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F0725
E

Delayed Call Light Responses Due to Insufficient Staffing

Randolph, Nebraska Survey Completed on 11-24-2025

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 timely responses to resident call lights, as evidenced by multiple documented instances where residents waited significantly longer than the facility's expected response time of 10 minutes. The facility's Resident Call Light Policy requires staff to respond to call lights as timely as possible and to ensure all residents have access to a functional and responsive call light system. However, review of call light response logs revealed numerous occasions where call lights were left unanswered for periods ranging from over 10 minutes to more than an hour. One resident, who was cognitively intact and dependent on staff for all activities of daily living due to conditions such as quadriplegia and pressure ulcers, experienced repeated delays in call light responses, with several instances exceeding 30 minutes and some over an hour. Another resident with heart failure and dependent on staff for bathing and toileting reported waiting up to 30 minutes for assistance, particularly during evening shifts. A third resident with spina bifida and paraplegia, who required assistance with personal hygiene and dressing, also reported frequent long waits for call light responses, including a documented grievance where the call light was not answered for 56 minutes. This resident indicated that the issue persisted, especially during certain shifts, and that submitting a grievance did not result in any noticeable changes. Interviews with the affected residents confirmed their experiences of delayed responses, with particular concern for insufficient staffing during evening shifts. The administrator acknowledged that the facility's expectation was for call lights to be answered within 10 minutes and confirmed that the documented response times did not meet this standard. There was also a lack of evidence that grievances related to call light response times were investigated or addressed.

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