Failure to Provide Accessible Call System During Outage
Summary
The facility failed to ensure that a working call system was available and accessible to all residents, particularly in bathrooms and bathing areas, after the electronic call system became inoperable. This failure was observed through multiple interviews, record reviews, and direct observations, revealing that several residents, including those with significant medical needs, were left without a functioning call light or an alternative means to summon assistance. One resident, who was admitted with diagnoses including Atrial Fibrillation, repeated falls, heart failure, and morbid obesity, was placed in a bed without a working call system and was not provided with a bell or any alternative device to call for help. The resident experienced chest pain and shortness of breath for over two hours without staff response, ultimately requiring emergency services for a new onset of atrial fibrillation. Other residents were also found to be without working call lights or bells, and staff interviews confirmed that some residents had never been provided with a bell. Residents reported having to rely on roommates or yelling for help, and in some cases, staff were unaware of the inoperability of the call lights. Documentation showed that the facility's call light system had been out of service for an extended period, and there was no documented plan to ensure all residents had access to an alternative call system. The facility's own policy required that all residents have access to a call system at all times, and that defects be promptly reported and addressed, but these procedures were not followed. The lack of a functioning call system affected all 40 residents in the facility, with specific incidents of delayed care and unaddressed needs, including a resident who was left in soiled clothing for hours and another who was unable to call for help during a medical emergency. Staff interviews revealed confusion and lack of communication regarding the status of the call system and the provision of alternative devices. Maintenance records did not reflect timely reporting or repair of the call system failures, and care plans were not updated to reflect the need for increased supervision or alternative call systems during the outage.
Removal Plan
- All resident care plans were updated to ensure residents receive frequent rounding to ensure needs are met and bells are within reach if a call light is found to be inoperable. Staff will complete a work order and submit to the Maintenance Department for service or repairs. The Maintenance Director will keep all work orders which will document what type of repair was conducted. The Administrator and/or Director of Nursing will be responsible for overseeing and maintaining plan until call light system is back online and operating appropriately.
- All staff were in-serviced on the facility's Call Light policy including reporting call bell system defects promptly to the Maintenance Department for servicing and checking rooms frequently until the call light system is repaired, providing dependent residents with a hand bell whenever a call light is found to be inoperable, and answering call lights promptly.
- V2 was educated on the facility's Comprehensive Care Plan policy, including developing a comprehensive care plan after completion of the comprehensive assessment that includes services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, resident's goals for admission and desired outcomes, resident's preference and potential for future discharge, including the resident's desire to return to the community and any referrals to local contact agencies.
- V6 (Maintenance Director) was educated to document when call lights were out of service, when repairs were made, and to keep a service repair/work order binder to document when call lights are out of service and when repairs are made.
- All resident bathrooms were provided with hand bells.
- Daily audits were completed to ensure all call lights were operational and hand bells were within reach of all residents that did not have working call lights with the exception of 300 hall which closed and does not currently have residents. These audits will continue.
- All staff were re-in serviced on ensuring V17 receives a work order whenever call lights are not working and ensuring V17 documents in the maintenance binder when the call lights are inoperable and are repaired.
- The new call system was fully operational and working on all of 100 and 200 hallway bathrooms and resident rooms. All resident rooms and bathrooms had bells as back up call devices. These bells were within reach of all residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that a cognitively impaired, functionally dependent resident with aphasia did not have a working bedside call light on multiple observations, and the alternative bell was placed out of reach on top of a mini refrigerator. The resident’s care plan and MDS documented extensive ADL assistance needs and fall/safety precautions. The Maintenance Director reported being unaware of the inoperable call light despite an equipment rounding program, while the Administrator described bedside bells as a matter of resident preference rather than a substitute for a nonfunctional call light. A CNA stated that staff are expected to keep call lights within reach and report malfunctions, and facility policy required fully functional, accessible call devices in resident rooms and bathrooms with regular testing, which was not followed in this case.
Call Light System Not Functioning in 500 Hall: A facility failed to ensure the call light system worked in the 500 hall bathroom and bathing area. Repeated observations showed the panel light stayed on while the light above the room did not illuminate, and one room's bed B call light did not light at either the door or the panel. The maintenance log also showed repeated call light issues, and the MDS stated the panel was sometimes reset when the error occurred.
