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F0725
D

Insufficient Staffing Leads to Delayed Call Light Responses

Iowa City, Iowa Survey Completed on 12-15-2025

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 all residents, as evidenced by prolonged call light response times and staff and resident reports of inadequate staffing. Observations showed that call lights in resident rooms remained unanswered for extended periods, such as one instance where a call light was activated at 10:40 AM and not answered until 10:58 AM, and another where a resident's call light was activated at 12:15 PM and not addressed until 12:38 PM. During these periods, residents were observed waiting for assistance, including one resident who was unable to begin eating lunch until staff responded to her call light and assisted her with positioning in bed. Interviews with staff and residents confirmed that staffing levels were insufficient, particularly on the East Hall, where only one aide was scheduled instead of the usual two. Residents reported that call lights often went unanswered for up to an hour on all shifts when staffing was low, and staff corroborated that they sometimes had to work late to complete resident care tasks such as baths. The facility's own policy requires timely response to call lights and holds all staff responsible for responding, but these procedures were not consistently followed due to inadequate staffing.

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