Failure to Document Required Nurse Call System Checks
Summary
The facility failed to follow its policy for routine testing and documentation of the nurse call system in resident bathrooms and bathing areas, resulting in missing documentation of required inspections. A complaint was received by the California Department of Public Health alleging that a call light had not been working for four weeks. Review of the maintenance logs for July, August, and September 2025 showed entries indicating all call lights were working, but there was no documentation of call system checks for November and December 2025. During an interview, the Maintenance Manager stated that call lights and the call system are supposed to be checked monthly and documented, and acknowledged that there was no documentation for those two months. The facility’s policy, revised in January 2025, required weekly checking of a proportionate number of nurse call buttons, buzzers, cords, and lights so that each part of the system is checked at least monthly, including verification that the signal lights over residents’ doors, the audible signal at the nurses’ station, and the annunciator lights function properly. This deficient practice placed the facility at risk for a non-functioning call system, as the required testing and documentation process was not followed or recorded for the specified months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Call Light Not Within Resident’s Reach: A resident with Parkinson’s disease, dementia, unsteadiness, and a fall history did not have an accessible call light while seated in his wheelchair watching TV. The call light was taped to a positioning pole near the bed, and both the resident and staff confirmed he could only use it if he moved his wheelchair back to the bed.
A resident with functional quadriplegia and stiff, curled fingers did not have an adaptive call light pad in the new room after readmission and was observed using a standard call light button with difficulty. Records showed the resident had previously used a call light pad, but the room was equipped with a standard button instead of the easier-to-use device noted in the resident’s history and care documentation.
A resident dependent on staff assistance with ADLs had a nonfunctioning call device after the cord was found wrapped on the siderail. When the resident activated it, neither the wall box nor the overhead indicator light illuminated, and the ADON and Maintenance Director both confirmed the device was not working. The resident had COPD, morbid obesity, HTN, and moderately impaired cognition, and the care plan directed staff to keep the call light within reach for toileting and incontinence assistance.
Unanswered and Malfunctioning Call Light System: A facility failed to maintain a fully functional call light system when pagers, the nursing station notification terminal, and the reset function did not reliably alert staff. Several cognitively intact residents who needed extensive assistance reported long waits for help, repeated unanswered call light activations, and in some cases bladder and bowel accidents. Staff interviews confirmed that pagers sometimes did not work, the app at the nurses’ station was unreliable, and the system could reset after multiple alerts without staff response.
Nonworking Bedside Call Light: A resident with Parkinson’s disease, dementia, weakness, and impaired coordination had a bedside call light that did not work when she pressed it while in bed, and the hall indicator did not light up. A CNA confirmed the failure, while the Maintenance Supervisor and DON were unaware the call light was not working. An email from the ADM noted there was no policy for call lights.
Call Light Not Kept Within Reach: A resident with chronic respiratory failure with hypoxia and paroxysmal atrial fibrillation, who was cognitively intact and needed partial/moderate assist with transfers, was found unable to reach the call light. The resident believed it was near the bed, but staff located it behind the head of the bed near the wall and placed it beside the resident. The facility policy required a call light or bell access to be kept within reach.
Call Light Not Within Resident’s Reach
Penalty
Summary
A resident with Parkinson’s disease, dementia, unsteadiness on his feet, and a history of falls did not have an accessible in-room call light while seated in his wheelchair. During observation, his call light was wrapped and secured with medical tape to the top of a positioning pole near the head of his bed, with the cord tucked behind the bedside table against the wall. The resident stated he had no access to the call light when he sat in his wheelchair watching television and would have to turn his wheelchair around and move it toward the bed to activate it for staff assistance. A later observation again showed the resident seated in his wheelchair watching television with no access to the call light taped to the positioning pole near his bed. The EMR showed care plan interventions directing staff to encourage him to use his call light and to keep it within his reach. A CNA acknowledged that securing the call light to the pole prevented access when he was in his wheelchair, and the DON agreed the resident could only reach it if he was in bed or able to move his wheelchair to the bed.
Call Light Pad Not Available for Resident With Limited Hand Function
Penalty
Summary
The facility failed to ensure that one of eleven residents, Resident 12, had a call light pad available for use in the resident’s room. Resident 12 had diagnoses including functional quadriplegia and stated that, before the most recent hospitalization, he used a call light pad that was easier to use because his fingers were stiff and difficult to straighten. During observation, Resident 12 was seen holding the standard call light button in his left hand and using the knuckle of his right index finger to depress the button to call for assistance. Record review showed that Resident 12 was initially admitted to the facility and later readmitted after hospitalization and transferred to a different room. The new room was equipped with a standard call light button instead of the adaptive call light pad previously used. A progress note documented that a calling pad was within reach, and later observation showed maintenance staff disconnecting the regular call light button and connecting a call light pad to the wall on the right side of Resident 12’s bed. The facility policy stated that if a resident has a disability that prevents use of the call system, an alternative communication usable for the resident is to be provided and documented in the care plan.
