Resident 13 told inspectors that two certified nursing assistants the previous night had turned off call lights without meeting anyone's needs. One CNA explained that "Surveyors were watching call lights so they needed to turn the call lights off," according to the inspection report.
The resident described a pattern of neglect that left some people soiled and waiting. "R13 has been incontinent due to waiting too long for help," inspectors wrote. When staff turned off the call light without providing assistance, the resident would turn it back on after 10 minutes if no one returned.
But that created an even longer wait. Staff "don't come back for a longer time" after residents reactivate their call lights, the resident explained.
The resident expressed concern for others who couldn't advocate for themselves, telling inspectors they "feels bad for residents whose needs aren't being met and who can't advocate for themselves."
Facility records revealed the scope of the delays. Call light audits from seven randomly selected rooms showed response times regularly exceeding 15 minutes throughout August and early September. On August 9, residents waited 29 minutes, 32 minutes, and 44 minutes for help. August 15 brought waits of 25 minutes and 57 minutes.
The longest documented wait stretched nearly an hour.
On September 1, four separate call lights remained unanswered for 15, 20, 26, and 26 minutes respectively. The pattern continued into September, with multiple waits exceeding 20 minutes recorded on August 30.
During the inspection itself, problems persisted. On September 8 at 1:54 PM, an inspector observed the call light monitoring screen with a registered nurse and noted active calls at 19 minutes, 25 minutes, and 41 minutes.
The nurse said that wasn't unusual.
Staff interviews revealed widespread awareness of the problems and their consequences. CNA-I told inspectors the facility was short-staffed and acknowledged that call light response times should be one to two minutes. The aide said they tried to respond within two to three minutes "unless CNA-I is giving a shower or doing something that takes longer."
Licensed Practical Nurse N said call lights should be answered "as soon as they are turned on" but estimated the average response time at approximately seven minutes. The nurse had seen waits stretch 15 to 20 minutes.
Another CNA described staffing as inconsistent and said response times "would be better if there were more staff." The aide identified the worst periods as mornings, between 3:00 and 4:00 PM, and between 7:00 and 8:00 PM. Most significantly, this staff member acknowledged that "residents' needs are likely not met at times."
Licensed Practical Nurse D provided the starkest assessment. The nurse estimated average call light response times at approximately 20 minutes, four times longer than the five-minute standard they believed appropriate. "If there were more staff, call light response times would be less," the nurse said, confirming that residents regularly complained about delays.
The facility had received at least one formal grievance about call light response times on August 25, just weeks before the inspection.
Nursing Home Administrator A defended some of the delays during a September 9 interview. The administrator said a 15-minute response time was "acceptable at a busy time like shift change" and suggested call lights should average seven to 10 minutes.
But the administrator also acknowledged staff shouldn't turn off call lights without addressing residents' needs, since the signals "serves as a reminder that the resident still needs services."
The administrator outlined procedures that weren't being followed. Staff should check with residents when multiple lights activate simultaneously, explain they'll return shortly, and use walkie-talkies to request help from colleagues on other halls when needed. Management should assist on the floor during busy periods.
The administrator claimed the facility was "staffed appropriately for the census."
Yet the documented waits, staff admissions, and resident experiences painted a different picture. Resident 13's nearly two-hour wait represented an extreme case of a systemic problem that left vulnerable people soiled, ignored, and unable to get basic care when they needed it most.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Health Services from 2025-09-16 including all violations, facility responses, and corrective action plans.