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F0919
E

Failure to Maintain Functional Call Light System in Resident Rooms

Gonzales, Texas Survey Completed on 11-26-2025

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 ensure that a fully functional call light notification system was available in three resident rooms across three hallways. During observation rounds with the Maintenance Director and Activity Director, it was found that the dome lights outside the entrances to two rooms did not activate when the call light was engaged, and the dome light apparatus was missing from the entrance of another room. The Maintenance Director, who had been in the position for about a month, was unaware of how long these issues had persisted and had not maintained a written log of call light checks, only checking them as needed. Record review indicated that maintenance repairs, including call light notification repairs, had been completed previously, but these deficiencies were still present at the time of the survey. Interviews with facility staff confirmed that the lack of an operating dome light hindered staff's ability to receive visual notifications of residents' care needs. The facility's policy required that the resident call system remain functional at all times, but this standard was not met in the identified rooms. The deficiency was identified through observation, interview, and record review, and it was acknowledged by both the Maintenance Director and Activity Director that the absence of a working call system could impede timely staff response to resident needs.

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