Insufficient Nursing Staff Leading to Delayed Call Responses and Missed ADL Care
Summary
The deficiency involves the facility’s failure to maintain sufficient nursing staff to meet residents’ total care needs, including timely response to call lights and provision of routine ADL care such as bathing and toileting. On the initial survey entrance, there were four licensed nurses and five CNAs on duty for 52 residents, despite the facility assessment indicating a need for 4 licensed nurses providing direct care, 13 nurse aides, and 3 other nursing personnel, with a general staffing plan based on 1:12 day/evening and 1:20 night ratios. The facility’s own assessment and staffing plan called for higher staffing levels than were present. The facility also had a policy on resident dignity and respect, including allowing residents flexibility and honoring preferences, which contrasted with reports of delayed care and unmet preferences. Multiple residents reported long delays in call light responses and inadequate assistance due to short staffing. One resident who required a mechanical lift for transfers stated he could only get into his electric wheelchair about once a week because there was not enough staff to help, causing him to miss resident council meetings despite being the council president. Another resident reported call light response times ranging from 45 minutes to two hours, and a resident admitted for therapy due to weakness stated it had taken up to two hours for staff to answer call lights. A resident reported waiting up to 30 minutes for call light response at night and having to pull a bedpan out from under herself after sitting on it so long that it became painful. Another resident, who required assistance with transferring and walking to the bathroom, reported waiting so long for help that she became incontinent, leading to raw and painful skin on her legs and vaginal area, and stated that staffing was short among both nurses and aides, especially at night. Staff interviews further described chronic understaffing and its impact on resident care. CNAs reported that it was nearly impossible to complete the expected number of showers per shift along with other responsibilities, and that there were usually only three aides on day shift. One CNA stated she had been told not to shower residents requiring a mechanical lift despite the presence of a lift chair in the shower room, and recounted a resident requesting a shower but only having her hair washed because the aide said she did not have time. Another CNA stated she never felt there were enough staff to meet resident needs and noted that extra staff were added to the schedule because surveyors were present. An RN stated that call light responses should be within five minutes and that responses over 10 minutes required follow-up, and confirmed there were 16 residents requiring mechanical lifts, which need at least two staff. Other staff reported residents not getting showers, the DON coming in on a short-staffed night and sleeping in her office, and that staffing expectations and workload, including care for residents on ventilators and with many wounds, were excessive and could affect resident care. Record review and resident interviews showed that residents were not consistently receiving scheduled showers or adequate ADL assistance, and that refusals were not always addressed with appropriate interventions. One resident with osteomyelitis, diabetes with foot ulcers, repeated falls, and impaired cognition required partial/moderate assistance with bathing and toileting and needed leg wounds covered before showering. Documentation showed only two showers over a period of more than two months, with multiple recorded refusals but no documentation of interventions to encourage or explain the need for ADL assistance. The resident reported wanting showers but being told staff did not have time to cover both legs, leading him to decline and instead wipe off. Another resident with diabetes, lung cancer, COPD, weakness, and urinary incontinence was care planned for maximum assistance with bathing and scheduled for showers three times weekly, but records showed multiple missed showers/bed baths on scheduled days. This resident reported not always receiving scheduled showers and having only one shower in the prior week; observation noted greasy, uncombed hair and body odor, and an RN verified missed bathing in March. A further resident with multiple serious diagnoses, including sepsis, dysphagia, pneumonitis, respiratory failure, obesity, malnutrition, and repeated falls, was cognitively intact and required partial to moderate assistance with bathing and dressing. Her care plan aimed to keep her clean, dry, and odor free, with staff assistance for hair care, oral care, dressing, and bathing. Electronic records showed she received showers on only three dates over approximately one month, and her spouse reported that he was present all the time and assisted with all of her care because he did not feel staff did enough to help with ADLs. The administrator confirmed the available shower documentation for this resident. Additionally, facility call light audit reports for a one-week period showed 19 instances where call light response times exceeded 30 minutes, with the shortest of these being 37 minutes and the longest 144 minutes, corroborating resident and staff reports of delayed responses and insufficient staffing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to provide enough nursing staff to meet resident needs, resulting in prolonged call light response times and unsafe use of mechanical lifts. Multiple residents reported that call lights often went unanswered for 30 minutes to over two hours, care felt rushed, and medications, including evening doses, were given late, especially on night shift. A resident on airborne precautions for COVID-19 had her call light activated for over 25 minutes while staff walked past without responding. Surveyors also observed a CNA performing a mechanical lift transfer alone, while residents reported that lifts were routinely operated by only one staff member because only one aide was assigned to the hall. In another case, a resident requesting incontinence care had her call light deactivated twice by non-nursing staff without the need being addressed or communicated, resulting in a delay of about 34 minutes before care was provided.
