Failure to Maintain Effective Resident Call System Resulting in Immediate Jeopardy
Summary
The facility failed to ensure that an effective and functioning resident call system was accessible to all residents on the first floor. Specifically, the call light system did not provide an adequate audible or visual alert to staff when the call light was disconnected from the wall at the bedside. This deficiency was observed in multiple rooms, including the rooms of two residents, where disconnecting the call light resulted in only a barely audible beep at the nurses' station and no visual indicator above the rooms. Staff interviews confirmed that the call light system was not effectively notifying them when disconnected, and frequent manual checks were relied upon instead. One resident, who had end-stage heart failure, chronic kidney disease, hypertension, and was on hospice care, required substantial to maximal assistance for toileting and hygiene and was at high risk for falls. The resident was care planned for hourly checks and had a pad-style call light intervention to be kept within reach at all times. Despite these interventions, the resident was found deceased on the floor with the call light detached and unalarmed at the nurses' station. The resident had a history of multiple falls and was receiving scheduled and PRN laxatives for bowel management, with evidence of recent bowel incontinence at the time of the incident. Further investigation revealed that the facility did not have any policies or routine procedures in place to ensure the call system's audible and visual indicators remained operational. The DON and Administrator confirmed that the call lights were easy to pull out of the wall, that residents did so frequently, and that there was no system in place for regular testing or maintenance of the call light system. These failures resulted in all residents on the first floor being left without a reliable means of calling for assistance during emergencies.
Penalty
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Bathroom emergency call light strings were observed too short for three residents to reach from the floor. One resident had muscle weakness, lack of coordination, and dementia; another had dementia, HTN, and depression; and a third had COPD, DM2, HTN, and major depressive disorder. Their MDS assessments showed varying levels of cognitive and toileting assistance needs, and staff confirmed the strings should be long enough for residents to reach if they needed help.
A shared bathroom used by two residents did not have a functioning call light cord accessible near the toilet. Surveyors observed the cord was missing and the call system could not be activated from the floor, and both a CNA and an LPN confirmed residents should have access to a working bathroom call light. The Maintenance Director later confirmed the cord was absent and a replacement was needed.
A facility failed to answer resident call lights in a timely manner for all sampled residents. Multiple residents reported waits ranging from 20 minutes to more than 2 hours for help with toileting, pain medication, and personal care, and one resident reported being left in wet clothes all night. Grievance logs and resident council minutes documented repeated complaints about excessive call light wait times, while the DSD said the issue was addressed with ongoing in-services but had no documented evidence they were effective. The DON stated call lights should be answered within 10 minutes.
A resident with COPD, prior CVA, repeated falls, pain, and moderate cognitive impairment did not have a working call light at bedside. The resident stated the call light had not worked since admission, and surveyors confirmed the button on the bed side did not function. Staff had moved another call light from across the room, but the issue was not documented in the maintenance logbook, and the DON, LVN, CNA, and Maintenance Supervisor each described that the problem had not been properly reported before surveyor inquiry.
Delayed response to resident call lights was observed and reported by two residents. One resident with a recent hip fracture and another resident with CVA-related weakness and incontinence stated staff often took more than 10 to 20 minutes to answer call lights, and a family member reported waits of more than 30 minutes. In one observed room, an LVN answered a call light after five minutes, despite facility leadership stating call lights should be answered as soon as possible and the facility policy requiring immediate response.
A facility failed to maintain a working call light system and did not document required resident checks while the system was down. Residents were given manual bells, but many CNA attestation forms were missing, and staff interviews confirmed the checks were not consistently documented. One cognitively intact, fully dependent resident with quadriplegia was left on a toilet in a common bathroom for hours and was later found on the floor after staff gave conflicting accounts about whether a bell or call device was available.
