Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to ensure sufficient nursing staff were on-site to provide necessary nursing services to residents. Multiple entries in the facility's Grievance Log from July to December 2025 documented repeated incidents where residents experienced long call light wait times, were left soiled for extended periods, or did not receive timely assistance with activities of daily living. Specific incidents included residents waiting up to two and a half hours for restroom assistance, being left in soiled clothing for hours, and not having their call lights answered promptly. In one case, a resident was left in the same clothes all weekend, and another was found soiled with urine and stool in their recliner. Staff interviews confirmed ongoing issues with call light response times. The Director of Nursing acknowledged that call lights were a constant problem and that administrative staff were encouraged to assist when possible. Despite audits and education efforts, the administration continued to struggle with finding a solution to the persistent issue of inadequate staffing and delayed response to resident needs.