Failure to Maintain Functional Call Light System and Timely Response to Resident Calls
Summary
The deficiency involves the facility’s failure to ensure that the call light system operated as designed, that call lights were accessible to residents, and that call lights were answered in a timely manner, as required by facility policy and resident care plans. The facility’s written policy required a functioning call system at each bedside, toilet, and bathing area, with alerts either directly to staff or to a centralized location, and required staff to keep call lights within reach and respond promptly. Review of the Device Activity Report for one hall over several weeks showed an average call light response time of approximately 70 minutes, with many individual calls taking from over 20 minutes to many hours, including one documented response time of over 1,100 minutes. Staff interviews confirmed that there were no audible or visual hallway alerts, that staff relied solely on a computer screen at the nurse’s station, and that the sound on the system was often turned down. Multiple residents with significant mobility, respiratory, and ADL deficits reported prolonged waits for assistance and difficulty accessing call lights. One cognitively intact resident with hemiplegia, polyneuropathy, foot drop, generalized muscle weakness, unsteadiness, and a history of falls stated that call lights were sometimes not answered for hours, including waits of up to 5 hours, and reported having to call 911 from a cell phone because staff did not respond. Device Activity Reports for this resident documented several extended response times, including one of 350 minutes. Another cognitively intact resident with COPD, anxiety, and depression, on continuous oxygen, reported waiting up to 3 hours for call lights to be answered, including episodes where oxygen ran out and assistance was delayed until the next shift. A third cognitively intact resident with hemiplegia, COPD, acute respiratory failure with hypoxia, and a history of falls reported that staff took hours to answer call lights, that family and friends had to seek staff for help with shortness of air, and that there were times when no one came until the next shift; this resident also reported incontinence episodes because staff did not respond. Additional residents with significant physical and cognitive impairments experienced similar issues. One cognitively intact resident with hemiplegia, difficulty walking, muscle weakness, need for personal care assistance, and repeated falls reported waiting hours for call lights to be answered, sometimes being unable to reach the call light, and remaining in urine and/or bowel for hours before being changed; this resident was observed attempting to transfer from a wheelchair to bed without being able to reach the call light. A resident with severe cognitive impairment, COPD, dysphagia, incontinence, and continuous oxygen was observed in bed with the door closed, unable to reach the call light, coughing, choking on saliva, and short of breath; this resident reported often being unable to reach the call light, waiting hours for help, and lying in urine and bowel for hours when staff did not respond. Another resident with multiple sclerosis, muscle weakness, reduced mobility, hemiplegia, and need for total assistance reported that call lights were on for over 30 minutes and often for multiple hours, including one episode where a call light activated at about 1:00 a.m. was not answered until nearly 8:00 a.m., during which the resident lay in urine. During observation, this resident’s call light had been on for over 30 minutes with no hallway light or audible alert, while a CNA sat at the nurse’s station using a cell phone until prompted by another CNA to answer the light. Staff interviews corroborated that the call light system did not provide adequate audible or visual alerts and that response expectations were not met. A CNA stated that the call light system was broken, that staff only knew a call was active if they were looking at the computer screen at the nurse’s station, and that there were no lights above resident rooms or sounds in the hallways when call lights were activated. An RN reported that CNAs were expected to answer call lights within 10 minutes but that staff only knew about calls by looking at the nurse’s station screen, with no lights or sounds elsewhere, and acknowledged extended call light times. An LPN stated that policy required call lights to be answered within 10 minutes, that the computers at the nurse’s station were the only alert mechanism, and that the sound on the system was often turned down. These observations, interviews, and records demonstrate that the facility failed to maintain a functional, accessible call light system and failed to ensure timely staff response to call lights for multiple residents with significant ADL, mobility, and respiratory needs.
Penalty
Resources
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Failure to Complete Restorative Nursing Program for ADL Support: The DON confirmed that restorative nursing activities were not documented as completed daily for four residents with significant mobility and ADL needs. The affected residents had conditions including cognitive impairment, stroke with right-sided paralysis, anoxic brain damage with dementia, and muscle weakness, and their care plans and therapy recommendations included AROM, strengthening, transfers, and assisted walking.
A resident with lung cancer and palliative care needs required staff assistance with oral hygiene, but oral care was not consistently provided or documented. The resident said staff did not clean her teeth and that friends had done it twice, while observation noted dull teeth. EMR review showed oral hygiene was documented 38 out of 60 opportunities, and NAs and the RN manager confirmed oral care should be offered at least twice daily but was missed on some occasions.
A facility failed to maintain a functional restorative nursing program. The Restorative/MDS Coordinator stated there was no active restorative program or designated restorative aides, and CNAs said restorative tasks were folded into routine care, not provided as separate 15-minute sessions. Record review for multiple cognitively intact residents showed missing or incomplete restorative logs, and residents reported that ordered ROM, ambulation, transfers, grooming, and prosthetic assistance were not being provided as care planned.
