F0565

E

Failure to Address Repeated Resident Council Concerns About Call Light Response

Dillsboro, Indiana Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly address and follow up on resident concerns about delayed call light response that were repeatedly raised in Resident Council meetings over several months. During a Resident Council meeting held on 03/24/2026, residents reported that call lights were not answered in a timely manner and that it sometimes took up to an hour to receive assistance. Review of Resident Council meeting minutes showed that in August 2025 residents reported nursing staff were sitting in the office discussing personal matters instead of answering call lights, and that on one station it was taking 45 minutes to an hour to respond. In September 2025, residents stated they felt CNAs sat at the nurse’s station, did not respond to call lights, forgot to return, and told residents they did not have time. In October 2025, residents reported one resident waited from 11:30 p.m. to 12:30 a.m. for help to go to the bathroom, another resident waited 25 minutes for help, and another resident waited for someone to change her despite being unable to remain in a diaper due to wound care needs. In December 2025, residents again reported staff were not responding to call lights in a timely manner and that they were waiting longer than 15 minutes for assistance.

Interviews and record review showed that the facility did not complete or document required follow-up to these concerns as outlined in its own Resident Council policy. The Activity Director stated she typed up concerns voiced at Resident Council meetings and distributed them to each department using a Resident Council Action Form, then attached the completed forms to the corresponding meeting minutes. The Regional Director of Operations stated that concern forms were to be completed after each Resident Council meeting, distributed to the appropriate departments, and the responses documented on the forms, which were then filed with the meeting minutes for review with residents at the next meeting. However, there were no Resident Council Action Forms completed for the August, September, October, or December 2025 meetings to show that the residents’ call light concerns were addressed. The facility’s policy “GUIDELINES FOR RESIDENT COUNCIL,” dated 06/20/2023, states that residents have the right to be involved in decisions affecting their lives, that group concerns require a timely response and resolution that satisfies the group, and that the Administrator monitors this process. The lack of completed action forms for these months demonstrates the facility’s failure to act promptly on and document resolution of the Resident Council’s call light concerns.