The Lodge at Taylor: Call Button Safety Failure - MI
The resident, identified as R102 in inspection records, was lying in bed receiving breakfast assistance from staff when inspectors observed his call button on the floor at 8:46 AM on August 21. The patient had been admitted to the facility less than a month earlier with diagnoses including morbid obesity and paralysis affecting his right dominant side following a stroke.
A Licensed Practical Nurse confirmed during the inspection that the resident could not reach the call button from his position and noted that he had the mental capacity to use it if it were accessible.
The violation occurred despite the facility's own care plans specifically requiring staff to encourage the resident to use his call light when assistance was needed. Those care plans, initiated the day after his July 24 admission, identified him as being at risk for falls and injury due to bladder incontinence, bowel incontinence, generalized weakness, and his need for assistance with daily activities.
R102's medical record documented severe cognitive impairment but no impairment of his upper extremities, meaning he retained the physical ability to operate a call button if one were within reach. His stroke had left him with hemiplegia affecting his right dominant side, and he also suffered from atrial fibrillation and morbid obesity.
The facility's own policy, dated December 28, 2023, requires call lights to be within reach at each resident's bedside, toilet, and bathing facility. The policy states its purpose is to "assure the facility is adequately equipped with a call light at each residents' bedside" and mandates that "residents are educated on how to call for help by using the resident call system."
During the inspection, a Non-Certified Nurse Aide who had been assisting R102 with breakfast was interviewed about the situation. The aide confirmed she had been in the room providing meal assistance when inspectors observed the call button on the floor.
The Director of Nursing, when questioned about the incident, acknowledged that residents' call lights should be within reach. However, the facility provided no additional documentation or explanation when given the opportunity during the exit conference.
Federal regulations require nursing homes to reasonably accommodate the needs and preferences of each resident. Call button accessibility represents a fundamental safety measure, particularly for residents with mobility limitations or cognitive impairments who may be unable to physically retrieve a fallen device.
For a resident like R102, who requires assistance with activities of daily living and has been identified as at risk for falls, an inaccessible call button creates a dangerous situation. His care plan specifically called for encouraging call light use, yet staff failed to ensure the device remained within his reach during routine care.
The violation was classified as causing minimal harm or potential for actual harm, affecting few residents. However, the incident highlights how basic safety protocols can break down during routine care activities.
R102's case illustrates the vulnerability of nursing home residents who depend on staff assistance for basic needs. With severe cognitive impairment and stroke-related paralysis, he was entirely dependent on the call button system to summon help when staff were not present in his room.
The inspection occurred as part of a complaint investigation, suggesting someone had raised concerns about conditions at the facility. The Lodge at Taylor, located on Northline Road, had admitted R102 just weeks before the inspection revealed the call button violation.
The facility's care plans recognized R102's multiple risk factors, including his incontinence, weakness, obesity, and medication use. These same factors that put him at risk for falls and injury made it even more critical that his call button remain accessible.
When federal inspectors found the call button on the floor during their unannounced visit, it represented a failure of the most basic safety accommodation required for nursing home residents. The device that was supposed to be R102's lifeline to assistance had become unreachable, leaving him unable to call for help while receiving what should have been routine breakfast assistance.
The incident occurred despite clear facility policies and individualized care plans that specifically addressed the need for call button access. Both the facility's written procedures and R102's personalized care requirements emphasized the importance of encouraging call light use, yet staff failed to maintain this essential safety measure during his care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Lodge At Taylor from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
The Lodge at Taylor in Taylor, MI was cited for violations during a health inspection on August 21, 2025.
His stroke had left him with hemiplegia affecting his right dominant side, and he also suffered from atrial fibrillation and morbid obesity.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at The Lodge at Taylor?
- His stroke had left him with hemiplegia affecting his right dominant side, and he also suffered from atrial fibrillation and morbid obesity.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Taylor, MI, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from The Lodge at Taylor or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 235541.
- Has this facility had violations before?
- To check The Lodge at Taylor's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.