F0725

F

Inadequate Staffing Leading to Prolonged Call-Light Delays and DON Working as Charge Nurse

Johnston, Iowa Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate nursing staff on a daily basis to meet resident needs and to ensure appropriate licensed nurse coverage on each shift. Surveyors documented prolonged call-light response times, closure of a dining room due to low staffing, reports of staff sleeping while on duty, and the DON functioning as a charge nurse despite a census over 60 residents. The facility census was 124. Multiple residents with varying levels of cognition, as measured by BIMS scores ranging from moderate impairment to fully intact cognition, reported frequent and extended delays in receiving assistance, particularly during nights and weekends.

Direct observation on one evening showed a resident’s call light in a specific room being activated repeatedly over more than an hour, with staff entering the room briefly several times, turning off the call light, and leaving within seconds without addressing the resident’s needs. When interviewed, the resident in that room stated that staff had not addressed her request for a bath or bed bath and that she had been using her call light for about an hour without receiving help or an explanation. She reported that staff entered only to turn off the call light without speaking to her and expressed frustration with this pattern. Resident Council minutes over several months documented repeated concerns about missed showers/baths, lack of fresh water, staff using cell phones while on duty, and long call-light response times.

Multiple residents reported that call-light response times were frequently 30 minutes to several hours, with nights and weekends identified as the worst periods. Several residents described waiting one to three hours for assistance with changing soiled incontinence briefs or getting off the toilet, and two residents reported that the North East dining room was closed on a recent weekend due to insufficient staff, resulting in residents being required to eat in their rooms. Residents also reported directly observing staff members sleeping on the job, including specific times and locations, and stated they had repeatedly reported these issues to administration and through Resident Council without perceiving improvement. Staff interviews corroborated that staffing was often inadequate, especially on nights and weekends, that call-light response could take hours, and that call-ins were frequent.

Staff members, including CNAs and RNs, reported working short-handed once or twice a week or more, particularly on overnight and weekend shifts, and stated that the DON had been working the floor to cover open shifts. Review of staffing records confirmed that the DON worked the floor on at least two dates, despite regulations prohibiting the DON from serving as a charge nurse when the average daily census exceeds 60 residents. Several staff and residents reported staff sleeping on duty or appearing to sleep at the nurses’ station, and some staff stated they had reported these incidents to the DON. The facility’s Rules of Conduct policy identified sleeping or giving the appearance of sleeping on the job as an unsatisfactory behavior warranting termination. The ADON stated that staff were prohibited from sleeping on the job and that the expectation was for call lights to be answered within 15 minutes, but the observed and reported delays and staffing practices demonstrated that this expectation was not being met.