Bathroom Call Lights Not Reachable for Three Residents
Penalty
Summary
The facility failed to ensure working emergency call light strings were available in the bathrooms for Resident #45, Resident #17, and Resident #41. On 8/10/2026, Resident #45’s bathroom call light string was observed to be approximately two and one-half feet above the floor, Resident #17’s bathroom call light string was observed to be approximately four feet above the floor, and Resident #41’s bathroom call light string was observed to be approximately two feet above the floor. The report states these call light strings were too short to reach the floor from the bathroom area. Resident #45 had diagnoses including muscle weakness, lack of coordination, and dementia, and his quarterly MDS indicated intact cognition with a BIMS score of 12, set-up assistance with personal hygiene, intermittent assistance with toilet hygiene, and use of a cane. Resident #17 had dementia, hypertension, and depression, with a BIMS score of 7 and partial/moderate assistance needed for toileting hygiene and supervision or touching assistance with walking. Resident #41 had COPD, type 2 diabetes, hypertension, and major depressive disorder, with a BIMS score of 12 and partial/moderate assistance needed for toileting hygiene and supervision or touching assistance with walking. The care plans for these residents included ensuring call lights were within reach, and staff interviews confirmed that all staff were responsible for checking that bathroom call lights were long enough for residents to reach if they needed help.
Missing Bathroom Call Light Cord
Penalty
Summary
A functioning resident call light system was not readily accessible in the shared bathroom used by two residents. During observation on 8/4/26, the call light cord was missing from the area adjacent to the toilet, and the call system could not be activated from the floor if a resident fell or was unable to reach the wall-mounted call light. The deficiency involved Residents #65 and #70, who shared the bathroom where the missing cord was identified. During interviews, a CNA confirmed residents should have access to a call light cord while using the bathroom, and an LPN also confirmed there should be a functioning call light in each bathroom for residents to summon staff assistance. On 8/6/26, the Maintenance Director confirmed there was no call light cord by the toilet in the shared bathroom, stated a replacement cord was required, and reported staff are expected to submit maintenance requests through TELLS when repairs are needed. The Maintenance Director stated he had not been notified of the missing cord before staff brought the concern to his attention, and the call light cord remained unavailable at the time of the 8/6/26 observation.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure resident call lights were answered in a timely manner for 11 of 11 sampled residents. The report states that the call system is intended to allow residents to request immediate assistance for pain medication, toileting, personal help, or medical emergencies, yet multiple residents reported long waits for response. Resident 1, who had a BIMS score of 14, stated call light response times were terrible and could take 45 minutes to an hour or more. Resident 2, with a BIMS score of 13, said she used the call light for care, toileting, and pain medication after hip surgery and typically waited 30 to 45 minutes. Resident 3, with a BIMS score of 15, said response times could take longer than 30 minutes, and Resident 4, with a BIMS score of 15, said waits were typically 20 to 45 minutes and that if the call light was not answered timely, she would have to go in her brief. The monthly grievance log documented repeated complaints about call light delays and unmet needs. Entries included Resident 9 reporting no staff response and later being sent to the ED where he was found with bowel movement up to his back and front causing a strong odor; Resident 8 reporting a wait of one hour and 10 minutes; Resident 10 reporting being left in wet clothes all night and no response when calling for assistance; Resident 11 reporting staff were not answering call lights; Resident 4 reporting a two-hour wait; Resident 7 reporting no one was answering call lights and that he had fallen multiple times but got himself up; Resident 5 reporting waiting more than two hours; and Resident 6 reporting call lights taking up to 45 minutes to be answered. The facility’s responses in the grievance log were documented as staff re-education or DSD re-education regarding call light response. Resident council minutes also reflected ongoing concerns about excessive call light wait times and call lights being turned off without addressing the concern. The council noted these concerns on multiple occasions, and the minutes stated nursing in-services were given or ongoing. During interview, the DSD stated the most common complaints from residents and family members were about call lights taking too long to be answered, and she said she responded with ongoing in-services but had no documented evidence that the in-services were effective. The DON stated her expectation was that call lights be answered within 10 minutes at the most and that the DSD should observe staff response after in-service to ensure effectiveness. The facility policy titled Answering the Call Light stated the purpose was to ensure timely responses to resident requests and needs and directed staff to answer the resident call system timely.
