Delayed Call Bell Response Times
Summary
The facility failed to meet the needs of residents in a timely manner, as evidenced by multiple resident complaints and documentation from a Resident Council meeting. During a facility tour and random resident interviews, nine out of eleven residents reported excessive delays in staff response to call bells, with several residents stating they often waited an hour or longer for assistance. Some residents expressed concerns about staff ignoring call lights, sometimes while using their cell phones, and others reported that after long waits, staff would promise to return but did not follow through. The issue of delayed call bell response was also documented in the Resident Council meeting minutes, and the Nursing Home Administrator acknowledged awareness of the problem and agreed that such delays were inappropriate.
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.
