Delayed Response to Call Lights Due to Equipment Shortage
Summary
The facility failed to ensure that staff were promptly notified of residents' calls for assistance, as evidenced by multiple instances of delayed response times to call lights. Resident 3, who was cognitively intact and had a history of cerebral infarction and a fracture, experienced significant delays in receiving assistance. On one occasion, Resident 3 activated the call light at 6:27 AM due to bleeding from a scratch and waited over two hours without a response, eventually requiring a family member to intervene. The call light log showed several other instances where Resident 3's calls went unanswered for extended periods, ranging from 23 to 114 minutes. Further review of call light activity reports for other residents revealed similar issues. Resident 2 experienced delays ranging from 22 to 65 minutes, while Resident 1 had call light response times ranging from 28 to 44 minutes. Observations indicated that the facility's call light monitoring system was inadequate, with monitors placed in locations not visible to staff working in various hallways. Staff interviews confirmed that they lacked pagers or walkie-talkies, which hindered their ability to promptly respond to call lights. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the shortage of pagers and walkie-talkies, which contributed to the delayed response times. The Administrator was unaware of the pager shortage and confirmed that staff had to leave their work areas to check call light monitors. The facility's expectation was for call lights to be answered within 15-20 minutes, but the current system and equipment shortages made it difficult to meet this standard, leading to the identified deficiency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, Parkinson’s disease, muscle weakness, and a high fall risk was found in bed without a call light within reach, despite being cognitively intact and care-planned to have the call light accessible and to receive prompt assistance. The call light cord was discovered wrapped and stored behind a roommate’s nightstand, and the resident reported not knowing it was there, while the roommate stated they would press their own call light when the resident needed staff. Multiple LVNs, the DOR, DON, and ADM confirmed the resident could use a call light, that all staff were responsible for ensuring call lights were within reach during rounds and room entries, and that facility policy required each resident to have a means to call staff from the bed and other areas, but this was not followed for this resident.
A resident was found to lack access to both a phone and a working TV remote in a semi-private room. Staff confirmed there was only one phone jack in the room, with the single phone line connected to the roommate’s phone, and that the resident did not have a personal or facility-provided phone. Staff reported the resident sometimes used the roommate’s phone for private communication with family. During observation, the Maintenance Director was unable to operate the TV with the resident’s remote and had to turn the TV on manually, confirming the remote was not functioning.
Surveyors found that multiple residents had non-functional call lights in their bathrooms and bathing areas, with some call lights failing to activate outside the room and others not signaling at the nurses’ station. A DOM and an RN confirmed these failures during testing, and a maintenance staff member reported that malfunctioning call lights were an ongoing issue. Review of work orders showed that these specific call light problems had not been reported, despite facility policy requiring staff to immediately report call system issues and ensure residents have access to a working call system.
A resident in room [ROOM NUMBER], Bed C reported that the bathroom/bathing area call bell did not work, and testing confirmed that pressing the red button failed to activate either the panel light or the hallway light. An LPN verified the call light was nonfunctional, and the Assistant Maintenance Manager acknowledged ongoing problems with this specific call bell and its wall panel. The Administrator also confirmed persistent issues with this call bell and believed the bed was striking the wall panel and causing repeated malfunctions.
Surveyors found that the call bell system in multiple rooms on three units illuminated in the hallway but did not produce an audible alarm when activated. A resident with chronic pain and dysphagia, dependent on staff for toileting and dressing and care planned for fall risk with a call light intervention, reported his call bell had not worked properly for two days, which was confirmed on observation. Another resident with diabetes and insomnia, also care planned for fall risk with a call light intervention, reported that his call bell worked only sporadically. Staff and the Administrator acknowledged that the call bells had been lighting but not sounding since the previous day.
A resident with an L4 wedge compression fracture and intact cognition was observed in bed with the call bell on the floor and not within reach while needing assistance to clean spilled water from his shirt. The resident reported having fallen the previous night after pressing the call bell without receiving a response and then attempting to pull the curtain, resulting in a fall onto his left side. Observations showed the call bell remained on the floor for an extended period until a CNA entered the room and placed it at the bedside, despite stating that resident rounds were done every 15 minutes. The Administrator later stated she had not been informed of this issue.
