Failure to Maintain Functional Call System in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident rooms were adequately equipped with a properly functioning call system that relayed calls directly to staff or a centralized work area. Surveyor observation on 01/29/2026 with the Maintenance Director showed that the call light system in the shared room of Resident #2 and Resident #3 was not functioning and the entire call light box was out of the wall. In Resident #2’s area, the non-functioning call button was placed on the bed within reach, and a bell intended as an alternative was on the nightstand but out of reach. In Resident #3’s area, the non-functioning call light was also placed within reach despite not working. The report states this failure placed residents at risk of being unable to obtain assistance for ADLs or in an emergency. During interviews, the Maintenance Director stated the call system in that room had broken sometime the previous week, that he had ordered a replacement part, and that he had provided bells to both residents and verbally informed staff of the problem. However, Resident #2 reported that her call system had been broken for about six months and that she could not reach the bell on the nightstand, so she went to the restroom and used the bathroom call button when she needed help. The DON and the Administrator both acknowledged awareness of the broken call system in that room; the DON was unsure how long it had been broken, while the Administrator estimated it had been broken for a couple of months. Review of the facility’s TELS work orders showed entries for a malfunctioning call light that was unscrewed and unplugged from the wall and, later, a call light completely broken out of the wall and separated from wiring, as well as an invoice for a replacement bedside patient station. Facility policies on Accommodation of Needs and Safe and Homelike Environment required the facility to provide a safe environment and make reasonable accommodations in residents’ physical environment, including bedrooms and bathrooms.
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