Staff failed to keep call systems within reach for three LTC residents who were incontinent and dependent on staff for ADLs, including residents with arthritis, bipolar disorder, chronic pain, stroke with one-sided impairment, and hemiplegia/hemiparesis. Surveyors observed call lights and call pads placed toward the head of the bed, behind the bed on a light fixture, or hanging on the wall above the bed, all out of the residents’ reach during multiple observations. These practices did not follow the facility’s policy requiring call lights to be within reach and accessible while residents are in bed.
A resident with dementia, anxiety disorder, chronic respiratory failure, and a documented need for substantial assistance with bed mobility was observed with her call light hanging from the bed rail out of her reach. Three pillows were stacked on the side where the call light cord was located, further preventing her from accessing it. An RN confirmed that the call light was not within the resident’s reach, resulting in a cited deficiency related to the call system.
A resident with Alzheimer’s disease, severe cognitive impairment (low BIMS score), and communication difficulties was care planned for supervision with toileting and partial assistance with bathing, yet was observed ambulating independently to a shared bathroom where the emergency pull-cord system was not functioning. Surveyors found that pulling the bathroom emergency cord did not activate lights or an alert at the nurse’s station, and a CNA was unaware whether the cord signaled at the station. This confirmed that a working emergency call system was not available in the bathroom and bathing area used by the resident.
The facility failed to maintain a functional call system for three residents on one hallway, resulting in non‑working call lights in bedrooms and bathrooms and, in one case, the complete absence of a call light. One resident, care planned to use a call light, instead received a drum she could not effectively use, requiring her to yell or wait for staff checks. Another resident with a traumatic brain injury and convulsions reported having no call light or alternative device and having to walk to the nurses’ station for help. A third resident with diabetes and anxiety also reported a non‑functioning call light and no alternative call system, stating he had to search for staff. The Administrator and a CNA confirmed the south hallway call lights had been inoperative for an extended period, and the acting Maintenance Director acknowledged awareness of the problem and the importance of a working call system.
Nonfunctioning Call Light and Inaccessible Bell for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the resident call system when a cognitively impaired resident with aphasia and significant self-care deficits did not have a functioning bedside call light on three separate observations. On each observation, the call light was present near the resident’s bed but was not operational, and the resident’s bell was placed on top of a mini refrigerator beside the bed rather than within reach. The resident’s care plan documented self-care deficits and the need for assistance with most ADLs, including fall and safety precautions, and the MDS showed total dependence for toileting and lower body dressing, setup assistance for eating, partial assistance for upper body dressing, and substantial assistance for showering and position changes. Interviews revealed that the Maintenance Director was unaware that the resident’s call light was not operating, despite a facility program in which department heads are assigned to check resident equipment. The Administrator stated that bedside bells were considered a resident preference and that residents could choose to use either the bell or the call light, but not because the call light was nonfunctional. A CNA reported that staff are expected to ensure call lights are within reach and to report nonfunctioning call lights immediately for repair. The facility’s policy required each resident room to have fully functional bedside, toilet, and shower call devices within reach of residents, with systems tested upon installation, monthly, and after maintenance, and accessible from beds, chairs, and bathroom floors, which was not met for this resident.
Call Light System Not Functioning in 500 Hall
Penalty
Summary
The facility failed to ensure the call light system was functioning in the 500 hall bathroom and bathing area. On 05/03/2026, 05/04/2026, and twice on 05/07/2026, observations showed the call light panel in the 500 hall with a room light lit while the call light above the room was not lit. The maintenance log for the 500 hall also documented call light issues on 03/03/2026, 03/06/2026, 04/10/2026, and 05/03/2026 for call lights not turning off. During an observation on 05/07/2026, the call light for room [ROOM NUMBER] bed B did not light above the door or at the call panel. In interview, the Maintenance Director stated the system was checked through periodic audits and review of the maintenance binder, and that the panel was reset when the error occurred. The Administrator stated the light on the call light panel should turn off when the light at the door was turned off, and that observations of them not turning off did not meet expectations.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves staff failing to ensure that resident call systems were within reach for multiple residents who were dependent on staff for activities of daily living. One resident with arthritis, bipolar disorder, chronic pain, and total bowel and bladder incontinence was observed in bed with her call light cord positioned toward the head of the bed and out of her reach; when asked, she confirmed she could not reach it and requested that it be moved closer. Another resident with a history of stroke and one-sided impairment, who was incontinent and dependent on staff for ADLs, was observed lying in bed without access to the gray call pad, which was hanging on a light fixture behind the bed; he stated he was able to use the call pad, but it was not placed where he could reach it until a CNA later repositioned it. A third resident with hemiplegia and hemiparesis affecting the left non-dominant side, impaired left upper extremity, and functional limitation in upper extremity range of motion was repeatedly observed lying comfortably in bed while the call light was left hanging on the wall above the bed and out of reach. This resident was able to communicate verbally and move the right upper extremity, but the call light remained out of reach during multiple observations on different days and times. Review of the facility’s policy titled “Call Light: Accessibility and Response” showed that staff were required to ensure the call light was within reach of the resident and accessible while the resident was in bed, which was not followed in these instances.
