§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
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Observations:
Based on review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call lights were accessible and answered timely for six of seventeen residents as required (Resident R1, R2, R3, R4, R5, and R6).
Findings include:
The facility policy "Call Lights" dated 7/15/25, indicated "Patients will have a call light or alternative communication device at each patient's bed side, toilet, and bathing room to allow patients to call for assistance when unattended. Staff will respond to call lights and communication devices promptly.
The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:
13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment
Review of Resident R1's clinical record indicated admission to the facility on 1/3/26 and discharged 2/24/26.
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/10/26, indicated diagnoses of retropharyngeal and parapharyngeal abscess (collection of fluid in the throat and neck area), chronic respiratory failure (lungs cannot exchange oxygen and carbon dioxide adequately), and fibromyalgia (widespread pain throughout the body) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R1 is substantial/maximal assistance with toileting hygiene, (helper does more than have the effort) and GG0170 toilet transfers requires partial/moderate assistance, (helper does less than half the effort).
During a facility reported event and investigation on 1/29/26 Resident R1 was interviewed by the facility. In a written statement by Resident R1, she noted (regarding the nursing assistant) "She gets on me about using the buzzer to much. Makes me wait, to go to the bathroom."
Review of Resident R2's clinical record indicated admission to the facility on 8/5/22.
Review of Resident R2's MDS dated 2/3/26, indicated diagnoses of spastic quadriplegic cerebral palsy (severe form of cerebral palsy with stiffness and paralysis affecting all four limbs), diabetes mellitus (body cannot properly use or make insulin), and anxiety disorder (excessive fear, worry, and anxiety that interfere with daily functioning) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R2 is dependent with toileting hygiene (helper does all the effort) and GG0170 toilet transfers, unable due to medical condition.
During an interview and observation on 3/9/26, at approximately 11:00 a.m. Resident R2 stated she uses the call light when she needs help. It takes a half hour or more to get help. It's not all the time but it happens often, I just wait, I can't take care of myself.
Review of Resident R3's clinical record indicated admission to the facility on 2/5/26.
Review of Resident R3's MDS dated 2/12/26, indicated diagnoses of multiple sclerosis (immune system attacks the protective covering of nerve cells in the brain and spinal cord), pressure ulcer stage IV (wound with exposed fascia, muscle, tendon, or bone), and malnutrition (imbalance between the nutrients your body needs and what it receives) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R3 is independent with toileting hygiene (resident does all the effort) and GG0170 toilet transfers requires partial/moderate assistance, (helper does less than half the effort).
During an interview and observation on 3/9/26, at approximately 11:10 a.m. Resident R3 stated she uses the call light when she needs help. It takes thirty to forty-five minutes to get help when you use your call light. It's happening more often with the evening and night shifts. It's not every day but a couple of times each week this happens.
Review of Resident R4's clinical record indicated admission to the facility on 11/21/24.
Review of Resident R4's MDS dated 2/25/26, indicated diagnoses of chronic obstructive pulmonary disease (COPD disease that blocks airflow to the lungs), diabetes mellitus (body cannot properly use or make insulin), and depression, a BIMS of 13. Review of Section GG: Functional Abilities GG0130, indicated that Resident R4 is independent with toileting hygiene (resident does all the effort) and GG0170 toilet transfers is independent, (resident does all the effort).
During an interview and observation on 3/9/26, at approximately 11:20 a.m. Resident R4 stated she uses the call light when she needs help when "requesting medication, not feeling well things like that". On the evenings and nights is mostly when the waiting happens, it's about thirty minutes probably longer at times.
Review of Resident R5's clinical record indicated admission to the facility on 5/23/14.
Review of Resident R5's MDS dated 2/24/26, indicated diagnoses of hypertension (high blood pressure), heart failure (heart muscle is unable to pump enough blood to meet the body's needs), and depression (imbalance between the nutrients your body needs and what it receives) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R5 dependent with toilet hygiene (helper does all the effort) and GG0170 toilet transfers, unable due to medical condition.
During a review of resident grievances, Resident R5 filed a grievance on 2/17/26 and 2/18/26 documenting her experiences regarding daily call light wait times on the evening and night shifts.
During an interview and observation on 3/9/26, at approximately 11:40 a.m. Resident R5 stated since she has filed the grievances things have improved, however are not resolved. It's no longer every day, it's still several times a week, mostly on the night and evening shift you have to wait. It can take thirty minutes to two hours for someone to come in and help you.
Review of Resident R6's clinical record indicated admission to the facility on 1/6/26 and discharged 2/17/26.
Review of Resident R6's MDS dated 1/13/26, indicated diagnoses of hypertension (high blood pressure), diabetes mellitus (body cannot properly use or make insulin), and cellulitis (bacterial infection of the skin and underlying tissues) a BIMS of 14. Review of Section GG: Functional Abilities GG0130, indicated that Resident R6 is substantial/maximal assistance with toileting hygiene, (helper does more than have the effort) and GG0170 toilet transfers requires substantial/maximal assistance, (helper does more than have the effort).
During a facility reported event and investigation on 1/22/26 Resident R6 was interviewed by the facility. In a written statement by Resident R6, he noted "I kept trying to call because I pooped in my pants and nobody was coming." Facility event report documentation reveals resident call his family who came to the facility and reported the resident was not being changed.
During an interview on 3/9/26 at 3:30 p.m. the Nursing Home Director and the Director of Nursing confirmed the facility failed to make certain call lights were accessible and answered timely.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
28 Pa Code: 201.29 (I)(o) Resident rights.
| | Plan of Correction - To be completed: 04/08/2026
R1, R2, R3, R4, R5, R6 were immediately evaluated and assisted with any unmet needs, including toileting, pain, positioning, hydration, and safety concerns related to delayed call bell light response. R1 discharged from the facility on 2/24/2026. R6 discharged from facility on 2/17/2026
Current residents were interviewed by the NHA or designee during Resident Council meetings to ensure their call lights are being responded to timely. Supervisors are conducting observational rounds on all shifts to validate staff responsiveness to call bells lights.
The Director of Nursing or designee will re-educate staff on the NSG 101 Call Light policy with the focus on facility expectations for timely call bell light response.
The DON or designee will conduct random call light audits of 10 residents weekly x 4, then monthly x 2, to ensure call lights are accessible and answered timely. The NHA or designee will conduct random interviews of 5 residents with a BIMS >10, and 5 family members for residents with a BIMS of <10, weekly x 4, then monthly x 2 to verify call bells were accessible and answered timely. Results of the audits will be presented at the QAPI meetings for review.
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