Failure to implement a PT-recommended walk-to-dine program for a resident who was supposed to ambulate to meals with a FWW while staff followed with a wheelchair and gait belt. Instead, the resident used his wheelchair to and from meals, and staff did not offer the planned assistance. The EMR showed the walk-to-dine approach in the care plan, but RN/CNA interviews showed uncertainty about the program, and the DON stated the recommendation was not added to the care plan, so the caregiver task was never populated.
A resident who was cognitively intact and needed substantial to maximal help with transfers and toileting, with a hx of stroke and IBS with diarrhea, repeatedly waited 24 to 35 minutes for call light response. The resident reported waiting about 30 minutes for bathroom help and soiling themselves multiple times, while an NA confirmed the resident had soiled their brief after waiting more than 30 minutes. The DON stated the facility expectation was to answer call lights within 10 minutes.
A resident who was fully dependent for transfers and required a Hoyer lift was left in bed for several hours after requesting to get up into her wheelchair. CNA C said she was busy with showers and would help later, while an LPN told the resident the CNAs would assist after lunch. The resident remained in bed during repeated observations and was not transferred until about 1:00 p.m., despite stating she had asked to get up around 9:00 a.m.
Failure to Complete Restorative Nursing Program for ADL Support
Penalty
Summary
The facility failed to complete a restorative nursing program for four residents reviewed for ADL concerns. Facility policy stated residents were to receive restorative nursing care as needed to promote optimal safety and independence, and the DON stated restorative activities were documented on the daily ADL documentation report. However, review of the daily documentation reports for July and August 2026 did not show that restorative tasks were completed daily as required for the affected residents. Resident R23 had cognitive impairment, lack of coordination, and a history of falls, and the care plan called for dependent assistance with all ADLs and restorative exercises for the upper and lower extremities. Therapy recommendations indicated the resident had been discharged from therapy and required AROM to both upper and lower extremities. Resident R26 had stroke and right-sided paralysis, with care plan interventions for assistance with all ADLs, restorative exercises to the upper extremities, ROM, and lifting weights; therapy recommendations included AROM to both upper and lower extremities, weight strengthening, and assisted walking up to 90 feet. Resident R91 had anoxic brain damage, dementia, and difficulty with walking and mobility, with restorative interventions for strengthening, transfers, and walking; therapy recommendations included AROM to both upper and lower extremities, weight strengthening, and sit-to-stand exercises. Resident R99 had diabetes, high blood pressure, muscle weakness, and lack of coordination, with restorative interventions for AROM and walking; therapy recommendations included assisted walking with a wheeled walker up to 100 feet. The DON confirmed the facility failed to complete the restorative nursing program for these residents.
Failure to Provide Consistent Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living to maintain oral hygiene for one resident who had diagnoses including malignant neoplasm of the right bronchus or lung and palliative care. The resident’s MDS indicated moderately impaired cognition, clear speech, and a need for partial-moderate assistance with oral hygiene. The care plan identified a self-care deficit and need for staff assistance with personal hygiene, but it did not specify whether oral care was included. The Kardex also listed personal hygiene assistance but did not specifically identify oral care or the frequency for providing it. Observation, interview, and record review showed oral hygiene was not consistently provided. The resident stated staff did not help clean her teeth and could not recall the last time her teeth had been cleaned by staff; she also said two friends had cleaned her teeth twice since admission. During observation, her top teeth looked dull, and on another occasion she stated no one had brushed her teeth that morning. Documentation in the EMR showed oral hygiene was recorded 38 times out of 60 opportunities, with several dates showing no oral care provided. An NA stated he had intended to brush the resident’s teeth but left when hospice arrived and did not return to provide oral care. Another NA stated she performed morning cares but did not do oral care, and the RN manager and DON both stated oral care should be offered at least twice daily.
