F0677

D

Failure to Provide Timely Assistance With Toileting and Call Bell Response

Elkridge, Maryland Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The facility failed to provide timely assistance with activities of daily living (ADLs), specifically toileting, to a resident who required staff help. The resident, admitted in January 2026 with hemiplegia and hemiparesis affecting the left non-dominant side, muscle weakness, difficulty walking, and lack of coordination, reported long wait times for staff to respond to the call bell when needing restroom assistance. Due to these delays, the resident stated they attempted to use the restroom without assistance and fell on multiple occasions. Record review showed the resident had unwitnessed falls in January and February 2026, and the baseline care plan from January 2026 documented a need for one-person assistance with transfers. An MDS from January 2026 indicated upper and lower extremity impairment and a need for partial to moderate assistance with toilet transfers.

The care plan documented a fall on 01/21/2026 and included a goal initiated on 01/22/2026 for the resident to use the call bell and wait for staff assistance. During an interview, the Administrator stated that staff are expected to respond to call bells immediately, but no longer than 20 minutes. Review of the call bell response log for the resident’s room between January and February 2026 revealed multiple instances where response times exceeded 20 minutes. On 02/09/2026, the call bell was activated at 6:59 PM and staff responded 24.31 minutes later. A GNA reported that the facility was not adequately staffed to meet residents’ care needs. The resident’s family member reported that the resident, who was continent of bowel and bladder at admission, had episodes of incontinence attributed to prolonged call bell response times. These findings were reviewed with the Administrator on 02/11/2026.