Nonfunctioning Call Device Not Available to Resident
Penalty
Summary
The facility failed to ensure that a resident dependent on staff assistance with ADLs had a functioning call device. During observation on 06/26/2026 at 10:39 a.m., R4’s call device cord was wrapped on the right-side rail. When R4 activated the device, no light illuminated on the call device box attached to the wall or on the overhead indicator box outside the room. R4 stated she had been calling but nobody seemed to notice. At 10:47 a.m., the ADON pushed R4’s call device and there was still no light on the call device box or the overhead indicator outside the room. At 11:00 a.m., the Maintenance Director tested the device and no light was lit on the call device box. He unwound the cord from the side rail and stated it should not have been tied there because raising the head of the bed pulled the cord off the call device box. He stated the cord should have been clipped to the resident’s gown or sheet and replaced the device with a new one. R4’s record showed diagnoses including COPD, morbid obesity, and HTN, with a BIMS score of 11 indicating moderately impaired mental status. Her care plan directed staff to keep the call light within reach and assist with toileting and incontinence care as needed.
Unanswered and Malfunctioning Call Light System
Penalty
Summary
The facility failed to provide a complete and fully functional call light system for residents in their rooms, bathrooms, and bathing areas. The report states that the facility did not have a process in place to notify staff when call light pagers were not functioning, when the nursing station notification terminal was not receiving notifications, and when the system reset a call light without staff answering it. The facility policy required call lights to relay directly to staff or a centralized location, staff education on the system, immediate reporting of problems, and response by all staff who see or hear an activated call light. Resident #16 was cognitively intact, had chronic kidney disease, protein calorie malnutrition, and major depressive disorder, and required assistance with all ADLs including dressing, transferring, and bathing due to lower body weakness. The resident reported being angry and frustrated because a call light pressed at 6:00 A.M. was not answered until after 9:30 A.M., and the resident was still waiting for help with breakfast. The call light log showed repeated activations over multiple dates that alerted staff seven times and were not answered. Staff interviews showed the LPN was not aware the call light was not working, the Social Worker believed the call light was not functioning properly, and the call light would alert seven times and then reset, requiring it to be pressed again. Resident #107 was cognitively intact, dependent for transfers, and required maximal assistance with toileting and showering. The resident’s call light log showed multiple activations that announced seven times over periods of about 45 minutes each without staff response. The resident stated call lights rarely got answered, often took over an hour, and had taken as long as four hours, causing the resident to urinate and defecate on him/herself. The resident also said staff told him/her that sometimes their pagers did not work properly. Resident #115 was cognitively intact, dependent for transfers, and required maximal assistance with toileting and showering. The resident filed a grievance stating no one answered the call light, and the call light log showed repeated activations that announced seven times and were not answered. The resident said staff do not like to answer call lights and that a bell placed on the table was rarely used because staff could not hear it when the door was closed. Resident #62 was cognitively intact, required assistance with most ADLs, and was always incontinent of bladder and bowel. The resident’s call light log showed multiple unanswered activations, and the resident filed grievances about waiting too long for call lights to be answered. The resident reported waiting an hour on average and as long as two to three hours, causing bladder and bowel accidents. Interviews with CNAs, LPNs, RNs, the SSD, Maintenance Director, ADON, DNA staff, DON, and Administrator showed inconsistent understanding of the system, reports that pagers sometimes did not work, that the system sometimes reset after seven alerts, that the nursing station app sometimes displayed “test system not found,” and that staff often relied on residents to report when call lights were not working.
Nonworking Bedside Call Light
Penalty
Summary
The facility failed to ensure that a working call system was available at a resident’s bedside. Resident #51 was admitted with diagnoses including Parkinson’s disease, muscle weakness, lack of coordination, dementia, and anxiety. Her quarterly MDS showed she was usually able to make herself understood, usually understood others, and had a BIMs score of 9/15, indicating moderate cognitive impairment. Her care plan identified an ADL self-care performance deficit related to dementia and Parkinson’s disease, noted impaired visual function requiring eyeglasses, and included interventions to keep the call light within reach and encourage its use for assistance. During an observation, Resident #51 pushed the call light while lying in bed and it did not work, and the hall light did not illuminate. The resident stated that sometimes staff did not come when she pushed the call light. A CNA confirmed the call light was not working. The Maintenance Supervisor stated he was not aware the resident’s call light was not working, and the DON stated she was not aware the call light did not work. The DON stated that because the call light did not work, it could cause a decrease in care and staff not being aware residents needed assistance. An email from the ADM also indicated there was no policy for call lights.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure that a working call system was kept within Resident #2's reach. Resident #2 was admitted with diagnoses including chronic respiratory failure with hypoxia and paroxysmal atrial fibrillation, and the quarterly MDS assessed the resident as cognitively intact with a BIMS score of 13 and needing partial or moderate assistance with sit-to-stand transfers. During interview, the resident stated the call light was believed to be on the floor next to the bed, but when the resident reached over the side of the bed, the call light could not be found and the resident said he did not know where it was. At observation, Housekeeper #212 entered the room and found the call light behind the head of the bed near the wall, then placed it next to the resident. The housekeeper stated they had deep cleaned the room earlier that morning and thought they remembered seeing the call light on the floor while cleaning, and could estimate how long it may have been out of the resident's reach. The facility policy titled Resident Rights stated residents should have a method to communicate needs to staff, such as a call light or bell access, kept within reach.
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