"They took the call light from me," the woman told federal inspectors on December 30. "They give you a hard way to go around here. They save me for last to help. They take a long time to change me. I am wet now from peeing on myself."
Federal inspectors found call lights on the floor in all five resident rooms they checked at Sedgewood Manor Health Care Center. The emergency buttons, designed to summon help in medical crises, were unreachable for residents who needed assistance.
The resident who complained about being left wet had been admitted with muscle weakness, stroke complications, dementia, and high blood pressure. Her cognitive assessment showed severe impairment, scoring just 7 out of 15 points on a standard mental status exam.
When inspectors found her call light on the floor at 1:23 PM, she was lying in bed watching television. A nursing assistant in training came to turn off the call button that had been ringing, but left without making it accessible to the resident.
The trainee told inspectors she would get the regular nursing assistant responsible for the resident's care. When informed that call lights were scattered on floors throughout the facility, the new employee acknowledged the problem but walked away without picking up any of the emergency devices.
Four other residents faced identical situations. Inspectors found one call light at the head of a bed, on the floor. Another was unreachable somewhere in a resident's room. Two more emergency buttons lay on the floor in separate rooms.
The nursing assistant caring for the wet resident offered an explanation: "She is not oriented. She usually pulls her call light out of the wall. Today is a good day. Most days she is screaming and tries to get out of bed."
The facility's own policy, updated in 2025, requires staff to ensure call lights remain "within reach of the residents and secured, as needed." The policy states that emergency buttons must be available at each resident's bedside, toilet, and bathing area to allow people to summon assistance.
Call lights are supposed to relay directly to staff members or a central monitoring station to ensure appropriate response times. The policy emphasizes that the purpose is allowing residents to call for help when needed.
The administrator acknowledged the violations during interviews with inspectors. "Call lights are supposed to be within reach for all residents," the administrator said at 3:03 PM.
In a follow-up interview thirteen minutes later, the administrator described the facility's training approach: "With my team, we educate staff annually. When incidents occur, I have a meeting with the department heads and we decide on what we need to implement going forward."
Staff education happens through paper materials and electronic training modules on a platform called Relias, according to the administrator.
The inspection occurred in response to a complaint about conditions at the 120-bed facility. Federal regulators classified the call light violations as causing minimal harm or potential for actual harm to residents.
But for the resident left sitting in her own waste, unable to reach help, the impact was immediate and personal. Her call light remained on the floor at the foot of her bed while she told inspectors about the delays in receiving care and the difficulty getting staff attention.
The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs. The findings become public record fourteen days after the facility receives the inspection report.
Sedgewood Manor serves residents requiring skilled nursing care and rehabilitation services in Hopkins, a small community in Richland County. The facility is part of the federal Medicare and Medicaid system, which requires adherence to safety standards including accessible emergency call systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sedgewood Manor Health Care Center from 2025-12-30 including all violations, facility responses, and corrective action plans.