F0725

F

Insufficient Staffing Leading to Prolonged Call Light Delays and Inadequate Incontinence Care

Peoria Heights, Illinois Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to respond to call lights in a timely manner, as required by its own facility assessment and policies. The Facility Assessment Tool specified that all residents required assistance with activities of daily living and that the facility would staff an average of five CNAs on day shift, five on evening shift, and three on night shift, totaling 104 CNA direct care hours daily. Staffing data submitted by corporate leadership showed that on multiple dates the facility provided only 73.5 to 80.25 CNA hours, below the assessed need. CNAs and an LPN reported that staffing on evening and night shifts was often as low as two to three CNAs, and at times only one CNA and one nurse on nights, with heavy reliance on agency staff whom they described as less efficient.

Residents, family, and the Ombudsman reported repeated problems with long call light response times and unmet care needs. Resident council minutes documented ongoing complaints about long waits for staff, problems with passing ice water, and poor customer service when answering call lights and following through on requests. The Ombudsman stated that residents complain about call light waiting times at every council meeting, and a resident council leader reported that for the last four meetings residents complained about call lights not being answered timely and having to sit in urine and feces for long periods, particularly on second and third shifts. During one observation period, a resident’s call light remained on for over 30 minutes without response.

Individual residents and staff described specific instances of inadequate care linked to low staffing. One resident’s guardian reported having to prompt staff to turn and clean the resident, stating that turning sometimes occurred only every three to five hours and that staff placed two disposable briefs on the resident so they would not have to change the resident as often; this resident was observed wearing two briefs. Another resident reported lying in urine and feces for hours when call lights were not answered, being left on a bedpan for up to two hours, and being told staff could not get the resident out of bed because it required two staff and there were not enough staff. A different resident reported repeatedly sitting in urine and feces for extended periods, including one episode where the call light was activated mid-afternoon and not answered for about three hours, and stated that staff frequently said there was not enough staff and that the resident would have to wait. CNAs corroborated that call lights could go unanswered for an hour or longer, that residents were placed in double briefs to reduce the frequency of changes, and that when they reported short staffing, management told them to “make it work.”