F0677

D

Failure to Provide Timely ADL Assistance and Call Light Response for Multiple Residents

Livonia, Michigan Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs) and to respond promptly and appropriately to call lights for multiple residents. One resident with right-sided paralysis, stroke, and heart disease, who required partial to moderate assistance for mobility, reported that on afternoon and night shifts their call light was sometimes left unanswered for more than thirty minutes. The resident and a family member stated there was a camera in the room and played a video showing empty hallways during late afternoon and nighttime hours. When the call light was not answered, the resident reported having to get out of bed independently despite documented needs for assistance.

Another resident with paraplegia and schizophrenia, who was care planned as requiring assistance with ADLs and having episodes of incontinence, reported not receiving timely wound care and stated that dressings on their feet had not been changed in two weeks. This resident also reported needing assistance to change their brief due to urinary incontinence. On one observation day, the resident was seen in a powered wheelchair at their doorway stating they were waiting for assistance, while three staff were in the area and one walked by without acknowledging them. After waiting, the resident moved to the nurse’s station to request help and later complained of having waited thirty minutes for assistance to be changed. The DON acknowledged awareness of this resident’s care needs and behavior history, including reports that the resident was not always truthful about care requests.

A resident with quadriplegia, bilateral hand contractures, dementia, and severe cognitive impairment, who was dependent on staff for all ADLs including bed mobility, transfers, and personal hygiene, was repeatedly observed lying on their back in bed or in a recliner for extended periods without effective use of positioning devices to offload pressure. Over multiple observations across several days, the resident remained on their back in bed or in a medical recliner, often with wedges or pillows present but not positioned under the resident in a way that would offload pressure from the back and buttocks. The resident was also observed with apparent foot drop and heels resting directly on surfaces without protective devices in place.

Another resident with legal blindness, adjustment disorder, and a history of falls, who required assistance with ADLs and minimal assistance for most tasks, reported needing help to get dressed and to walk with a walker to the dining room but was later observed eating lunch in their room instead. On a subsequent day, this resident was seen seated at a dining room table before lunch and remained there for an extended period, asking if their aide was available to walk them back to their room while no staff were visible in the halls or at the nurse station. The resident later reported that restorative staff, who walk with them a few times a week, had assisted them back to their room. The same resident activated their call light to request help to the bathroom; several minutes later, the DON happened to walk by, answered the call light, and assisted the resident, with no other staff responding. The resident also reported having requested a t-shirt from night staff to wear under their hospital gown and not receiving it.

A further resident, cognitively intact and requiring staff assistance for ADLs following a right lower leg bimalleolar ankle fracture, reported that staff sometimes took over an hour to answer call lights. During one observation, this resident’s call light was on for several minutes before staff arrived and the resident requested a brief change. Staff then went to the nurse’s station, returned to the room, and turned off the call light despite the resident asking to keep it on because staff often did not return once the light was turned off. The resident explained that staff frequently turned off the call light without providing the requested care. Facility policies reviewed by surveyors stated that comprehensive care plans must be implemented to meet residents’ medical, nursing, mental, and psychosocial needs, and that all staff are responsible for responding to call lights and ensuring requested services are provided in a timely manner.