Call Light Not Left Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a working call system was left within reach for a resident in her room, as required for resident bathrooms and bathing areas and evaluated under environmental concerns. The resident had been admitted with dementia, anxiety disorder, and chronic respiratory failure, and her MDS 3.0 assessment documented that she required substantial assistance from staff for bed mobility. During observation, the resident’s call light was found hanging from the bed rail on the right side of the bed, outside of her reach, with three pillows stacked on that side further preventing her from accessing the call cord. A registered nurse confirmed this observation during interview. This deficiency was cited as non-compliance under Complaint Number 2726820.
Non-Functional Bathroom Emergency Call System for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functional emergency call system in a resident bathroom and bathing area used by a cognitively impaired resident. Resident #16, who has Type 2 diabetes without complications and Alzheimer’s disease, was assessed on a recent quarterly MDS as having severely impaired cognitive abilities, with a BIMS score of 5/15. The resident’s care plan identified communication problems related to dementia, a primary language of Spanish, and the need for various communication supports and monitoring of her ability to express needs and discomfort. Functionally, the resident required supervision or touching assistance for toileting hygiene and partial-to-moderate assistance with showering/bathing, but was observed during the survey to ambulate independently to the shared bathroom. On an initial bathroom tour on 4/21/26, surveyors observed that the emergency pull alarm in the bathroom shared by specified rooms on Unit 1 appeared non-functional, as it would not light up or be heard at the nurse’s station. This same bathroom was used by Resident #16, who was repeatedly observed ambulating independently to this restroom despite the non-operable emergency call system. On 4/24/26, the emergency pull cord was tested again and, when pulled, did not send an alert to the call enunciator at the nurse’s station. When asked, CNA #3 stated he was not aware whether the emergency pull-cord alarm sent an alert while at the nurse’s station. These observations and staff interviews confirmed that a working emergency call system was not available in the bathroom and bathing area used by Resident #16.
Failure to Maintain Functional Call System for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system in resident rooms, bathrooms, and bathing areas for three residents on the south hallway. One resident’s admission record showed she was elderly and care planned to have her call light within reach and to be encouraged to use it for assistance. On observation, her bed and bathroom call lights were not working, and she confirmed this, stating staff had given her a drum to signal for help. She reported she was unable to use the drum effectively, and when she attempted to use it, no audible sound could be heard at her door. She stated that when she needed help, she had to yell or wait for staff to check on her. Her daughter‑in‑law confirmed that the resident was not physically capable of making a loud sound with the drum and that the call light system had not worked since admission. A second resident, with diagnoses including traumatic brain injury and convulsions, was observed in bed with no call light present in the room and a non‑functioning call light in the bathroom. This resident stated she did not have a call light and had to walk to the nurses’ desk to find staff when she needed help, and that no alternative call system such as a noise maker had been provided. A third resident, diagnosed with diabetes and anxiety, reported his call light was not working and that staff had not provided an alternative call system; he stated he had to look for staff when he needed assistance, and no noise maker was observed in his room. The Administrator stated the call light system on the south hallway had not been working for about two weeks. A CNA reported that call lights on the south hallway were not working and that the facility had provided drums as noise makers, while the acting Maintenance Director stated he became aware of the call light system problem the previous week and acknowledged the importance of a working call system so residents can contact staff.
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