F0725

E

Insufficient Nursing Staff Leading to Prolonged Call Light Response Times

Maryville, Missouri Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff, including aides, to respond to residents’ call lights in a timely manner, despite policies requiring staffing based on resident needs and prompt call light response. The facility’s staffing policy states that staffing levels and competencies must be determined by resident care plans and the facility assessment, and its call light policy requires staff to respond promptly, ideally completing requests within five minutes when possible. However, staffing schedules on multiple dates showed only one nurse on duty from 6:00 P.M. to 6:00 A.M., with the DON working as a nurse aide during those hours, and on one date only one nurse and one nurse aide were scheduled overnight, even though 19 of 30 residents required assistance with care.

Resident #1, who had intact cognition, limited physical mobility related to cerebral palsy, and required assistance with transfers to the toilet but was continent of bowel and bladder, experienced prolonged call light response times. Call light logs showed that on three separate dates, staff took between approximately 35 and 48 minutes to turn off the resident’s call light. The resident reported that there were not enough staff to care for him/her, that he/she had waited so long for staff to respond that he/she wet the bed, and that this caused frustration and embarrassment because he/she could remain continent if staff assisted to the bathroom in time.

Resident #2, cognitively intact with limited mobility due to weakness and COPD, at risk for falls, and dependent on staff for ADLs, had multiple call light activations with response times ranging from about 42 to nearly 100 minutes. The resident stated there was not enough staff, that call lights sometimes took one and a half to two hours to be answered, and that he/she was frustrated and could not count on staff to respond. Resident #3, cognitively intact with an unsteady gait, multiple prior falls, and urinary incontinence related to impaired mobility, also experienced delayed responses, including waits of about 32 and 56 minutes, and reported wetting his/her pants while waiting, feeling angry and embarrassed. Multiple staff, including CNAs, an RN, and an anonymous staff member, reported that staffing had been consistently short, that several staff had quit due to heavy workloads, and that attempts to obtain agency staff were not allowed. The DON confirmed she frequently worked as a charge nurse or aide due to low staffing and acknowledged that the facility’s goal of answering call lights within 5–15 minutes was not being met with current staffing levels.