F0550

G

Failure to Respond Promptly to Call Lights and Provide Timely Incontinence Care

Peoria Heights, Illinois Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor residents’ rights to dignity and timely care by not responding promptly to call lights and not providing timely incontinence care. Facility policies on dignity, incontinence care, and call light response require that residents be treated with respect, checked for incontinence approximately every two hours, and that call lights be answered promptly by all staff. Despite these policies, the Ombudsman and a resident council representative reported ongoing complaints over multiple resident council meetings about long call light wait times and residents having to sit in urine and feces for extended periods, particularly on second and third shifts when staffing was reportedly short.

One resident, a cognitively intact female with multiple medical conditions including periprosthetic fracture, diabetes, osteoporosis, and muscle wasting, was dependent on staff for ADLs and toileting hygiene and frequently incontinent of bowel and bladder. Her care plan required dependent assistance and use of a mechanical lift with two staff for transfers. She reported lying in urine and feces for hours before staff answered her call light, sometimes waiting more than two and a half hours to be cleaned after an incontinence episode. She also stated that when staff placed her on a bedpan, they often did not return for up to two hours, leaving her sitting on the bedpan in pain. She described feeling embarrassed, ashamed, humiliated, and disgusted, and reported that staff repeatedly told her they did not have enough staff to change everyone timely. Nursing staff and an occupational therapist corroborated that she had to wait extended periods, especially on nights, due to staffing.

Another resident, a male with a history of intracerebral hemorrhage, acute kidney failure, muscle wasting, hypertension, and other conditions, was dependent on staff for ADLs, required substantial to maximum assistance with toileting hygiene and transfers, and was occasionally incontinent of bladder and frequently incontinent of bowel. During one observation period, his call light remained on for at least 30–40 minutes. He stated that a CNA had come in about 25 minutes earlier, was told he was wet and had defecated, said she would get washcloths and return, but never came back, leaving him lying in his own feces. He reported that this happened frequently, describing his feelings as disgusted and like “hell,” and recounted a prior episode where he turned on his call light after soiling himself and waited approximately three hours before staff responded, during which his buttocks were burning and sore. CNAs acknowledged that his call light had been on for a long time, that staff sometimes answer call lights and then fail to return, and that limited staffing and competing tasks made it hard to respond to all residents timely. The corporate interim DON stated that call lights should be answered as soon as possible and that 30–45 minutes was too long for a call light to go unanswered.