F0550

E

Failure to Timely Respond to Resident Call Lights

Sherman, Texas Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure resident call lights were answered within a reasonable time, affecting three residents who relied on the call system for assistance. During initial rounds, surveyors observed two active call lights on the panel at the nurse’s station while three staff members sat at the station typing on computers without attempting to respond. One resident, who used a wheelchair and had diagnoses including muscle weakness, unsteadiness, lack of coordination, hyperlipidemia, and erosive osteoarthritis, reported that call light response times usually ranged from 15–30 minutes and sometimes up to an hour. At his request, his call light was activated and remained unanswered for approximately 23 minutes while staff, including an RN and the Facility Administrator, were present and made no attempt to respond.

A floor technician reported that while working in laundry and housekeeping, he frequently observed residents waiting 30 minutes to an hour or longer for call lights to be answered, and that residents sometimes asked him to get a nurse because their call lights had been on for an hour without response. On the same day, staffing records showed four CNAs on duty for the morning shift, all of whom were observed in the dining room passing trays at noon, with no staff member observed as assigned to answer call lights during the meal. Multiple staff, including an RN, a CMA, and a CNA, stated that everyone could answer call lights and that there was no reason for licensed nurses not to respond, and one CMA stated her expectation that call lights should be answered within ten minutes. However, surveyors repeatedly observed active call lights on the panel with no attempts by available staff, including RNs and LVNs, to answer them.

Two additional residents, both alert and oriented with BIMS scores of 15, reported prolonged call light response times. One resident, with a history of stroke, unsteadiness, lack of coordination, and wheelchair use, stated that call lights were answered anywhere from 15 minutes to one and one-half hours and activated his call light during the interview; another resident, who was blind with multiple diagnoses including repeated falls, myocardial infarction, anxiety disorder, muscle weakness, lack of coordination, cancer, hypertension, and polyneuropathy, stated that it took too long for call lights to be answered and that her family member sometimes had to help her lift her legs into bed. Both residents’ call lights remained unanswered at the end of a 45-minute interview. Later observations again showed two room call lights active while an RN, an LVN, and a CNA sat at the nurse’s station typing on computers without responding. In an interview with leadership staff, it was confirmed that the facility had no policy or procedure for any staff member regarding answering active call lights and assisting residents with needs and activities of daily living.