Failure to Document Required Nurse Call System Checks
Summary
The facility failed to follow its policy for routine testing and documentation of the nurse call system in resident bathrooms and bathing areas, resulting in missing documentation of required inspections. A complaint was received by the California Department of Public Health alleging that a call light had not been working for four weeks. Review of the maintenance logs for July, August, and September 2025 showed entries indicating all call lights were working, but there was no documentation of call system checks for November and December 2025. During an interview, the Maintenance Manager stated that call lights and the call system are supposed to be checked monthly and documented, and acknowledged that there was no documentation for those two months. The facility’s policy, revised in January 2025, required weekly checking of a proportionate number of nurse call buttons, buzzers, cords, and lights so that each part of the system is checked at least monthly, including verification that the signal lights over residents’ doors, the audible signal at the nurses’ station, and the annunciator lights function properly. This deficient practice placed the facility at risk for a non-functioning call system, as the required testing and documentation process was not followed or recorded for the specified months.
Penalty
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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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