Resident 15 needed to be changed after soiling himself. Resident 16 had diarrhea and was sitting in waste. Both had pressed their call buttons at 3:05 p.m. on September 22.
Nobody came.
Inspectors watched the call lights flash and listened to them sound for 20 minutes straight. At 3:25 p.m., they interviewed both residents about why they had activated their call systems.
Resident 15 confirmed he had pressed his call light because he needed help being changed. Resident 16, a woman with dementia who had been at the facility since January 2023, confirmed she needed to be changed because she was soiled and had diarrhea.
The residents remained in their waste.
At 3:34 p.m., nearly 30 minutes after the call lights first sounded, Certified Nursing Assistant 25 entered Resident 15's room. She turned off his call light and left without providing any care.
When inspectors questioned her two minutes later, CNA 25 said she had been off the unit on a lunch break and had just returned. She was unaware that no one had been available to answer the call lights during the entire period from 3:05 p.m. to 3:25 p.m.
The inspection report does not indicate when either resident finally received care.
Resident 15 had been at Maple Knoll Village since February 2024 following a stroke. His medical assessment from August showed he had no cognitive problems but required substantial to total assistance with basic daily activities like toileting and personal care.
Resident 16's September assessment also showed no cognitive impairment despite her dementia diagnosis, but she was completely dependent on staff for all daily care activities.
The facility's own policy states that residents unable to perform activities of daily living independently "would receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene."
During the 20-minute period when call lights went unanswered, the 66-bed facility apparently had no nursing assistant available on the unit to respond to residents needing basic care.
Federal inspectors classified this as a violation of requirements to provide adequate assistance with activities of daily living. The citation notes this represents the fourth recent complaint investigation at Maple Knoll Village related to similar care failures.
The inspection was conducted in response to complaints filed against the facility. Previous complaint numbers referenced in the report suggest an ongoing pattern of care deficiencies that prompted multiple federal investigations.
Maple Knoll Village operates as a continuing care retirement community on Springfield Pike in Cincinnati. The facility markets itself as providing various levels of care from independent living through skilled nursing services.
The September inspection focused specifically on the facility's response to resident call lights, a basic safety system that allows residents to summon help when needed. Federal nursing home regulations require facilities to ensure residents receive timely assistance with personal care needs.
Both residents affected by the delayed response required significant daily assistance according to their care assessments. Resident 15's conditions included diabetes in addition to his stroke effects. Resident 16 suffered from Barrett's esophagus alongside her dementia and depression.
The inspection found that when the lone nursing assistant returned from lunch, she was completely unaware that residents had been calling for help during her absence. This suggests the facility lacked adequate staffing coverage or communication systems to ensure continuous care during shift changes and breaks.
Federal inspectors determined the violation caused "minimal harm or potential for actual harm" to residents, the lowest level of severity in the citation system. However, the finding represents a fundamental failure to provide basic dignity and hygiene care that residents depend on.
The citation requires Maple Knoll Village to submit a plan of correction detailing how it will prevent similar incidents. The facility must demonstrate adequate staffing levels and systems to ensure resident call lights receive prompt responses, particularly during meal breaks and shift transitions.
For residents like 15 and 16, who cannot independently manage their personal care needs, delayed responses to calls for assistance can result in prolonged exposure to unsanitary conditions, skin breakdown, infections, and loss of dignity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maple Knoll Village from 2025-09-25 including all violations, facility responses, and corrective action plans.