The facility failed to maintain sufficient nursing staff and clear staffing plans, resulting in delayed call light responses, missed ADL care, and incomplete treatments for multiple residents. Residents and families reported long waits for assistance, especially at night and on weekends, with some residents lying in urine for hours, not receiving scheduled showers, and being left without proper bedding or repositioning. Staff confirmed that halls were sometimes staffed with only one CNA despite several residents requiring mechanical lifts, and that lifts were at times performed by a single staff member contrary to policy. Nurses described heavy treatment loads across multiple halls, leading to missed wound care and, in some cases, documentation that treatments were completed when they were not. One resident with complex wounds did not receive ordered daily leg dressings, another dependent resident was bathed only twice in 18 days, and a resident with a urinary catheter continued to have catheter care documented after the catheter had been removed by a urologist, with later orders to remove the catheter not carried out promptly. High staff turnover and miscommunication contributed to these care and documentation failures.
The facility failed to provide adequate nursing staff to meet residents’ needs in a timely manner, resulting in prolonged waits for assistance with meals, toileting, and call light responses. Multiple residents and a family member reported delayed call light response, lack of timely help with ambulation and incontinence care, and concerns about safety. Surveyors observed several residents waiting extended periods between breakfast tray delivery and staff assistance, with food left uncovered and no offers to reheat or provide alternatives, while only two CNAs assisted about 13 residents in the dining room. Staff interviews confirmed that CNAs had to finish serving other residents before helping those needing feeding assistance, causing breakfast to be served much later than residents preferred. During meal periods, most CNAs were pulled into the dining room, leaving one CNA to monitor the hall, respond to call lights, and feed a resident, which led to call lights remaining unanswered for over 20 minutes and residents waiting in soiled briefs or in the bathroom without timely help.
The facility failed to maintain continuous licensed nurse coverage and adequate CNA staffing, resulting in periods when no nurse was present in the building and routine delays in care. On one afternoon, all nurses left the building, leaving dozens of residents without access to a nurse while they requested medications and IV care. Multiple CNAs, LPNs, and residents reported chronic understaffing, especially on nights, with only one CNA per hall and two nurses and two CNAs for nearly 70 residents, causing late medications, delayed incontinence care, missed showers, prolonged call-light response times, and residents remaining in bed or on the toilet for extended periods. Residents also described inadequate supervision, including confused residents wandering into rooms, and a resident with a PICC line reported walking the halls with IV tubing hanging from her arm without finding a nurse. The admission agreement promised 24-hour nursing care and assistance with ADLs, but the facility assessment did not specify needed licensed nurse numbers or detailed recruitment and contingency plans, despite acknowledged staffing chaos and high-acuity residents requiring intensive supervision and assistance.
A resident with severe cognitive impairment, dysphagia, and total dependence for ADLs was brought to the dining room in an open-back hospital gown, leaving the resident exposed, and left sitting alone with a full breakfast tray and no staff assistance for an extended period. Breakfast had been delivered earlier, but no staff were present in the dining area, and the resident, who required full assistance with eating, was not fed until a CNA arrived from another unit and provided feeding without reheating the food. Staff interviews indicated there were not enough personnel or time to dress the resident appropriately before breakfast and that morning medication pass limited nurses’ ability to assist with feeding, despite a facility policy requiring care that maintains resident dignity and privacy.
