Federal inspectors discovered the safety violation at Paradigm at the Prairies on November 17, 2025, when they observed Resident #14 awake in her bed at 10:47 AM. The call light lay on the floor at the head of her bed, completely out of reach.
When inspectors attempted to interview the resident, she was unable to answer questions appropriately due to her cognitive status. Her care plan from November 5 had specifically identified her as at risk for falls and injuries, with one key intervention being to ensure her call light remained within reach and that staff answer it promptly.
CNA J happened to be in the hallway and entered the room during the inspection. She picked up the call light from the floor and clipped it to the resident's pillow. The nursing assistant told inspectors it was important for Resident #14's call light to be within reach in case she needed to call for help.
The facility's own policy, revised in December 2023, requires that call lights be placed within reach of residents' beds or sitting areas. The policy states the facility will provide a call light system that is "accessible, functional, and responsive to meet the needs of the residents."
Director of Nursing acknowledged the severity of the lapse during an interview the following day. She explained that call lights serve as crucial safety measures allowing residents to contact staff when they need something or require assistance with activities that could result in falls and injuries.
"Residents might try to go to the bathroom by themselves because she had no way to call the staff that might result to a fall and injuries," the DON told inspectors.
She said all staff members, including herself, were responsible for ensuring call lights remained accessible. The expectation was for staff to scan residents' rooms during rounds and confirm call lights were within reach before leaving each room.
Assistant Director of Nursing A emphasized the life-or-death importance of the devices during her interview. She said call lights should be with residents at all times when they are in their rooms because the devices are "the only way they could reach out to the staff if they were in distress or just needed water."
The ADON stressed that call lights were necessary for all residents, whether independent or dependent. She painted a stark scenario: "An independent resident might be having a heart attack and could not call anybody because the call light was not with the resident."
LVN L reinforced the critical nature of call light accessibility, stating it was important to ensure residents could reach staff if they needed assistance.
Assistant Director of Nursing K noted that all call light cords came equipped with clips specifically designed to secure them to beds, making the violation even more preventable.
The facility's Administrator captured the emotional impact of the safety failure during her interview. She explained that for some residents, call lights represent "their sense of protection that if something happened to them, they would be able to call the staff for help."
"Without the call light the residents might feel helpless," she told inspectors.
The Administrator emphasized that everyone was responsible for ensuring call lights remained with residents, regardless of whether the resident was independent or dependent. She said she would collaborate with the DON to address the call light issues.
Multiple staff members told inspectors that in-service training had already begun in response to the violation. The DON said she would monitor staff compliance regarding call lights, while ADON A stated she would coordinate with the DON to conduct random checks ensuring call lights remained accessible to residents.
The violation occurred despite universal acknowledgment among leadership that call lights serve as residents' primary lifeline to staff assistance. For Resident #14, whose cognitive impairment already left her vulnerable, the missing call light represented a complete breakdown in a basic safety protocol designed to prevent exactly the kind of falls and injuries her care plan sought to avoid.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Paradigm At the Prairies from 2025-11-18 including all violations, facility responses, and corrective action plans.