F0725

F

Failure to Maintain Adequate Nursing Staff and Timely Call-Light Response

Grayville, Illinois Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure timely response to call lights. Multiple alert and oriented residents reported waiting 30 minutes to an hour for assistance, particularly on evening and night shifts. One resident stated she intentionally activated her call light to see which staff were working and waited over 30 minutes before the administrator answered her light, noting this type of delay happens frequently in the evenings when there is often only one CNA per hall. Another resident reported waiting over half an hour on several nights for staff to answer her call light, including an occasion when her bed was soaked and she was freezing from lying in urine. A third resident stated she had to wait 30–45 minutes for staff to respond when she needed to be changed and had to lie in urine during the wait, and that this occurs often on both day and evening shifts. A fourth resident reported being on her call light for over 30 minutes after an incontinent episode and ultimately called the nurses’ station before the DON came to assist her, stating that evening call light response can take 30–45 minutes or up to an hour.

Surveyor observations on one evening documented that only two CNAs were initially working the floor, with an agency nurse on duty who had never been at the facility before. One CNA was observed taking residents outside to smoke on the North Hall, leaving no other CNA on that hall. During this time, four call lights were observed going off in separate rooms on the North Hall and remained unanswered for an extended period. The DON directed the CNA to obtain vital signs equipment and assess a sick resident in the dining room while the call lights continued to sound. The CNA then answered the phone and reported that a resident was calling for help. A resident’s voice was later heard yelling for help from the North Hall while the same call lights remained on. It was not until approximately 7:21 p.m. that the CNA entered one of the rooms, followed by the administrator entering another room, and call lights in the affected rooms were gradually turned off. Another CNA arrived later in the evening to assist.

Time clock records and staff interviews further demonstrated staffing shortages. Punch records showed that from just before midnight until 1:42 a.m. on one date, only one CNA and one agency nurse were in the building to care for 45 residents. Multiple CNAs and an RN stated the facility did not have enough staff to adequately care for all residents, describing frequent call-ins, no-shows, and the lack of agency CNAs to cover open shifts. Staff reported that when they worked short, some resident care needs were not completed and that on some nights there was only one CNA on the North Hall and one CNA on the South or memory care unit with one nurse. One CNA confirmed being called in at 1:40 a.m. because only one CNA and one nurse were on duty. Another CNA stated that North Hall was more demanding and that, although the schedule called for multiple CNAs, call-ins often left the facility short without coverage. Despite this, the administrator stated he felt call lights were answered timely and that the facility had enough staff, although he also stated he did not think a single CNA on a hall should be taking residents out to smoke and leaving no staff on the hallway, and he was not aware of the period when only one CNA and one nurse were working overnight.

The facility’s undated staffing policy stated that it is the policy of the facility to provide an adequate number of staff to meet resident needs and to maintain adequate staffing ratios, including scheduling relief staff during vacations, holidays, and relief periods. However, the documented resident reports of prolonged call light response times, observations of unanswered call lights and residents calling out for help, verified periods with only one CNA and one nurse on duty for the entire facility, and staff statements that resident care needs sometimes could not be completed due to insufficient staffing, all occurred despite this written policy.