F0725

F

Insufficient Evening Staffing Led to Delayed Call-Light Response and Care

Metropolis, Illinois Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on the evening shift to meet residents’ needs and to ensure timely response to call lights. On the night of 02/27/26, there were 62 residents in the facility, with one CNA assigned to the 100 hall and one CNA to the 200 hall, and one LPN (V5) passing medications on both halls. Observations between approximately 9:00 PM and 10:07 PM showed repeated instances of call lights activating and residents yelling for assistance while V5 attempted to complete a medication pass. V5 repeatedly had to stop preparing and administering medications to respond to call lights and residents calling out, as no other staff were visible on the halls during much of this time. One resident (R1) was observed asleep in a wheeled recliner at the nurses’ station at 9:04 PM and was not taken back to her room until approximately 9:50 PM.

Additional observations documented multiple residents yelling for a nurse or CNA and several call lights going unanswered for periods while V5 continued to juggle medication administration and responding to calls. Around 9:57 PM and again at 9:59 PM and 10:07 PM, two call lights were activated at a time and residents, including R5, were heard yelling in the hallway for help and to talk to someone. R1 was taken to her room by CNA V6 around 9:50 PM and then brought back to the nurses’ station shortly thereafter, with her clothes changed and mumbling to herself. Staff interviews confirmed that on 02/27/26 there was one CNA on each hall, and CNAs had to go back and forth between halls to assist each other, including for residents requiring two-person assistance.

Resident and staff interviews, along with staffing records, further supported that staffing levels were insufficient at times to meet residents’ needs in a timely manner. One resident (R6), who was alert and oriented, reported having to wait over 30 minutes at times for assistance with toileting and changing, and stated that staff sometimes did not have time to provide a bed bath, leading him to use wipes to clean himself. Another resident (R8), also alert and oriented, reported having to wait quite a while in the afternoon and evening for help. A grievance form for R6 dated 02/17/26 documented a concern about call lights not being answered timely. CNAs V6 and V7 stated that having only one CNA on each hall can make it challenging to answer all call lights and meet care needs promptly, especially when residents such as R1 and R5 or those requiring two-person assists need more attention. The DON (V2) and Regional Nurse (V17) acknowledged that staffing is based on census, that there are times with only one CNA per hall due to call-ins or no-shows, and that this situation can be very challenging for timely completion of required duties such as answering call lights, toileting, changing, dining assistance, and showers.