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F0725
H

Failure to Provide Sufficient Nursing Staff Resulting in Delayed Resident Care

Morton, Illinois Survey Completed on 08-21-2025

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 needs of all residents, as evidenced by multiple documented instances of delayed responses to call lights and toileting assistance. The facility's own Call Light policy requires timely responses, especially for bathroom lights, which are to be treated as emergencies. However, interviews with staff, including LPNs and CNAs, revealed that frequent staff call-ins and understaffing led to longer wait times for residents. Residents reported waiting extended periods, sometimes up to three hours, for assistance with toileting and call lights, resulting in residents remaining in soiled briefs for prolonged periods. The Activity Director confirmed that concerns about delayed call light responses were raised in resident council meetings but were not documented in the minutes as instructed by previous administration. Review of facility records, including Daily Assignment Sheets and the Facility Assessment, showed that the facility was consistently short of the required nursing hours on several days, with shortages ranging from 33 to 47.1 hours per day based on their own staffing calculations. The Regional Director of Operations confirmed these staffing shortages. Resident complaints documented in concern forms and interviews further corroborated the impact of insufficient staffing, with reports of residents being told to wait for assistance and experiencing significant delays in care.

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