Spring Creek Nursing: Call Light Failures Leave Residents Stranded - OH
The woman, identified as Resident #23 in the August inspection report, told investigators the incident happened sometime in July. She pulled the bathroom call light but nothing happened. She remained trapped on the toilet, calling out until someone finally heard her cries and came to help.
Federal inspectors found the call light was still in the pulled position when they arrived weeks later. It wasn't working.
The failure wasn't isolated. Inspectors discovered broken emergency call systems throughout the 74-bed facility, affecting at least three residents and potentially dozens more who use the shower facilities on the first and third floors.
Resident #22's bathroom call light was completely non-functional. When asked how he would get help if needed, he told inspectors he would "just wait for staff to come back after he was toileted." He couldn't remember if he had ever tried to use the call light.
Resident #24 faced an even more dangerous situation. Both his bedside call light and bathroom call light were broken, leaving him with no way to summon help from his room.
The problems extended beyond individual rooms. In the west hall shower room, inspectors found two call lights that didn't function when pulled. On the third floor, the bathroom shower area had no call light within reach at all. The nearest emergency devices were positioned ten feet away near a wash basin, and those didn't work either.
Plant Operations Director #102 acknowledged the widespread failures during interviews with inspectors. The director explained that bathroom call systems run on batteries, and when those batteries die, "there was no way to know."
The maintenance chief described a more fundamental problem with the facility's emergency communication infrastructure. "Sometimes the wiring in the call systems fry the wiring and do not allow the batteries to function for more than a day," the director told inspectors.
This admission revealed that Spring Creek's emergency call system was prone to electrical failures that could render new batteries useless within 24 hours, creating an ongoing cycle of broken safety equipment.
The facility's own policy, dated March 2021, required staff to ensure call lights remained "plugged in and functioning at all times." The policy specifically instructed employees to "report all defective call lights to the nurse supervisor promptly" and to check frequently on residents who cannot use their call systems.
Yet the inspection found no evidence that staff had identified or reported the multiple call light failures before federal investigators arrived. The policy also required staff to periodically explain and demonstrate call light use to residents, but Resident #22 couldn't even remember attempting to use his non-functional system.
For residents like #23, the consequences were immediate and frightening. Unable to stand or move safely without assistance, she had no choice but to remain seated and hope someone would eventually hear her calls for help. The failure of this basic safety system transformed a routine bathroom visit into an hour-long ordeal.
The broken call lights represented more than mechanical failures. They eliminated residents' primary means of communication with staff during emergencies, medical crises, or basic care needs. Without functioning call systems, residents became entirely dependent on staff making regular rounds or happening to pass by their rooms.
Federal inspectors classified the violations as having caused minimal harm but with potential for actual harm. The assessment understated the reality for Resident #23, who endured significant distress during her hour-long wait, and the ongoing risk faced by residents whose emergency communication remained severed.
The Plant Operations Director's explanation that battery failures provided "no way to know" about broken call lights highlighted a critical gap in the facility's maintenance protocols. Effective nursing home operations require systematic testing of emergency equipment, not reactive repairs after residents report problems or federal inspectors discover failures.
Spring Creek's call light breakdown emerged from a complaint investigation, suggesting residents or families had raised concerns about the facility's emergency response capabilities. The inspection occurred on August 14, 2025, but the facility's policy failures dated back months, with Resident #23's bathroom incident occurring in July.
The violation affected residents across multiple floors and room types, from individual bedrooms to shared shower facilities. With 74 residents in the facility, the scope of the call light failures potentially compromised emergency communication for a significant portion of the population.
Resident #23's hour on the toilet, calling out desperately for assistance, illustrated the human cost of Spring Creek's maintenance failures. In a system designed to provide immediate access to help, she was reduced to shouting and hoping someone might hear.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spring Creek Nursing and Rehabilitation Center LLC from 2025-08-27 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 21, 2026 · Our methodology
SPRING CREEK NURSING AND REHABILITATION CENTER LLC in GREEN SPRINGS, OH was cited for violations during a health inspection on August 27, 2025.
The woman, identified as Resident #23 in the August inspection report, told investigators the incident happened sometime in July.
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.