Federal inspectors found the call light cord at Castleton Health Care Center wrapped around the bed rail and hanging eight inches from the floor, well beyond reach of the bedridden resident who suffers from impaired balance, limited mobility, and shortness of breath.
"Most of the time I can't reach my call light," the resident told inspectors during a September 17 visit. "I take my stick and start beating on the table, and they can hear me, and then they come."
The resident, identified in records as Resident N, demonstrated her improvised system during the inspection. She kept a wooden stick, one inch wide and eighteen inches long, on her bedside table specifically for attracting staff attention when her call light remained out of reach.
Her medical conditions include chronic obstructive pulmonary disease, chronic kidney disease, heart failure, and arthritis. Care plans noted she would often refuse to get out of bed due to pain and breathing difficulties. An August assessment classified her as moderately cognitively impaired.
When inspectors first observed the resident at 12:18 p.m., she was lying in bed with the call light cord tied around her right bed rail. She attempted to reach it with her wooden stick but couldn't grasp the cord.
"I can't get it in my hand and do anything," she said, demonstrating her unsuccessful attempts to grab the dangling cord.
Staff had been in her room about ninety minutes earlier but failed to place the call light within reach before leaving, the resident reported. She explained that when she soiled her brief, hitting the bedside table or bed rail with her wooden stick was her only way to get help.
Nearly two hours later, at 1:55 p.m., inspectors returned to find the call light still in the same position. The resident was eating lunch alone in her room. Whoever delivered her meal tray had not adjusted the call light placement.
"She wasn't sure who brought her lunch tray to her, but they did not ensure her call light was in reach," inspectors documented.
Only when the unit manager accompanied inspectors at 1:57 p.m. was the call light finally untangled from the bed rail and placed within the resident's reach.
The unit manager acknowledged the violation immediately. "Her call light should always be within her reach," the manager told inspectors, suggesting staff might need to get a clip for the call light or find a different type of device entirely.
The facility's own policy, provided to inspectors two days later, explicitly requires staff to "ensure call light is within reach of resident prior to leaving the resident's room" and warns that call lights should never be placed "on the floor or bedside stand."
The policy states it is facility protocol "to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use."
Federal regulations require nursing homes to reasonably accommodate residents' needs and preferences. The violation was classified as causing minimal harm or potential for actual harm.
The resident's care plan, revised in August, specifically included an intervention to "encourage her to use bell to call for assistance" due to her self-care deficits related to impaired balance, limited mobility, pain, and shortness of breath.
Yet for hours on the day of inspection, this resident with multiple chronic conditions and cognitive impairment had no reliable way to summon help except beating a wooden stick against furniture.
The inspection was conducted in response to complaints about the facility. Records show the call light violation affected few residents, but inspectors noted it related to two separate intake complaints filed with state regulators.
The resident's improvised system of banging for attention worked, she told inspectors, noting "I don't suffer too much not being able to reach it." But her wooden stick solution highlighted a basic failure in care for someone whose medical conditions made reaching a dangling cord impossible.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Castleton Health Care Center from 2025-09-23 including all violations, facility responses, and corrective action plans.