F0725

F

Failure to Maintain Continuous Licensed Nurse Coverage and Adequate Staffing

Bridgeport, Ohio Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient licensed nursing staff on all shifts and adequate CNA staffing to meet resident needs, including a period when no nurse was present in the building. On one afternoon, two nurses left the facility, resulting in a gap of approximately 40 minutes to 1.5 hours with no licensed nurse on site while about 65–70 residents remained in the building. During this time, residents requested medications and nursing interventions, including removal of IV tubing from a PICC line, but no nurse was available to respond. A resident with diagnoses including peritoneal abscess, anemia, and a history of substance abuse reported that medications were often late and that on the day she left against medical advice, she walked the halls with IV antibiotic tubing hanging from her arm and could not find any nurse in the facility.

Multiple CNAs and nurses reported that staffing was routinely insufficient across shifts, especially on nights, with only one CNA on each side of the building and two nurses and two CNAs for nearly 70 residents. Staff described being unable to complete timely incontinence care, showers, toileting, feeding assistance, and medication and treatment administration. They reported residents being found soaked in incontinence products at shift change, residents remaining in bed most or all day due to lack of staff to get them up, and residents waiting extended periods for call lights to be answered, sometimes 30 minutes or longer. Staff also reported that medications were consistently late, often documented as being “in the red,” and that nurses and CNAs frequently had to stay hours past their shifts due to call-offs and high workload.

Residents and a resident representative corroborated that there were not enough staff to supervise and assist residents. Residents reported long waits for call lights to be answered, delays in receiving water and other basic assistance, and instances of being left on the toilet for prolonged periods while waiting for staff to return. Some residents described other residents wandering into their rooms without staff intervention, and one resident reported that she had to redirect confused residents herself. Another resident reported not receiving migraine medication after notifying a nurse leader and activating the call light twice more, with no staff response. Residents also noted that staff appeared frustrated and that staff turnover was high.

Review of the facility’s admission agreement showed that the facility agreed to provide 24-hour nursing care and assistance or supervision with activities of daily living, including toileting, bathing, feeding, and ambulation. The facility assessment stated that its purpose was to determine necessary resources to care for residents during routine operations and emergencies and to inform staffing decisions, including day, evening, and night shifts, recruitment and retention, and contingency planning for staffing shortages. However, the assessment only identified the need for a full-time DON, ADON, MDS nurse, and part-time wound care nurse and did not specify how many licensed nurses were needed for the resident population or provide details on recruitment or contingency plans. This lack of detailed staffing planning, combined with ongoing staff departures and reliance on minimal staffing, contributed to repeated instances where resident care and supervision needs were not met.

Human resources staff acknowledged difficulty filling night shift schedules for both nurses and CNAs and described recent initiation of agency use to fill open shifts. A newly hired LPN reported being scheduled to work independently on a unit during what was supposed to be an orientation day, without prior training on that unit. Staff interviews consistently described high-acuity residents, including geriatric psychiatric residents with behavioral issues, residents with frequent falls, and residents requiring 1:1 supervision or two-person mechanical lift transfers, being cared for with staffing levels that staff considered inadequate. The facility’s failure to ensure continuous licensed nurse coverage and adequate direct care staffing on all shifts, as well as its incomplete facility assessment regarding licensed nurse staffing and contingency planning, led to delays and omissions in resident care and supervision for the entire resident population.