The most alarming case involved Resident #6, who nearly fell out of bed trying to retrieve her call light from the floor when an inspector asked where it was located. The woman, who has a documented history of falls and muscle weakness, had to reach down from her bed to grab the device that was supposed to keep her safe.
Federal inspectors conducting a complaint investigation found call lights on floors, behind bed rails, and otherwise out of reach across multiple rooms during their morning rounds. The violations affected residents who care plans specifically identified as fall risks requiring immediate access to staff assistance.
Resident #5, a patient with muscle weakness who needs full help with daily activities, was found lying in bed at 8:50 AM with his call light on the floor behind the head of his bed. His comprehensive care plan, dated August 1, explicitly required staff to ensure his call light remained within reach and encourage him to use it.
Three other residents faced similar situations. Resident #1, admitted in July with a history of falls and muscle weakness, was discovered with her call light on the floor next to her bed. Resident #2, also a fall risk with muscle weakness requiring full assistance, had his call light positioned where he couldn't access it. Resident #4's call light was found behind the bed rail, completely out of reach.
When confronted with the evidence, nursing staff acknowledged the failures but offered different explanations for how the systematic breakdown occurred.
CNA O, who discovered multiple residents without call light access, told inspectors the devices "needed to be within reach of the resident so they could contact staff if they needed help." She explained it was only her second day at the facility and she was still learning what to look for during resident rounds.
LVN R, shown the six cases of inaccessible call lights, confirmed that "call lights should be in reach of the resident so they could contact staff" and that "staff should be checking to ensure call lights were in reach of the residents when they made their rounds."
CNA C, also confronted with the widespread violations, repeated the same acknowledgment that call lights needed to remain accessible for residents to contact staff for help.
The facility's leadership admitted the problems extended beyond individual staff oversights.
Assistant Director of Nursing J, informed about all six cases at 2:40 PM, told inspectors that "call lights needed to be within reach of the residents so they could be able to contact staff if they needed assistance or had an emergency." He stated staff should check and ensure call lights remain accessible "every time they entered the residents' room."
Director of Nursing, who started at the facility September 1, was shown photographs of the six residents with inaccessible call lights. She acknowledged she was "in the process of training staff to ensure call lights were within the residents' reach whenever they did their rounds and to also clip them to the bed to ensure they did not fall off."
The violations occurred despite the facility maintaining an undated policy requiring that "Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation."
For residents like those at Mustang Park, call lights represent the only immediate connection to help during medical emergencies, falls, or other urgent situations. When these devices become inaccessible, residents face potentially dangerous delays in receiving assistance.
The inspection findings revealed a systematic failure in basic safety protocols affecting some of the facility's most vulnerable residents. Those identified without call light access included patients specifically documented as fall risks with muscle weakness requiring comprehensive assistance with daily activities.
Federal inspectors classified the violations as having "minimal harm or potential for actual harm" affecting "some" residents. The October 8 complaint investigation documented the call light failures as part of the facility's inability to ensure residents could access emergency assistance when needed.
The case of Resident #6 nearly falling while trying to reach her dropped call light illustrated the dangerous irony of the situation: residents risking injury to access the very device designed to prevent harm by summoning help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mustang Park Therapy and Living Center from 2025-11-26 including all violations, facility responses, and corrective action plans.
Additional Resources
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