Failure to Maintain Audible and Functional Call Light System
Penalty
Summary
Surveyors observed that the facility failed to maintain a functional and audible resident call light system in multiple resident rooms and bathrooms. On several occasions, call lights were visibly activated above resident rooms but were not audible in the hallway, preventing staff from being alerted to resident needs. These observations occurred over several days and at various times, indicating a persistent issue. Interviews with staff, including the Maintenance Director and nursing staff, confirmed that the call light system's sound had been turned off by night shift staff to avoid disturbing residents, and that staff were sometimes unsure how to ensure resident safety when the call lights were not functioning properly or audible. Residents reported experiencing excessively long wait times for call light responses, sometimes waiting over an hour. The Resident Council and individual residents confirmed that call lights were often inaudible during the night shift. Staff interviews revealed uncertainty about the system's security and the ability to restrict access to call light volume controls. Despite attempts to address the issue, further observations showed that the call light system continued to be inaudible at times, and staff acknowledged the ongoing problem.