Failure to Ensure Dignified Care and Timely Call Light Response
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and respect, specifically regarding timely call light response, food palatability, and accessibility of call lights. During a Resident Council meeting, nine residents unanimously reported prolonged call light response times, often averaging 30 minutes or more. Residents described instances where staff would turn off call lights and promise to return but failed to do so, leaving residents waiting for assistance with activities of daily living (ADLs). Staff were also observed talking loudly, using cell phones, and gathering at the nurse's station while residents waited for help. Some residents reported being left soiled and wet for extended periods, and staff sometimes gave false reasons for delays, such as claiming equipment was unavailable when it was not. Residents also expressed dissatisfaction with the quality and variety of food, noting repetitive menus and unappetizing meals. They reported that alternative meal options often consisted of leftovers from previous meals, and that bedtime snacks were either not provided or only available if residents went to the nurse's station themselves. These concerns were consistently raised in Resident Council meetings from December to May, but meeting minutes showed a lack of follow-up or resolution. The March meeting was not held due to a COVID-19 outbreak, and there was no documentation of attempts to address the issues or communicate with the Resident Council president. Specific resident observations further supported these findings. One resident, who was cognitively intact and had a history of chronic embolism, muscle weakness, and dysphagia, reported average wait times of over 30 minutes for call light response and noted that staff sometimes did not return after turning off the call light. Another resident was found unable to locate his call light, which was on the floor and out of reach, despite housekeeping staff entering and exiting the room without noticing. A nurse aide eventually found and repositioned the call light. These events demonstrate the facility's failure to maintain an environment that promotes dignity, timely care, and respect for residents' rights.