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F0919
D

Non-Functional Call Light System Results in Delayed Resident Assistance

Pasadena, California Survey Completed on 05-31-2025

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

A deficiency was identified when a resident's call light system was found to be non-functional. The resident, who had diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and schizophrenia, was moderately cognitively impaired and required supervision or assistance with toileting hygiene. During an observation and interview, the resident reported waiting for help for about an hour, stating that the call light was not working. The resident was observed pressing the call light with no audible or visual response, and the call light was noted to have come out of the wall. Further interviews with the Director of Nursing and the Maintenance Supervisor confirmed the importance of a functioning call light system for resident care and safety. Review of facility policy indicated that call lights should be plugged in and functioning at all times. The failure to ensure a working call light system in the resident's room led to a delay in response to the resident's request for assistance.

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