The safety violations put residents at risk of falls and medical emergencies without any way to contact nursing staff for assistance.
During the inspection, a certified nursing assistant discovered multiple call lights had been placed where residents couldn't reach them. In one room, she found a resident's call light stuffed inside a bedside table drawer, completely inaccessible to the person who needed it.
The CNA told inspectors she routinely checked residents' rooms and "always" found call lights out of reach. She had to retrieve the device from the drawer and place it where the resident could actually use it.
"If the call lights were not within the reach of the residents, the residents might fall or might get mad when they could not get hold of the staff," the nursing assistant explained to investigators.
The facility's Director of Nursing acknowledged the severity of the problem during her interview. She told inspectors that without accessible call lights, "residents might try to go to the bathroom by themselves because she had no way to call the staff that might result in a fall and injuries."
But despite recognizing the safety risk, multiple staff members admitted they weren't following basic protocols.
Licensed Vocational Nurse B was blunt about her failures: "To be honest, she did not check if the call lights were with the residents on her hall."
The nurse acknowledged that call lights "should be with the residents at all times so the residents could call the staff if they needed help," and that staff "should make sure that the call lights were with the residents when they leave the residents' rooms."
The Assistant Director of Nursing painted an even starker picture of the potential consequences. She told inspectors that call lights were "the only way they could reach out to the staff if they were in distress or just needed water."
She described a worst-case scenario: "An independent resident might be having a heart attack and could not call anybody because the call light was not with the resident."
The violations affected both dependent and independent residents throughout the facility. The DON confirmed that call lights were safety measures for all residents, regardless of their level of independence.
Multiple supervisors admitted responsibility for the systemic failure. The DON said "all the staff were responsible for the call lights, including her." The ADON similarly acknowledged she was "one of the responsible in checking if the call lights were with the residents."
The facility's own written policy, revised in May 2020, explicitly required staff to "place the call device within resident's reach before leaving room." The policy stated it was facility protocol "to provide the resident a means of communication with nursing staff."
Yet staff consistently ignored these requirements, leaving vulnerable residents isolated and unable to request help.
The Administrator told inspectors that call lights were particularly important because "for some resident, call lights were their sense of security." She emphasized that "all the staff were responsible in making sure the call lights were within reach."
The DON said she expected staff to "scan the resident's room when they do their rounds and ensure the call lights were within reach of the residents before they leave the room."
But the evidence showed this wasn't happening. The systematic failure to ensure call light access created dangerous conditions where residents faced potential medical emergencies, falls, or other urgent needs without any way to summon assistance.
By the time inspectors arrived, facility leadership was scrambling to address the violations. The DON said "an in-service was already on-going as soon as CNA C told her about the call light not within reach."
The ADON promised she would "coordinate with the DON to randomly check if the call lights were with the residents." The Administrator similarly pledged to work with the DON to "re-educate the staff with regards to call lights."
The violations represented a fundamental breakdown in basic safety protocols that left residents vulnerable and isolated when they most needed help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northgate Plaza from 2025-11-25 including all violations, facility responses, and corrective action plans.