Failure to Keep Resident Call Light Within Reach at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure a working call system was available and within reach at a resident’s bedside as required by facility policy and the resident’s care plan. Record review showed the resident was an older male with unspecified dementia and Parkinson’s disease with dyskinesia, who was cognitively intact per a BIMS score of 14. His care plan identified an ADL self-care performance deficit due to muscle weakness related to Parkinson’s disease, a need for assistance by one to two staff for transfers, and a high risk for falls related to gait/balance problems and psychoactive drug use. The care plan specifically directed that his call light be kept within reach and that he receive a prompt response to all requests for assistance. During an observation and interview, the resident was found lying in bed without a call light within reach. He stated he had never had a call light in his room. The surveyor observed that the call light cord was wrapped and placed behind his roommate’s nightstand, approximately three feet from his bed, and the resident reported he did not know it was there. The roommate confirmed that the resident did not have a call light and that the roommate would press his own call light when the resident needed staff. When the roommate pressed his call light, an LVN entered the room in response, located the resident’s call light behind the nightstand, unwrapped it, and placed it within the resident’s reach, confirming it was functional and acknowledging it should have been within reach while the resident was in bed. Multiple staff interviews, including with the DOR, several LVNs, the DON, and the ADM, confirmed that the resident was capable of using his call light, even though he did not use it frequently and often sought staff by going out of his room. They each stated that the call light should always be within the resident’s reach while in his room for safety and that all staff were responsible for ensuring call lights were within reach during nursing rounds, every time staff entered a room, and as they walked down hallways. Review of the facility’s “Call System, Residents” policy stated that each resident is to be provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and from the floor, and that the resident call system is to be routinely maintained and tested by maintenance. Despite these expectations and policies, the resident’s call light had been wrapped and stored behind the roommate’s nightstand, leaving him without an accessible means to call for assistance while in bed until it was discovered during the survey.
Resident Lacked Access to Phone and Working TV Remote
Penalty
Summary
Surveyors identified a deficiency in which a resident did not have access to a personal or facility-provided phone and had a non-functioning TV remote control in their room. During review of an intake alleging multiple concerns, staff confirmed that there was only one phone jack in the semi-private room, and that the single phone line was connected to the roommate’s phone. The resident therefore did not have a phone of their own in the room. When asked how the resident communicated privately with family, a GNA and an RN stated that the resident sometimes used the roommate’s phone, and the RN confirmed that the resident did not have a personal or facility phone. Further observation in the resident’s room with the Administrator and Maintenance Director showed that there was only one phone jack available in the room, consistent with prior staff statements. During the same observation, the surveyor asked whether the resident’s TV remote control worked. The Maintenance Director attempted multiple times to turn on the TV using the remote and was unable to do so, ultimately turning the TV on manually. These observations confirmed that the resident lacked direct access to a working phone and a functioning TV remote control in their room.
Non-Functional Call Lights in Resident Bathrooms and Bathing Areas Not Reported or Repaired
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call lights in bathrooms and bathing areas were functional and operating as required. During an observation period with the Director of Maintenance (DOM), call lights for four residents were tested and found not to activate outside the rooms. For two of these residents, the call lights did not light up outside the room when tested, and the DOM stated he thought the light bulbs had gone bad. For the other two residents, their call lights did not activate outside the room and also did not ring at the nurses’ station when pressed, which was confirmed by both a Registered Nurse (RN) and the DOM. Further interviews and record reviews showed that these non-functioning call lights had not been reported through the facility’s work order system. A Maintenance Assistant stated that non-working call lights were an ongoing issue and that he was sure some were outstanding. Review of electronic work orders for the relevant period did not show any entries for the rooms where the call lights were found to be non-functional. The facility’s policy on call lights states that staff are educated on proper use of the call system, including ensuring resident access, and that staff will report problems with call lights or the call system immediately to a supervisor and/or maintenance director and provide immediate or alternative solutions until the problem can be remedied. This policy was not followed for the four residents identified in the complaint investigation.
