F0725

E

Failure to Provide Sufficient Nursing Staff and Timely Call Light Response

Greenville, Pennsylvania Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff and timely call light response to meet residents’ needs, as required by facility policy and job descriptions. The facility’s call light policy and CNA/RN job descriptions state that staff must respond to call lights and resident needs promptly, check frequently on residents unable to call for help, and that all employees must answer call lights regardless of department. Resident Council minutes over a three‑month period documented repeated concerns that call bells were not answered as timely as residents preferred, particularly on afternoon and midnight shifts. Grievance logs from the same period showed multiple complaints of residents waiting from 30 minutes up to two to three hours for assistance after activating their call bells.

Interviews conducted with multiple residents and a resident representative confirmed ongoing delays of 30 minutes or more in call bell response, with some residents reporting they had stopped using their call bells because staff did not respond. One resident reported waiting two hours for assistance on a specific evening. Another resident stated they had to self‑propel in a wheelchair to the nurses’ station to obtain help. During an observation, a resident with a Foley catheter was found in bed, upset and calling out for a nurse, and reported having activated the call bell approximately 1 hour and 45 minutes earlier due to bleeding; this resident ultimately called 911 and was found by the DON to have bleeding with large blood clots before being transferred to the hospital. The DON acknowledged that all residents should have their call bells answered in a timely manner and that waiting 30 minutes or more for staff response was unacceptable.