Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to answer call lights in a timely manner for three residents, as evidenced by grievance logs and resident council minutes documenting extended wait times for assistance. Grievance logs from October, November, and December 2025 recorded multiple instances where residents waited prolonged periods for help with various activities. Resident council minutes from December 2025 noted that staff needed to respond to call lights more quickly, with 13 residents present at the meeting. Interviews with residents and family members confirmed delays, including one resident who did not have a standard call light but instead used a bell that went unanswered several times. Medical records and interviews provided further details about the affected residents. One resident, admitted with multiple diagnoses including weakness, hemiparesis, cognitive decline, and multiple sclerosis, lacked an admission assessment or note from a licensed nurse during their stay. Another resident with cognitive impairment reported call light response times ranging from 30 minutes to two hours. A third resident, cognitively intact, also reported waiting up to two hours for assistance. Facility policy and statements from the corporate nurse and DON indicated that call lights should be answered within 10-15 minutes, but this standard was not met.