F0550

E

Failure to Honor Resident Self-Determination and Timely Call Light Response

Parkston, South Dakota Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to honor residents’ rights to self-determination and a dignified existence during meal service and in response to call lights. Surveyors observed that three residents (6, 8, and 9) were seated in the dining room before other residents but were consistently served last at both breakfast and lunch. A CNA stated these residents were usually served last, and a food service worker reported that nursing staff had requested these residents be served last due to one resident’s high fall risk. Despite the Director of Food Services’ expectation that residents be served when seated, these three residents waited about 19 minutes for their lunch while other residents were already eating. Additionally, another resident (7) requested a cut-up apple during lunch; the cook deferred the request until after meal service and only provided the apple after a surveyor prompted a second time, placing the bowl in front of the resident without verbal acknowledgment.

The deficiency also includes prolonged call light response times that resulted in negative outcomes for multiple residents. Call light logs over a several-day period showed repeated response times greater than 25 minutes for four residents (1, 2, 3, and 4), with some instances approaching or exceeding 45–50 minutes. One resident reported having to sit in soiled bowel movements for one to two hours after using her pendant or call light, stating that staff sometimes turned off the light and said they would return but did not. Another resident reported feeling he waited a long time for assistance, urinated on himself while waiting for help to the bathroom, and felt disgusted by being unable to get needed help in time.

Further interviews confirmed that another resident frequently waited for his call light to be answered, was incontinent before staff arrived, and sometimes yelled from his doorway for help when his call light had been on for over 30 minutes, which he described as embarrassing. A fourth resident reported waiting 20 to 30 minutes for staff to assist him up for meals and stated that on one occasion he was left in his room at suppertime until staff had finished getting everyone out of the dining room before helping him, which he found frustrating. CNAs interviewed stated their expected call light response times ranged from 1 to 10 minutes, while the DON stated her expectation was that no call light should go unanswered for more than 20 minutes. The facility’s call light policy required prompt responses to resident requests, but the DON acknowledged that although call light audits were done once or twice monthly, nothing had been done with the completed audits.