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F0725
D

Delayed Call Light Response Due to Insufficient Nursing Staff

Mandan, North Dakota Survey Completed on 07-28-2025

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 residents who required staff assistance, as evidenced by multiple instances of delayed responses to call lights. Observations and call light logs showed that several residents waited between 25 minutes to over three hours for staff to respond after activating their call lights. For example, one resident's call light was activated at 7:52 p.m. and staff responded one hour and 30 minutes later, while another resident waited over three hours for assistance. These delays were confirmed by both direct observation and review of facility call light logs. A confidential staff member reported being consistently short-staffed, resulting in residents crying and remaining in soiled conditions due to the lack of timely assistance. An administrative staff member stated that the expectation was for call lights to be answered within 15-20 minutes, which was not met in these cases. The facility's own policy and assessment indicated that adequate staffing should be provided to ensure resident safety and well-being, but the documented delays and staff interviews demonstrated that this standard was not maintained for several residents.

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