Failure to Maintain an Operable Call Bell in Resident Bathroom/Bathing Area
Penalty
Summary
The facility failed to ensure that a working call system was available and operable in a resident’s room bathroom/bathing area, resulting in a nonfunctioning call bell for one of nine residents interviewed. During an interview in room [ROOM NUMBER], Bed C, the resident reported that the call bell did not work; when the red button was pressed, neither the red light on the panel where the cord was plugged in nor the white light in the hallway above the door frame illuminated. A licensed nurse (Employee E6) confirmed that the call light was not working. The Assistant Maintenance Manager (Employee E4) stated that he had repaired the call bell, but when it was tested shortly thereafter, it still did not function. Employee E4 acknowledged ongoing issues with this particular call bell and indicated that the wall panel had required repeated replacement. The Administrator also confirmed that maintenance had ongoing problems with the call bell in room [ROOM NUMBER], Bed C, and believed that the bed was striking the wall panel and causing the malfunction. This deficiency was cited under 28 Pa. Code 205.67(k) Electric requirements for existing construction, 28 Pa. Code 201.18(b)(1) Management, and 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Failure to Maintain Functioning Call Bell System on All Units
Penalty
Summary
Surveyors identified that the facility failed to provide a properly working call bell system in resident bathrooms and bathing areas on all three units. On multiple observations on March 19, 2026, call bells in rooms 103, 105, 203, and 316 illuminated in the corridor but produced no audible sound when activated. Staff interviews, including with a nurse and another employee, confirmed that the call bells were lighting up in the hallway but not sounding when used. The Administrator also confirmed that the call bell system had not been functioning properly and that this issue, with lights working but no audible alarm, had been occurring since the prior day. Clinical record review showed that one resident had chronic pain and dysphagia, was alert and oriented, and was dependent on staff for toileting and dressing. This resident’s care plan identified a risk for falls and included an intervention for staff to ensure the call light was within reach and to encourage its use; the resident reported that his call bell had not worked properly for two days, and observation confirmed there was no sound when the call bell was activated. Another resident with diabetes and insomnia, who was also alert and oriented and care planned as at risk for falls with the same call light intervention, reported that his call bell sporadically did not work properly. These findings demonstrated that the malfunctioning call system affected multiple rooms and residents whose care plans relied on a functioning call bell for fall-risk interventions.
Call Bell Inaccessibility in Resident Room
Penalty
Summary
Surveyors identified a deficiency in ensuring that a working call system was accessible in resident care areas when one resident’s call bell was not within reach while he was in bed. The resident, who had a wedge compression fracture of the fourth lumbar vertebra and was on a subsequent encounter for fracture with routine healing, had been assessed on the 5-day MDS with a BIMS score of 15/15, indicating intact cognitive abilities for daily decision making. On 03/12/26 at approximately 10:45 a.m., the resident was observed lying in bed with the head of the bed elevated to about 45 degrees, while his call bell was on the floor beside the bed and not accessible. During an interview at that time, the resident attempted to drink water and spilled a small to moderate amount on his shirt, then requested something to wipe off the water. When asked to use his call bell for assistance, he stated he could not find it. The resident also reported that he had fallen the previous night, stating that he had pressed the call bell but no one came, and that he had been trying to pull the curtain when he fell onto his left side. Follow-up observations on 03/12/26 showed that at 10:55 a.m. the call bell remained in the same location on the floor, still not accessible to the resident. At 11:14 a.m., CNA #2 entered the room, picked up the call bell from the floor, and placed it at the bedside, stating that she performs resident rounds every 15 minutes. In a final interview on 03/18/26 with the Administrator, DON, ADON, and two corporate consultants, the findings were discussed, and the Administrator stated she had not been made aware of the issue.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