Restorative Nursing Program Not Implemented or Documented
Penalty
Summary
The facility failed to maintain a functional Restorative Nursing Program to help residents maintain functional abilities and range of motion according to comprehensive assessments and care plans. Surveyors found that the facility did not have dedicated restorative nursing personnel, did not maintain supervisory oversight, and did not provide structured restorative interventions. Instead, restorative tasks were incorporated into general CNA point-of-care documentation, with check-box entries used without verification of session duration or whether the care was actually delivered. The Restorative and MDS Coordinator stated the facility did not operate an active restorative nursing program or employ designated restorative nursing aides, and that restorative care was not supervised, monitored, or audited across units. Record review showed approximately 27 long-term residents were listed on restorative care tasks assigned to general floor CNAs, but documentation only reflected daily check-box entries without details such as time spent or techniques used. CNAs interviewed stated they did not provide separate restorative therapy, did not spend 15 minutes per resident on restorative care, and documented tasks as completed because they considered them part of routine daily care. Several CNAs stated they had too many duties to provide restorative care, and one CNA stated no residents on the floor received restorative care. The facility also stated that residents who completed formal therapy were discharged without restorative programming, and that the current restorative roster had been grandfathered in under the new operating entity. Four cognitively intact residents on the restorative roster were reviewed in detail. One resident had care plans for dressing and grooming, ambulation, and transfers, but stated staff did not spend the required 15 minutes with him and did not assist with grooming or ambulation as planned; records showed missing and incomplete implementation logs. Another resident had care plans for active ROM and bed mobility and daily prosthetic assistance, but stated staff failed to apply her prosthesis for two days and never instructed or assisted her with ROM; records were incomplete. A third resident had care plans for ambulation, dressing, and stand-pivot transfers, but stated staff did not provide separate restorative assistance; records were incomplete. A fourth resident had care plans for daily active ROM with equipment and dressing assistance, but stated restorative services stopped after therapy discharge and he had never worn the ankle weights; records lacked the required 15-minute daily tracking logs. The facility policy required restorative needs to be evaluated and restorative flow sheets to document staff implementation of planned interventions.
Failure to Implement Walk-to-Dine Program
Penalty
Summary
The provider failed to implement a PT-recommended walk-to-dine program for a resident who was supposed to use a front-wheeled walker to walk to and from the dining room with staff following behind him with a wheelchair and gait belt. During observation and interview, the resident stated he used his wheelchair to get to breakfast because staff were too busy to follow behind him while he walked with his walker, and he said the purpose of using the walker was to keep his strength up. A dry-erase board in his room also indicated assist x1 with a FWW and gait belt for mobility needs. Repeated observations during meal services showed the resident sitting in his wheelchair in the dining room and using his wheelchair to travel to and from meals, while staff did not offer to walk behind him with a wheelchair as the walk-to-dine program directed. The resident's EMR showed a revised care plan entry for ambulation to walk to dine with staff following with a wheelchair and gait belt, and OT confirmed therapy had recommended walk-to-dine after discharge from therapy services. RN and CNA interviews showed uncertainty about whether the resident was on the program, and the DON stated the process failed because she did not add the recommendation to the resident's care plan, which would have populated the task on the caregiver list.
Delayed Toileting Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance for one resident who was cognitively intact and required substantial to maximal assistance with transfers and toileting. The resident’s MDS identified the resident as continent of bowel and bladder, with diagnoses including stroke and irritable bowel syndrome with diarrhea. The care plan stated the resident needed assistance with toileting related to impaired mobility after a stroke and that staff would respond promptly to toileting requests, provide one-person pivot transfers as indicated, and assist with toileting hygiene. The resident’s call light log showed four instances in which the resident waited 24 to 35 minutes before the call light was answered. During interview, the resident stated they sometimes had to wait 30 minutes for bathroom assistance and, because of the delay, soiled themselves numerous times and became embarrassed. A nursing assistant stated the resident had soiled their brief after waiting more than 30 minutes and that when staff were busy, residents might have to wait longer than 30 minutes for assistance. An RN stated there were times when there were not enough staff to help residents quickly and that nursing would assist NAs in answering call lights, while the DON stated the facility expectation was to answer all call lights within 10 minutes and that it would be unacceptable for residents to wait longer than 20 minutes.
Delayed Assistance With Requested Transfer
Penalty
Summary
The facility failed to provide timely assistance with transfers for a resident who required maximal assistance with ADLs and was fully dependent on staff for transfers. The resident had multiple sclerosis, cervical spondylosis, stiffness of an unspecified joint, pain, anxiety disorder, and a history of fractures including the left radius, left radial styloid process, and left femur. Her care plan directed that a Hoyer lift be used for all transfers and that staff provide support with transferring needs each shift. On 7/28/26, the resident stated she had requested to get out of bed at about 9:00 a.m. and into her wheelchair, but CNA C told her she was busy with another resident and would help later. The resident said she rang the call light again and was told by another CNA that CNA C was giving showers and would help when finished. She also told LVN D she was ready to get out of bed when the nurse came to ask about her breathing treatment. At 11:51 a.m. and again at 12:42 p.m., the resident was still in bed and said she had been waiting a long time to be transferred. CNA C stated she checked on the resident at about 9:30 a.m. and told her she would be transferred when staff were less busy, explaining that she had been giving showers and planned to get the resident up at lunch. LVN D stated she was not aware the resident had requested to get up at 9:00 a.m. and told the resident the CNAs would assist after lunch. The resident later stated staff transferred her out of bed at about 1:00 p.m. The DON and Administrator both stated they expected transfers to be completed as soon as possible or within about an hour when feasible, and both acknowledged the resident waited too long for the transfer.
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