Failure to Maintain Functional Resident Call System in All Halls
Penalty
Summary
The facility failed to maintain a functioning resident call system in all resident bathrooms and bathing areas across four halls when the call light system became inoperable. Observations confirmed that the call lights were not working, and residents were instead provided with cow bells to signal for assistance. Staff were required to make rounds every 15 to 30 minutes to check on residents, particularly those unable to use the call bells. The breakdown of the call system was first noted on 11/11/25, and as of 11/15/25, the system remained nonfunctional. Interviews with the DON, Maintenance Director, and RN confirmed that the call system outage affected all residents on the impacted halls. The Maintenance Director reported that the system had previously been checked weekly and was functioning until the complete failure. A technician was called, but there was no clear timeline for repair. The facility's policy requires a functional call system at all times, but this standard was not met during the period in question.