Failure to Provide Sufficient Staff for Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure timely responses to resident call lights across three hallways (100, 300, and 400). Observations revealed that call lights were illuminated in multiple rooms without any audible alert at the nurses' station, and staff interviews confirmed that the 400 hall call lights were not audible. Multiple residents reported excessive wait times for call light responses, with some stating they waited up to an hour or more, particularly during night shifts. Resident Council meeting minutes over several months consistently documented ongoing concerns about delayed call light responses, including instances where staff turned off call lights without returning and prolonged waits when residents were in the bathroom or required urgent assistance, such as for oxygen needs. The facility's grievance logs from January through May 2025 showed a recurring pattern of complaints related to call light wait times, with the number of grievances increasing over time. Staff interviews acknowledged awareness of the staffing issues and the impact on call light response times. The combination of insufficient staffing, non-functioning audible call light systems, and repeated resident and family complaints contributed to the deficiency, placing residents at risk for accidents, injuries, and diminished quality of life.