F0725

E

Inadequate Night and Weekend Staffing Leading to Prolonged Call Light Response Times

Indianola, Iowa Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain adequate nursing staff on the overnight and weekend shifts, resulting in prolonged call light response times for multiple residents. Surveyors observed that during an overnight shift there were only three CNAs and two nurses in the building until an additional CNA arrived, bringing the CNA count to four for a building with four halls, including an isolated rehab hall staffed by only one person. The facility census was 82 residents. The DON later confirmed that the facility’s expectation was to have five CNAs on the overnight shift, and acknowledged that recent resignations and staff on paternity and maternity leave had led to operating with fewer staff than typical. The facility assessment stated that staffing was to be based on resident acuity and needs, feedback, and use of pool and agency staff as needed.

Multiple cognitively intact residents reported long waits for assistance via call lights, particularly at night and on weekends. One resident who could not get to the bathroom independently stated that while daytime staffing was often sufficient, nighttime staffing was inadequate and call lights were not answered in a timely manner, leading him to feel he had to advocate for other residents. Another resident who was dependent for care reported waiting at least 45 minutes, and possibly over an hour, for assistance after soiling herself, describing this as a daily and nightly occurrence and noting that she felt miserable and ashamed having to sit in urine and feces. A third resident reported that call light response times were usually 45 minutes or longer, especially on nights and weekends, and that she had reduced how often she used her call light because help did not come; she also reported not reliably receiving water at night. Another resident stated that staffing was usually bad at night and that she typically waited over an hour for assistance with going to bed, with night and weekend staff frequently reporting they were short staffed.

Objective call light response logs for several residents over a three-day period showed numerous instances of call lights remaining unanswered for extended periods, including times ranging from approximately 18 minutes to over two hours. Resident council minutes from two separate months documented ongoing resident concerns about insufficient staffing and a desire for call lights to be answered within 15 minutes, showing the facility had been made aware of these issues over time. Staff interviews across multiple CNAs, an RN, and an LPN consistently described the facility as always or frequently short staffed, especially at night and on weekends, with reports of operating with only one CNA per hall and sometimes only two to three CNAs total. Staff stated that the low staffing levels caused slow call light response times and made it impossible to be everywhere they were needed, with one nurse reporting that it could take 45 minutes or more to answer other call lights when they were already responding to one. The DON confirmed the expectation of a 15-minute call light response time and acknowledged that the recent call light times were unacceptable, and also stated there was no chain-of-command protocol when the manager on call was unavailable.