Deficient Staffing and Call Light Response
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the needs of all residents, as evidenced by ongoing and repeated concerns regarding delayed call light response times and inadequate staff coverage. Resident council meeting notes over several months documented persistent complaints from residents about excessive wait times for assistance, with some residents reporting waits of over an hour and instances where staff would turn off call lights without providing the requested help. Observations confirmed that staff sometimes entered rooms, turned off call lights, and left without assisting residents, contrary to facility policy. A review of staffing records indicated the facility had a 1-star staffing rating for the first quarter of 2025. Additionally, a critical incident occurred when an LPN was assaulted by a resident and sustained a concussion. Despite being instructed to seek medical attention, the LPN was unable to leave the facility due to the lack of a replacement licensed nurse. The facility's backup plan for on-call staff was ineffective, as the on-call person was a Qualified Medical Assistant rather than a licensed nurse, and no licensed staff were available to cover the shift. Facility policies required that all staff answer call lights and provide the requested service before turning off the light, and that sufficient staff be available to meet resident needs. However, documentation and interviews revealed that these policies were not consistently followed, resulting in unmet resident needs and inadequate licensed nurse coverage during critical incidents.