The facility failed to maintain adequate nursing staff and to respond promptly to resident call lights. Staffing records showed that nurse staffing fell below the facility’s minimum requirement on multiple days, and call light logs documented that dozens of residents had call lights activated for more than 30 minutes before staff responded. Several residents reported routinely waiting over 30 minutes for assistance after activating their call lights. The facility’s own policy requires timely response to call lights by any staff who see or hear them, but this was not consistently followed.
Insufficient Nursing Staff Leading to Delayed Call Responses and Unsafe Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet resident needs, resulting in delayed call light responses and unsafe operation of mechanical lifts. Multiple residents reported that there was not enough staff on various shifts and that call lights often took from 30 minutes to over two hours to be answered. Surveyors directly observed a resident on airborne precautions for COVID-19 activate her call light, which remained unanswered for approximately 26 minutes while various staff, including regional RNs and the Assistant DON, walked past the room without responding. The resident later stated that it took over 30 minutes to answer her call light because she was on isolation for COVID-19. Additional resident interviews corroborated ongoing delays in call light response and care. Several residents stated that care was rushed, call lights took from 30 minutes to an hour or more to be answered, and that this occurred particularly on night shift. Some residents also reported problems receiving medications timely, including evening medications and other scheduled meds. During a Resident Council meeting, multiple residents stated that call light response time was always a long wait and that staff had assignments that were too large, with one resident reiterating that when she had COVID-19 she felt staff did not want to take the time to don PPE and enter her room. Surveyors also observed unsafe use of mechanical lift devices related to staffing. One CNA was seen operating a mechanical lift alone to transfer a resident from wheelchair to bed, with no other staff present, despite the CNA later claiming another aide had briefly assisted. Another CNA confirmed she did not assist because she had to return to another unit and that the CNA using the lift was the only aide assigned to that hall. Residents reported that staff routinely transferred them with only one person operating the lift because there was only ever one aide on the hall. In another instance, a resident twice activated her call light requesting to be changed; a medical records coordinator entered, deactivated the call light each time after being told the resident needed changing, but did not provide care. No staff entered for approximately 34 minutes after the initial request, and the medication aide later stated she was unaware the resident needed to be changed, indicating the need was not communicated or addressed when the call light was turned off.
Insufficient Staffing Leading to Delayed Care, Missed Treatments, and Documentation Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure timely, complete care and accurate documentation. On the initial survey day, staffing consisted of one medication tech, one RN, three LPNs, and five CNAs for 57 residents. The facility assessment identified that 27.9% of residents were clinically complex and that the facility was responsible for a full range of care and services, but the staffing assessment did not specify the number of staff needed per shift. Resident council minutes over multiple months documented ongoing concerns about delayed call light response, lack of aides for showers, aides using phones instead of assisting residents, and staff hiding to avoid work. A CNP reported that her provider group had repeatedly met with the management company about concerns for resident care and attributed some challenges to staffing turnover. Multiple residents and family members reported that the facility was understaffed, especially on nights and weekends, resulting in long delays in call light response and missed care. One resident stated there was often only one aide at night for two halls and that call lights could take over 30 minutes to be answered. Another resident reported waiting up to five hours for a call light to be answered and noted that a staff member transferred him alone with a mechanical lift. A family member reported finding a resident lying on a mattress with no sheet and not being turned, repositioned, or gotten up. Other residents reported that there were not enough staff, that call lights took a long time to be answered, and that on afternoons and weekends response times could be one to two hours. In a special resident council meeting, residents described having to help other residents who were sliding out of chairs because no staff were present and tracking their own shower schedules because showers were not being provided as planned. Staff interviews corroborated that staffing levels were often inadequate and that required care could not be completed. LPN supervisors and CNAs reported that at times there was only one aide on a hall with multiple residents requiring mechanical lifts, and that mechanical lifts were sometimes performed by a single staff member despite facility policy requiring two staff. Staff stated that when there were call-offs, they were expected to work short, leading to missed showers, inability to turn and reposition residents or provide incontinence care every two hours, and delayed call light response. Nurses reported that heavy treatment loads and being responsible for multiple halls made it difficult to complete all ordered treatments and medications. One CNA stated that staffing had only recently improved with a new DON, and that previously there were not enough staff to safely transfer dependent residents with two staff as required. Specific resident records and