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F0725
D

Insufficient Staffing Resulting in Delayed Resident Care and Call Light Response

Dekalb, Illinois Survey Completed on 05-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the care needs of residents, as evidenced by multiple residents reporting long wait times for call light responses and delays in receiving personal care. One resident with hemiplegia and weakness reported waiting from 4:00AM until almost 10:00AM to be cleaned after a bowel movement, with staff confirming that they were behind in getting residents up and passing meal trays due to staffing shortages. Another resident dependent on assistive devices reported inconsistent staffing and waiting 30-45 minutes for call light responses. A third resident with quadriplegia and reduced mobility stated that call light wait times could reach up to 30 minutes, especially on weekends, and that staff did not round every two hours as expected. Staff interviews confirmed that there were multiple call-ins from CNAs, requiring agency staff and additional help to be called in, resulting in delays of 60-90 minutes to catch up with resident care. The DON acknowledged that call lights should be answered within 5 minutes and that residents should not be left in stool. Resident Council Minutes from several months documented ongoing concerns from residents about untimely call light responses and requests for more consistent rounding and communication from staff. The facility's policy on Activities of Daily Living states that care, treatment, and services should be provided to each resident, but the observed staffing levels did not meet these standards.

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