WESTLAND, MI - A recent state inspection at Four Seasons Nursing Center of Westland documented significant delays in responding to resident call lights, including a stroke patient who waited 33 minutes for assistance while experiencing discomfort and anxiety.
Prolonged Response Times Leave Vulnerable Residents Waiting
The May 29, 2025 inspection revealed that facility staff failed to meet their own established standards for call light response times. A resident with sequelae of cerebral infarction (stroke effects), functional quadriplegia, and anxiety waited over half an hour for basic care assistance despite repeated attempts to get help.
The resident, who required substantial assistance for all daily activities due to their stroke-related disabilities, reported that "if I put it on too much they (facility staff) don't like it" when asked about using the call light system. This statement suggests residents may feel discouraged from seeking necessary assistance.
During the inspection, surveyors observed a concerning sequence of events. After the resident activated their call light at 1:51 PM requesting a brief change and repositioning due to foot pain from contact with the footboard, nursing staff acknowledged the request but failed to provide timely care. A certified nursing assistant (CNA) entered the room at 2:06 PM, turned off the call light, and told the resident their assigned aide would help them soon - but left without addressing the resident's needs.
Medical Significance of Timely Response Systems
Call light systems serve as critical safety lifelines for nursing home residents, particularly those with mobility limitations or cognitive impairments. For stroke survivors like the resident in this case, timely responses are essential for preventing secondary complications.
Prolonged periods in wet clothing can lead to skin breakdown, pressure ulcers, and urinary tract infections. For individuals with functional quadriplegia, the inability to reposition themselves makes timely staff assistance crucial for circulation, comfort, and dignity. Additionally, extended periods of discomfort can exacerbate anxiety disorders, creating a cycle of distress.
The facility's own nursing leadership established clear expectations for call light response times: 10 minutes under normal circumstances, with a maximum of 20 minutes when staff are assisting other residents. These standards align with industry best practices that emphasize prompt response to maintain resident safety and well-being.
Staff Response Protocols Ignored
The inspection revealed that staff members failed to follow established protocols when responding to call lights. According to the facility's Assistant Director of Nursing, staff answering call lights should address resident needs directly rather than simply turning off the light and deferring to other personnel.
However, the observed response pattern showed exactly the opposite approach. When CNA B responded to the call light, they turned it off and told the resident to wait for their assigned aide without determining what assistance was needed. This practice defeats the purpose of having multiple staff members available to respond to emergencies and routine needs.
When care was finally provided 33 minutes after the initial request, the resident had become anxious about remaining in wet clothing. The responding aide's comment to "not be so dramatic" demonstrated insensitivity to the resident's legitimate distress and discomfort.
Industry Standards and Regulatory Requirements
Federal regulations require nursing homes to maintain functioning call systems in all resident areas and ensure timely responses to resident requests for assistance. These requirements recognize that many nursing home residents cannot independently meet their basic needs and rely entirely on staff responsiveness for safety and comfort.
The regulation specifically mandates that call systems be available and functional, but effectiveness depends on staff training, adequate staffing levels, and institutional commitment to prompt response protocols. When facilities fail to meet their own established timeframes, it indicates systemic issues rather than isolated incidents.
For residents with stroke-related disabilities, communication about needs may already be challenging. Lengthy delays in receiving assistance can compound these difficulties and create additional barriers to receiving appropriate care.
Additional Issues Identified
The inspection focused specifically on call light response times and identified this violation as causing minimal harm with potential for actual harm, affecting few residents in the sample reviewed.
The documented case represents a broader concern about care responsiveness and staff attitudes toward resident requests for assistance. The resident's comment about staff not liking frequent call light use suggests an institutional culture that may discourage residents from seeking help when needed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Four Seasons Nursing Center of Westland from 2025-05-29 including all violations, facility responses, and corrective action plans.
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