARs and TARs have holes in charting, which nurses attribute to not having enough time due to low staffing. At the time of the survey, the facility’s CMS LTC application documented a census of 110 residents, all of whom had the potential to be affected by these staffing shortages.