F0725

E

Insufficient Nursing Staff Leading to Delayed Call Light Response and Missed Hygiene Care

Perry, Iowa Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs in a timely manner, resulting in delayed responses to call lights and missed or delayed bathing and hygiene care. Multiple cognitively intact residents, as evidenced by BIMS scores of 14–15, reported extended wait times for assistance and missed showers. One resident stated she waited about 20 minutes after activating her call light to use the commode and ultimately had to go to the nurses’ station to find staff to bring in her commode; she also reported waiting approximately 30 minutes on other occasions for post-toileting hygiene assistance and documented specific dates when this occurred. Another resident reported missing showers because the facility was short staffed and stated that records showed her as refusing showers even though they were not offered; facility grievance documentation confirmed that this resident did not receive a shower for one week and that the last shower documented for her was several days earlier.

Additional residents described frequent long call light response times and inadequate staffing patterns. One resident reported that when staff were busy putting other residents to bed, she was told she would have to wait, and she stated that long call light waits of over 15 minutes occurred daily, with her roommate reportedly waiting up to an hour for care. She also reported that typical staffing consisted of two CNAs, one CMA, and one nurse, and that on the day of the survey there were five CNAs on the floor, which she believed was due to the surveyors’ presence. Another resident reported not being offered a scheduled bath on a specific evening due to staffing issues related to staff call-ins; she stated that an agency aide had to stay over on a later date to provide her second shower of the week and described feeling unclean, with stringy hair and itching skin. She also reported that staffing had been poor enough that the HR staff member had to work on the floor.

Review of facility staffing records and interviews with staff and management corroborated that staffing levels were frequently below the facility’s own assessment and staffing plan. The facility assessment for a census of 32 residents called for four CNAs on dayshift, three on evenings, and two on nights, along with one nurse on each shift and a CMA on days and evenings. However, daily nursing assignment sheets for multiple dates showed only one to three CNAs on the day shift, with additional CNAs not starting until mid-morning on some days, and some days with as few as one CNA for part of the shift. The Social Services Director reported that staffing had been “very rough,” with dayshift sometimes having only one or two CNAs, requiring her and the HR Director, both CNAs, to help on the floor and resulting in call light response times of 15–20 minutes. The Administrator acknowledged that dayshift staffing had been “sketchy and rough,” particularly from 6 a.m. to 10 a.m., and that management staff, including herself, HR, and Social Services, often had to assist with direct care. The ADON stated that the expectation was to answer call lights as soon as possible within 15 minutes, but that there had been resident complaints about long call light waits on days with fewer than three CNAs, and that call lights were more problematic on weekends. The facility’s call light policy required immediate response and completion of resident requests within five minutes when possible, which was not consistently achieved under the documented staffing conditions.