Federal inspectors documented the 31-minute delay at Auburn Manor during their February inspection, watching as multiple nurses and staff members ignored the call light outside R14's room. The resident missed her scheduled choir practice and expressed frustration about the facility's response times.
"My light was on for almost an hour," R14 told inspectors. "I need them to get me up. I can't do it by myself. It is frustrating for me. I am late for my activity and am mad about it. They need more help here to get us all up and ready."
The inspection report details a minute-by-minute account of staff ignoring the call light starting at 9:20 a.m. on February 5. Two registered nurses walked past the room multiple times, with one stopping to use hand sanitizer and obtain gloves from a cart directly outside R14's door without acknowledging the illuminated signal.
When a laundry worker finally noticed the call light at 9:46 a.m., they told another staff member but didn't respond themselves, saying "Oh I don't do that." A nursing assistant didn't arrive until 9:51 a.m., apologizing and saying "Sorry I didn't know your light was on."
The nursing assistant explained she was covering two units due to short staffing and working with an agency aide who couldn't document care, slowing down their response times. "I have to prioritize," she told inspectors. "That was unacceptable for her to wait that long. We are responsible for answering call lights. The nurses can answer but don't really."
Multiple residents described similar delays throughout the facility. R33 said call lights could take up to an hour to answer regardless of time of day, causing her to have accidents when she couldn't reach the bathroom in time. "What if I fall and no one comes for how long?" she asked.
The facility's staffing coordinator said call lights should be answered within 10 to 15 minutes maximum, but the director of nursing told inspectors that 30 to 45 minutes was more realistic. "Half an hour is common," the director said. "Things happen and we want to answer them right away. Sometimes we cannot. It is frustrating."
Staff consistently blamed inadequate staffing for the delays. A trained medication aide responsible for 25 residents said the facility recently reduced staffing "to cut costs apparently" and that residents had missed showers as a result. "I don't feel there is enough staff to meet the needs of the residents," she said.
A licensed practical nurse caring for 21 residents said some days she couldn't complete her assigned work, including range of motion exercises. "Sometimes I don't get to it," she said, adding she wasn't surprised when showers weren't completed due to staffing issues.
The facility's staffing plan calls for one aide per 10 residents, increased from the previous ratio of one aide per eight residents. Management recently assigned the staffing coordinator responsibility for both the nursing home and assisted living portions of the building.
Resident council meeting minutes from multiple months showed ongoing complaints about inadequate staffing. During a council meeting with inspectors, residents said "mornings are bad" and "facility has not been responding real well." One resident described call lights as being "like Christmas out here" when multiple signals were illuminated simultaneously.
A registered nurse responsible for reviewing fall reports admitted she often couldn't complete required assessments due to being "pulled to the floor so much due to staff call-ins." She said it was "a chore and a struggle to get all assigned things such as fall reports and admissions done timely."
The facility's infection control nurse, who was also pulled to work regular nursing shifts, missed completing required weekly wound assessments for a resident's injury. She had been out sick for 13 days in December and said the assessments "fell off my radar" because "I get pulled to the floor a lot."
Inspectors also found medication carts left unlocked and unattended in hallways on three separate occasions across multiple units. In one instance, a registered nurse left a cart unlocked for four minutes while responding to a resident who was "hollering." The nurse acknowledged that unattended carts should always be locked "so residents couldn't get into it."
Another nurse forgot to lock a medication cart and told inspectors it contained "important medications that are deadly in there and we don't want anyone to get into there and take whatever they want." A third cart was left unlocked and unattended for over 30 minutes while residents and family members walked past.
The facility failed to offer a recommended pneumococcal vaccination to an 80-something resident with dementia despite CDC guidelines. The infection control nurse said she had spoken with the resident's family member about other vaccines in December but didn't have the proper consent form available at the time and never followed up.
"Part of the reason for the delay in follow-up was possibly due to myself repeatedly being pulled to work on the floor due to call-ins," the nurse explained, calling such circumstances "the way it is now-a-days."
The facility assessment shows Auburn Manor is licensed for 60 beds with an average census of 48 residents. Eighty percent of residents are totally dependent on staff for mobility and require skilled nursing care including range of motion exercises, transfers, and assistance with dressing and feeding.
Federal inspectors also cited the facility for failing to comprehensively reassess fall risks for residents who had sustained multiple falls, though specific details of those incidents were not included in the available inspection narrative.
Family members expressed concern about the staffing levels. The family member of R44, who had sustained several falls since admission, said the falls led him to believe "the facility did not have enough staff to provide adequate supervision."
R4, who required maximum assistance with daily activities, told inspectors she felt the facility was understaffed and "it takes a long time and sometimes they don't come." She expressed frustration that she needed more assistance than she was receiving since her admission.
The director of nursing acknowledged staffing challenges on the day of inspection, saying she had to fill in for a nurse who called in sick and administer morning medications until an evening shift nurse agreed to come in early. The facility does not maintain call light logs or conduct audits to track response times.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Auburn Manor from 2025-02-06 including all violations, facility responses, and corrective action plans.