Delayed Call Light Response and Resident Fall
Summary
The facility failed to ensure that call lights were answered in an appropriate timeframe for three residents, leading to significant delays in response times. Resident #10 reported waiting up to 20 minutes for assistance, particularly during shift changes or after 6:00 p.m., and noted that staff would sometimes turn off the call light without addressing all her needs. The facility's call history confirmed that eight out of fifteen call light uses for this resident exceeded 15 minutes, with some waits extending up to an hour. Resident #6 also experienced prolonged wait times, with 13 out of 14 call light uses exceeding 15 minutes, including one instance of a two-hour wait. Resident #5 reported waiting over 45 minutes for assistance, and in one instance, attempted to get up without staff help, resulting in a fall. The call history for this resident showed multiple instances of extended wait times, including a 59-minute wait. The facility's expectation for call lights to be answered was stated to be seven to nine minutes, as per staff member A. However, the documented wait times for the residents significantly exceeded this expectation, indicating a failure in the facility's response system. The delays in responding to call lights not only compromised the residents' ability to have their needs met promptly but also contributed to a fall incident for one resident who attempted to move without assistance due to the prolonged wait.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
