Call Bell System Failure Leads to Immediate Jeopardy
Summary
The facility failed to ensure that the call bell system was fully functional in three out of four areas, specifically the 100, 200, and 300 Halls, placing residents in an Immediate Jeopardy situation. The malfunction was caused by a possible lightning strike, which led to the call bell system being inoperable. As a temporary measure, tap bells were provided to residents, but these were not sufficient as they could not be heard throughout the facility or over long distances. Observations revealed that some residents did not have tap bells in their rooms, and staff were not adequately informed about the frequency of safety checks or how to manage the situation effectively. Interviews with staff members, including a maintenance director and nursing staff, highlighted a lack of communication and training regarding the nonfunctional call bell system. Staff were not instructed to increase the frequency of resident rounding, and there was confusion about how residents could alert staff if they needed assistance, particularly in the bathrooms where no call bells were accessible. Some staff members assumed they would hear residents yell for help, but this was not a reliable method of ensuring resident safety. The deficiency was further underscored by specific incidents involving residents. One resident, who was cognitively intact but had physical impairments, was found on the floor with injuries after being unable to call for assistance due to the nonfunctional call bell. Another resident expressed frustration with the tap bell system, noting that staff could not determine the source of the call. These incidents illustrate the immediate risk to resident safety due to the facility's failure to maintain a functional call bell system and adequately address the situation with effective interim measures.
Penalty
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Bathroom emergency call light pull cords in several resident rooms were observed hanging above the handrail and not readily accessible from the floor. The Maintenance Director stated they were unaware of any regulation related to bathroom pull cords, and the Administrator stated the expectation was that resident bathroom pull cords should be accessible if a resident was on the floor.
Nonfunctioning Resident Call Lights: A resident reported waiting a long time for staff to answer her call light and said it had been disconnected from the wall extender, while another resident said her call light had been unplugged and she had to get help by having a friend use his call light. Staff and residents also reported repeated call light problems for another resident, and the DON stated call lights were expected to always be in working order; the facility did not have a call light policy.
Nonfunctioning Resident Call Buttons: Two residents had call buttons that did not work, and testing showed no light or alarm at the nurse’s station. An LVN later gave each resident a handbell as a temporary replacement, but one resident reported ringing it overnight without response and woke up with a soaked brief. Staff interviews showed the handbells were not clearly communicated to all aides, and the MAINTD said the call system problem was related to cords wrapped around bed frames causing a short.
A resident with hemiplegia/hemiparesis, HF, gait impairment, and muscle weakness required max assist with showering and toilet hygiene, and the care plan included keeping the call light within reach. During observation, the resident was seated in a shower chair while an NA left the room, and the bathroom call light box was located across the room next to the toilet, making it unreachable from the shower. Staff and the DON stated residents were not to be left unattended in the shower, but the new call light setup left no accessible call light or cord in the shower area despite the facility policy requiring call lights at the bedside, toilet, and shower/bathing facility.
A resident call light system on the Cove unit was not working, and multiple residents reported they could not summon help when needed. Residents said their call lights did not illuminate or sound, some had to yell, wheel into the hallway, or wait for staff rounds, and not all residents were given bells. Staff knew parts of the system were down, but communication and response were inconsistent, and maintenance was not notified immediately.
Call Light Not Within Reach for Two Residents: A facility failed to ensure a working call system was available in resident rooms and bathing areas. Two cognitively intact residents who needed assistance with ADLs reported they had no call light or bell to summon staff, and observations confirmed no call light or bell was present in their rooms. The facility policy required call lights to be within the resident’s reach at all times.
Bathroom Emergency Call Light Pull Cords Not Accessible
Penalty
Summary
The facility failed to ensure bathroom emergency call light pull cords were accessible to residents from the floor in resident rooms 106, 107, 121, and 311 on 2 of 4 sampled halls (100 and 300) reviewed for call light systems. Observations showed the pull cords in those bathrooms hung above the handrail on the wall and were not readily accessible to a resident if the resident were on the floor after a medical emergency or fall. During interview, the Maintenance Director stated they were unaware of any regulation related to bathroom call light pull cords, and the Administrator stated the expectation was that resident bathroom pull cords should be accessible to call for help if the resident was on the floor.
Nonfunctioning Resident Call Lights
Penalty
Summary
The provider failed to ensure that resident call lights were functioning for three sampled residents whose call lights were not working. Resident 34 was observed in bed and stated she had waited a long time for staff to answer her call light and then would be incontinent of urine. She said she had turned her call light on a while ago and no one had come. When RN P checked, resident 34’s call light was found disconnected from the call light extender that plugged into the wall, so it did not turn on when pushed. Resident 34’s EMR showed a BIMS score of 14, indicating intact cognition. Resident 73 stated she had problems with her call light being unplugged from the wall and had to yell to a friend across the hall to turn on his call light to get staff help. Her EMR showed a BIMS score of 15, indicating intact cognition. During the Resident Council Meeting, staff and residents reported that resident 41’s call light had not worked numerous times and that resident 73 had issues with her call light not working. On another observation, resident 34’s call light turned back off on its own, and the ADON/LPN/IP stated that it did that sometimes. RN P also stated that call lights sometimes get hooked under the bed and pulled out of the connector, causing them not to work. The DON stated she expected call lights to always be in working order, and the facility did not have a call light policy.
