F0725

E

Insufficient Nursing Staff Leading to Missed Feeding Assistance and Delayed Call Light Response

Signal Hill, California Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, including failure to ensure documented feeding assistance for a dependent resident and timely response to call lights. One resident was admitted with multiple diagnoses including a left tibia medial malleolus fracture, GERD, dementia, and muscle weakness, and had an MDS showing moderately impaired cognition and dependence on staff for all ADLs. This resident had orders for a fortified mechanical soft diet with thin liquids and participation in a restorative nursing assistant feeding program. However, review of the resident’s February documentation showed no documented evidence that the resident was assisted with meals three times a day on a specific date, including breakfast and lunch, despite the resident’s dependence on staff for feeding.

Additional evidence of insufficient staffing came from resident council meeting minutes on two dates, which documented concerns that call lights were not being answered in a timely manner. A family member reported during a phone interview that there were not enough nurses to help residents, particularly on weekends, which delayed care and services. During interviews and record reviews, the RN supervisor confirmed the lack of documented meal assistance for the dependent resident on the identified date, and the DON confirmed that Certified Nurse Assistant DHPPD on several dates, including the date of missing meal assistance documentation, were below the required 2.4 hours per patient day. The DON stated that short staffing affected resident care. The facility’s own staffing policy indicated it would provide enough nursing staff to deliver nursing and related care services for all residents, which was not met on the identified dates.