observations showed missed treatments and inadequate hygiene care linked to staffing and workload. One resident with morbid obesity, diabetes, heart failure, and chronic bilateral lower extremity wounds had physician orders for daily leg dressings, but surveyors observed dressings dated four days prior, and the treatment record showed missed or undocumented treatments in March and April. The LPN responsible for one missed treatment day stated the hall had a heavy treatment load and she was too busy to complete the dressings; another LPN admitted documenting that treatments were done on two days when they were not, explaining that working two halls and admissions made it difficult to complete all treatments and that she typically signed off treatments before actually doing them. Another resident, incontinent and dependent for toileting and transfers, reported waiting 2–4 hours for call light response, lying in urine for long periods, and not being gotten up at his preferred time, with aides attributing delays to insufficient help; this resident required a mechanical lift, and facility policy required two staff for such transfers. Additional record review showed a resident who was dependent for showers and incontinent of bowel and bladder received only one bed bath and one shower over an 18-day period, despite the regional nurse consultant confirming residents were to be bathed twice weekly and no evidence of additional baths or showers was found. Another resident with metabolic encephalopathy, benign prostatic hyperplasia, and a cognitive communication deficit had a urinary catheter placed for urinary retention and UTI, with catheter care documented as provided for weeks. After a urology visit determined the catheter was no longer needed and it was removed, no new orders were entered to discontinue catheter care, and TAR entries showed catheter care continued to be signed off by multiple nurses even though the catheter was not present. Later, orders were written to remove the catheter and associated orders, but the TAR showed the catheter was not removed over several days and catheter care orders remained. The resident was eventually sent to the hospital with decreased level of consciousness, confusion, and pus and blood at the penile meatus. Nurses interviewed stated the catheter had been in place the entire time they cared for the resident and were unaware of orders to remove it or any complications, while the CNP cited high staff turnover and miscommunication as concerns during that period. Overall, the survey findings showed that insufficient and unstable staffing, combined with lack of a specific staffing plan, led to delayed call light responses, incomplete ADL care, missed or falsified treatments, unsafe one-person mechanical lift transfers, inadequate bathing, and failures in communication and documentation regarding catheter management for multiple residents.
Insufficient Nursing Staff Leading to Delayed Meals and Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs in a timely manner, particularly during meals and in response to call lights. During confidential interviews with 25 residents, nine residents and one family member reported that staffing levels were inadequate to provide timely assistance. Reported concerns included delayed responses to call lights, staff turning off call lights and not returning, lack of assistance with ambulation, and untimely toileting and incontinence care, as well as worries about safety in an emergency. The facility’s staffing policy required adequate staffing on each shift to ensure residents’ needs and services were met, but observations and interviews showed this was not consistently achieved. Multiple observations during breakfast service showed residents waiting extended periods between tray delivery and staff assistance, with food left uncovered and no offers to reheat meals. One resident was seated in the dining room shortly before 9:00 A.M., but her tray was not uncovered until after 9:30 A.M., and staff did not begin assisting her until nearly 10:00 A.M., after which she consumed only a small portion of her meal and was not offered to have it warmed. Another resident had a meal placed in front of her without a cover and did not receive feeding assistance for over 20 minutes; she ate toast with encouragement but stopped after the first bite of eggs, and staff did not offer to warm the food. A third resident’s tray was placed in front of him uncovered, and he did not receive assistance for about 18 minutes; after one bite he refused further food, and no alternative or reheating was offered. CNAs reported that residents who required assistance with eating had to wait until CNAs finished serving other residents on the units, resulting in breakfast often not starting until around 9:30–10:00 A.M. for those needing help, with typically only two staff assisting about 13 residents in the dining room. Additional observations showed delayed responses to call lights and untimely toileting and incontinence care. One resident activated his call light at 11:00 A.M. because he was wet and needed changing; the light remained on until 11:41 A.M., when a CNA returned from break and provided incontinence care, finding the resident’s brief full of urine. The CNA and the DON both acknowledged that a 41‑minute wait was too long. In another instance, a resident’s call light remained on for approximately 25 minutes while she waited for assistance to get out of the bathroom; she eventually ambulated to the nurses’ station to report the delay. A CNA explained that during meals, all but one CNA were required to assist in the dining room, leaving a single CNA to monitor the hall, respond to call lights, and feed a resident, which prevented timely responses to all call lights. Family and therapy staff also reported that residents were receiving breakfast significantly later than they had previously, and that one resident who required one‑on‑one supervision for safe eating could not be accommodated in her room due to insufficient staffing.
