F0725

F

Insufficient Nursing Staff and Supervision During ADLs and Meals

Mount Vernon, Illinois Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to supervise and attend to residents’ needs in a timely manner, as required by facility policy and regulatory standards. One resident with a history of cerebral infarction, hemiplegia/hemiparesis, and age-related physical debility was care planned as cognitively intact, with bilateral lower extremity impairment, requiring substantial to maximum assistance with transfers and supervision or touching assistance with eating. His care plan also documented an ADL self-care deficit and the need for assistance or dependence in transfer, dressing, and toilet use, as well as supervision with meal consumption. Despite these documented needs, the resident reported that staff told him they needed two people to transfer him and that someone was always on break or there was not enough staff, resulting in him remaining either in bed or in his chair for prolonged periods.

On multiple observations over several days, this resident was repeatedly found lying in bed at various times of day, including during mealtimes, and was observed eating alone in his room without supervision. He stated that if he got up into his chair, he should expect to stay there all day, and if he stayed in bed in the morning, he would remain there. He also reported that when he asked to get out of bed in the morning, staff told him it was fine but that he should not expect to return to bed until after lunch. On another day, he stated he did not ask to get out of bed because he anticipated being left in the chair all day and reported that he started hurting after a couple of hours of being in the chair. These statements and observations demonstrate that his care-planned needs for supervised meals and assistance with transfers were not consistently met due to staffing limitations.

A second resident, newly admitted with diagnoses including cerebral atherosclerosis and bilateral blindness, had a care plan identifying high fall risk with interventions such as anticipating and meeting needs, ensuring the call light was within reach, encouraging its use, and being aware of blindness. Another resident with traumatic brain injury was care planned as an elopement risk and wanderer, at risk for falls/injury related to wandering and poor safety awareness, and having behavior problems such as entering other residents’ rooms and taking their items. Interventions included frequent observation of whereabouts, redirection when entering other residents’ rooms or beds, and use of diversional activities. A psychiatry note documented additional concerning behaviors for this resident, including pacing, inappropriate sexual behaviors, stealing other residents’ belongings and food, digging in and eating from trash, and becoming physically aggressive with redirection. However, the care plan did not initially address abuse or potential for abuse or the full scope of these behaviors.

Over several days, surveyors observed this behaviorally complex resident repeatedly taking food from other residents’ plates and trays in the dining room, eating from plates and cups that other residents had already used, and removing multiple plates and trays to his room without effective staff intervention. Staff reported having to remove up to 15 plates from his room on some days. During multiple observation periods, there were no staff present in the dining room or hallways to supervise him, and a CNA stated there were no staff on the hallways to supervise him. The resident was also observed climbing over the nurses’ station countertop, moving a locked treatment cart, and entering a closet containing snacks, activity supplies, personal staff items, and medical supplies, with no staff present. He was seen entering the locked nurses’ station on more than one occasion, opening bags and boxes in the closet, and staff later acknowledged that he had climbed over the nurses’ station multiple times to obtain snacks.

Dietary staff and CNAs reported that this resident had climbed into the kitchen through the serving and dirty dish windows, which were approximately three feet off the ground, and that he had entered the kitchen several times in the past to obtain food. Staff described him as very agile and hard to redirect. During one observation, a laundry staff member had to seek out a CNA from the dining room because there were no staff around the nurses’ station when the resident climbed over the counter. These repeated incidents of unsupervised wandering, access to restricted areas, and taking of other residents’ food occurred in the context of documented staffing gaps, including periods when no staff were observed in the dining room or hallways. Facility policies required adequate staffing levels and sufficiently trained or supervised staff to deliver services necessary to attain or maintain each resident’s highest practicable well-being, but the observed lack of staff presence and supervision contributed directly to the identified deficiency.