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F0919
D

Failure to Maintain Functioning Call Light System in Resident Rooms

Salem, Illinois Survey Completed on 08-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a functioning call light system for three residents who required assistance, as observed during the survey. All three residents had significant medical conditions, including hemiplegia following cerebral infarction, vascular dementia, chronic respiratory failure, and other motor neuron disease, with varying levels of cognitive impairment. The call lights in their shared room were not operational, and instead, the residents were given hand bells to use for summoning assistance. Interviews with the residents revealed that the call lights had been nonfunctional for periods ranging from about a week to several months. The Maintenance Director confirmed awareness of the issue and stated that the company responsible for repairing the call lights refused service due to unpaid bills. The deficiency was further compounded by the presence of large, loud industrial fans in the hallway, which made it difficult or impossible for staff to hear the hand bells when residents attempted to call for help. Staff interviews confirmed that the noise from the fans significantly interfered with their ability to hear the bells, especially when they were not in the immediate vicinity. A family member also observed the use of hand bells and was informed by staff that the call light was not working. The facility's policy required prompt reporting of defective call lights to the nursing supervisor, but the issue persisted without resolution, and the administrator was unaware of the payment issue with the repair company until the time of the survey.

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