Nonfunctioning Resident Call Buttons
Penalty
Summary
The facility failed to ensure that two residents had functioning nurse call buttons in their rooms on multiple days. Resident #53 was a male with diagnoses including cerebral infarction, hemiplegia and hemiparesis, history of falling, lack of coordination, muscle weakness, abnormalities of gait and mobility, and need for assistance with personal care. Resident #84 had diagnoses including type II diabetes mellitus, congestive heart failure, history of falling, hemiplegia and hemiparesis, and repeated falls. His quarterly MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and Resident #53’s care plan directed staff to keep the call light within reach and encourage him to use it for assistance. During observation and interview, Resident #84 stated his call button was not working, and testing showed the light outside the room did not come on and no alarm sounded at the nurse’s station. Resident #53 then stated his call button also did not work, and testing showed the same result. The next day, both residents’ call buttons were still not working. LVN C observed the problem and later returned with two handbells, giving one to each resident as a temporary replacement. On the following day, Resident #53 again tested his call button and it did not activate the light outside his room. Resident #53 stated he had tried to ring his handbell overnight and no one responded, and his bed was soaked in urine when he woke up. NA I, who was standing in the hall, did not respond when he rang the handbell and stated she had not heard it. Interviews with staff showed that NA I had not been told the handbells were being used as call bells, and LVN C stated she had told aides about the temporary replacement but was unsure whether the instruction was understood. The MAINTD stated he had been told about the broken call buttons, had tried to replace them, and believed the problem was caused by cords wrapped around bed frames creating a short at the wall panel. The DON and ADM stated the residents should have had functioning ways to call staff, and the ADM stated the responsibility for the call system was ultimately hers.
Call Light Not Accessible in Shower Area
Penalty
Summary
A resident who was cognitively intact and had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, heart failure, abnormalities of gait and mobility, and muscle weakness required maximal assistance with showering and toilet hygiene. The resident’s care plan identified an ADL self-care performance deficit and included assistance from one staff member with showering and toilet hygiene, along with ensuring the call light was within reach as a fall-risk intervention. During an observation and interview, the resident was seated in a shower chair with the water running while an NA had left the room after receiving a call on a walkie-talkie. The resident stated the bathroom call light box was located across the room next to the toilet and could not be reached from the shower, leaving the resident unable to contact staff or call for help if needed. Observation confirmed the call light placement and the resident’s inability to access it while in the shower. Staff interviews indicated residents were not supposed to be left alone in the shower, and the DON stated the facility’s new call light system had moved the call light box next to the toilet, leaving no call light box or cord accessible while a resident was in the shower, despite the policy stating a call light should be available at each resident’s bedside, toilet, and shower/bathing facility.
Nonfunctioning Call Light System on Cove Unit
Penalty
Summary
The facility failed to maintain a functioning call light system in the Cove unit, including in residents’ rooms and bathroom/bathing areas. On 05/14/2026, Resident 3 and Resident 4 each reported that their call lights had not been working since the previous day. When each resident pushed the call light, the light above the door did not illuminate, there was no audible sound, and the room number did not appear on the call system panel across from the nursing station. Resident 3 said they had to wheel into the hallway to find staff, and Resident 4 said they had to yell for help because their voice was not loud enough to be heard. Additional residents on the Cove unit reported the same problem. Resident 5 said they had not had a functioning call light since about 5:00 PM the day before and had not been given a bell or other instructions for alerting staff. Resident 6 said they had been pushing the button and no one came, were told the system was down, and had not been given a bell; they said they had chronic shortness of breath and had no way of yelling loud enough. Resident 7 said they pushed the call light and no one came, later used a cell phone to contact the front desk, and eventually received a bell from staff, but said the bell could not always be heard and the wait for assistance was longer. Staff interviews showed the problem had been known before the surveyor observation, but the issue was not promptly resolved or consistently communicated. A CNA said the call light in Resident 3’s room had stopped working the day before and that the Cove unit system was still not working, with only some residents given bells because there were not enough for everyone. An LPN said the evening supervisor had discussed Resident 7’s concern and that a message was sent through the staff phone app about the Cove lights not working. The ADON said a stand-down meeting had been held and staff were told maintenance had been notified, but the ADON did not investigate how many call lights were affected or ensure all residents had a way to alert staff. Maintenance staff said they were not notified until the morning of 05/14/2026 and stated they would have responded immediately if told the prior day. The Administrator said they learned of the issue only after reading a grievance from the grievance box that morning.
Call Light Not Available Within Residents’ Reach
Penalty
Summary
The facility failed to provide a working call system in resident bathrooms and bathing areas, and failed to ensure call lights or another mechanism to alert staff were within residents’ reach in their rooms for 2 of 6 residents reviewed. R7’s records showed diagnoses including Type 2 DM, HTN, CKD, and muscle weakness. R7 was cognitively intact, needed partial/moderate assistance with toileting hygiene and showering/bathing, supervision or touching assistance with chair/bed transfers, and was occasionally incontinent of bladder. R7 stated she did not have a call light, bell, or other device to get staff’s attention and said she would yell for staff if she needed help. No call light or bell was observed in R7’s room during two separate observations. R12’s records showed diagnoses including pulmonary embolism without acute cor pulmonale, prediabetes, and personal history of venous thrombosis and embolism. R12 was cognitively intact, used a wheelchair, needed partial/moderate assistance with toileting hygiene, showering/bathing, sitting to standing, and chair/bed to chair transfers, and was always continent of bowel and bladder. R12 stated he did not have access to his call light or a bell and did not know what to do if he needed help. The Administrator stated a third call light had been ordered for rooms with three residents and that bells had been purchased for residents to use while waiting for the call lights to arrive. The facility’s policy stated to ensure the call light is within the resident’s reach at all times.
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