F0550

E

Ongoing Delays in Call Light Response and Failures in Resident Dignity

San Diego, California Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents’ rights to dignity, self-determination, communication, and timely response to call lights. Multiple residents with intact cognition reported prolonged waits, often up to an hour or more, for staff to respond to call lights for medications, toileting, and personal care. One resident with quadriplegia reported routinely waiting an hour or more for call light response and specifically described a 90‑minute wait for medication, stating that long delays in receiving medication or toileting assistance could cause serious complications to her health. Resident Council minutes from October 2025 through February 2026 repeatedly documented resident complaints about delayed call light response, including concerns about registry staff performance, lack of CNA communication during breaks, and difficulty finding available CNAs during some shifts.

Another resident admitted for aftercare following joint replacement surgery and needing assistance with personal care reported that she chose to leave the facility AMA due to call light response problems. She described waiting over an hour for a call light to be answered, and when a staff member finally entered her room, the staff member stated they would get her CNA, even though that staff member was actually the CNA assigned to her. This resident’s room was near the nurses’ station, and she reported hearing staff seated for long periods, laughing and talking, while she waited for assistance. A third resident’s family member documented that call lights often took up to 40 minutes for staff to respond and reported observing three CNAs sitting at the nurses’ station while call lights were alarming. When the family member requested assistance, staff frequently stated that the assigned staff person was on break or busy with other residents and that no other staff were available to help.

Surveyor observations and staff interviews further demonstrated failures in timely and appropriate call light response and respect for resident dignity. During an observation, an admissions employee walked past an active call light without responding and acknowledged that all staff were expected to answer call lights but admitted she had not done so, stating she had kept another resident waiting about an hour. In another observation, a resident in a wheelchair requested help to use the bathroom; a CNA entered, turned off the call light without addressing or looking at the resident, and stated he could not assist because the resident requested female CNAs, acknowledging he should have left the call light on since he could not provide the requested care. A subsequent CNA arrived and spoke to the resident’s private caregiver instead of the resident, later admitting she should have addressed the resident directly and consulted coworkers about the resident’s toileting needs. Additional residents reported that staff routinely turned off call lights and left, with actual assistance often delayed about an hour, and described feeling as though no one could see them or that staff had an attitude when they finally responded. The Activities Director and DON both acknowledged that call light response was an ongoing problem, and the Activities Director stated that additional training and monitoring had not improved the process.