F0919

E

Failure to Maintain Functional Call Light System in Multiple Resident Rooms

Avon Park, Florida Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to ensure that resident room call light systems were maintained in working order on one of two units and across three halls (100, 200, and 300). On a specified survey date and time, multiple resident rooms (including rooms 101, 102, 200, 202, 204, 209, 304, and 300) were observed to have nonfunctioning call lights. In several rooms, when the call lights were activated and tested multiple times, the corridor light above the room door did not illuminate and the system did not enunciate at the nurses’ station. In another room, the call light would not reset after initial activation. These findings were based on direct testing of the call light devices by surveyors.

During interviews, a CNA assigned to the 100 unit confirmed that at least one room’s call light did not illuminate above the door or enunciate at the nurses’ station and explained that staff submit electronic work orders to maintenance and provide residents with handheld bells when call lights are not working. The DON acknowledged prior call light problems on a different wing and stated there was no awareness of current issues on the observed hall until the survey findings were presented, while confirming that all call lights should be functional and within residents’ reach. The Director of Maintenance confirmed previous call light concerns on the North unit, stated he was unaware of issues on the South unit, and verified that the identified room call lights were not working. Additional LPN staff reported that nonfunctioning call lights are reported via the electronic work order system and that residents are given handheld bells until repairs are made. The facility did not have a specific written call light maintenance policy and procedure available for review.