Failure to Maintain Continuous Licensed Nurse Coverage and Adequate Staffing
Penalty
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.
Insufficient Staffing Led to Delayed Feeding and Inappropriate Attire in Dining Area
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to maintain the highest practicable psychosocial well-being of a resident who was dependent for all ADLs and required full assistance with eating. The resident had severe cognitive impairment (BIMS score of 0), highly impaired vision, unclear speech, and multiple medical diagnoses including dementia, dysphagia, psychosis, delusional disorder, depression, anxiety, and significant physical limitations such as muscle weakness, difficulty walking, and unsteadiness. The MDS documented that the resident was dependent for eating and all ADLs, required a mechanically altered diet, and needed to be up in a chair for meals with assistance for intake per speech therapy. On the morning of the survey observation, breakfast trays arrived to the memory care unit shortly before 8:00 A.M. At 8:55 A.M., the resident was observed sitting alone in the dining room in a wheelchair, wearing a hospital gown that was open in the back, leaving his back and legs exposed, with a full breakfast tray in front of him. No staff were present in the dining area, and the resident was not feeding himself. A CNA confirmed that the resident had been brought to the dining room in the hospital gown because there was not enough time or enough staff to get him dressed before breakfast, despite knowing this attire was not appropriate for the dining room. The care plan included interventions for fall risk and having the resident eat meals in the all-purpose room for closer monitoring when awake. The resident remained without feeding assistance until 9:23 A.M., when another CNA arrived from a different unit and began feeding him, giving a few bites without reheating the food and then completing the meal. This CNA believed the resident sometimes fed himself and was unsure why he had not been fed earlier, estimating that breakfast trays arrived around 8:00 A.M. An LPN stated that nurses helped feed residents when they could but that mornings were very busy with medication pass, and she believed it was acceptable for a resident to be in the dining area in a hospital gown, even though the resident could not choose his clothing due to cognitive impairment. The resident’s spouse reported that he had required assistance with eating since a recent hospitalization for pneumonia and that she came daily to feed him lunch, noting that staff response could be delayed because they were very busy. The facility’s Dignity, Respect, and Privacy Policy required that residents be treated with respect and cared for in a manner that protected their privacy.
Insufficient Staffing and Delayed Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet resident needs and to ensure timely response to call lights. Review of the facility’s staffing tool showed that staffing levels fell below the Minimum Staffing Requirement on three identified dates. Review of call light system logs for a four-day period showed that 42 residents had call lights that remained activated and unanswered for 30 minutes or longer before staff responded. The facility’s own policy, dated 12/01/25, states that call lights will relay to staff or a centralized location to ensure appropriate response and that all staff who see or hear an activated call light are responsible for responding or notifying appropriate personnel. Multiple resident interviews corroborated the call light data, with several residents reporting that call lights were not responded to in a timely manner and that they often waited more than 30 minutes for a response. These interviews occurred over two days and consistently described prolonged wait times for assistance. The Administrator confirmed that staffing fell below the Minimum Staffing Requirement on the identified dates, and an RN confirmed that 42 residents had call lights unanswered for 30 minutes or longer during the reviewed period. This deficiency was investigated under Complaint Number 2743940.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