Nonfunctioning Bedside Call Light
Penalty
Summary
The facility failed to ensure a working call system was available at a resident’s bedside. Resident #42 was a male with diagnoses including acute and chronic respiratory conditions, COPD, pain, chest pain, repeated falls, cerebral infarction, shortness of breath, and hemiplegia and hemiparesis following a cerebral infarction. His MDS assessment reflected moderate cognitive impairment with a BIMS score of 12, and he was dependent on all ADLs. He was also occasionally incontinent of bowel and bladder, and his care plan included interventions to encourage use of the call light and keep it within reach. During observation and interview, the resident stated his call light did not work beside his bed and had not worked since he had been in the room. The surveyor tested the call light button on the resident’s side of the bed and it did not work. The resident stated staff knew the call light did not work, and staff had moved the other call light from the opposite side of the room to his side of the bed. Later observations again showed the call light at bedside was not working, and the resident stated the facility still had not fixed it. Record review of the maintenance request book did not show an entry for the room’s call light problem. A CNA stated the call light next to the bed was not working and that she was not sure if anyone had looked at it or if it had been reported. An LVN stated she was not aware of the problem and would put it in the maintenance logbook. The Maintenance Supervisor stated he was not aware of the issue until staff contacted him that day and that it had not been in the maintenance logbook before then. The facility policy stated defective call lights should be reported promptly.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure that resident call lights were answered immediately, as required by its policy titled, "Answering the Call Light." Resident 1, admitted with an intertrochanteric left femur fracture and needing assistance with personal care, stated that staff often took more than 20 minutes to answer the call light for incontinent care and other needs. Resident 1's significant family member stated the wait was sometimes more than 30 minutes and that she had gone into the hallway to find a CNA after waiting for staff to respond. Resident 1's records showed intact cognition, bowel and bladder incontinence, and a care plan directing staff to provide incontinent care after each episode and encourage use of the call light for assistance. Resident 2, admitted with cerebral infarction affecting the right dominant side and needing assistance with personal care, stated that staff sometimes took more than 10 minutes to answer the call light and that staff were responding right away only because a state person was in the building. Resident 2's records showed intact cognition and bowel and bladder incontinence, with care plan interventions for incontinent care and peri care after each episode. During observation of another resident room, a call light was noted on for five minutes before an LVN answered it, and the LVN confirmed the delay. The DSD and interim DON both stated call lights should be answered as soon as possible, and the facility policy stated to answer the resident call system immediately.
Failed Call Light System and Inadequate Resident Supervision
Penalty
Summary
The facility failed to maintain an adequate functioning call light system and did not follow its own plan while the system was down by providing documented resident supervision through CNA attestation statements. The call light system began malfunctioning when some resident room call lights were not showing as activated, and after an attempted reset the entire system went down. Residents were then given manual hand bells, staff were told to perform room checks at least every two hours, and CNAs were supposed to document those checks with attestations. Review of the attestations showed many CNAs did not document resident checks on multiple days between 06/01/26 and 06/14/26, and the Administrator and DON confirmed there were no CNA attestations during that period to show residents received adequate routine checks while the call system was not functioning. Resident #334 was admitted with diagnoses including toxic encephalopathy, peripheral vascular disease, quadriplegia, traumatic brain injury, major depressive disorder, anxiety disorder, delusional disorder, and antisocial personality disorder. The quarterly MDS showed the resident was cognitively intact, dependent for all ADLs, used an electric wheelchair with setup assistance, and required a mechanical lift for transfers. On 06/20/26, a progress note documented that an LPN was notified that the resident had not been seen for a while and was found on the floor in the common bathroom after another CNA had placed him on the toilet before leaving for the day. Interviews with the resident and staff described that the resident had been left on the toilet for hours while the call lights were down and there was no working call light in reach. The resident stated he had to push himself off the toilet and scoot to the door to knock for help. Staff gave conflicting accounts about whether a manual bell or a call light string was present in the bathroom, and one CNA stated she asked another aide to stay near the resident because the call system was not working correctly. The resident was later found on the bathroom floor with no call light going off, and the DON stated she could not confirm whether the call light system was working at the time of the incident.
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