F0584

D

Failure to Maintain Comfortable Sound Levels Due to Broken Exit Door Keypad

Pacific, Missouri Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

Facility staff failed to maintain a comfortable and homelike environment by not ensuring a functional keypad on the secure metal door leading to an outside exit on C hall, resulting in a loud, continuous beeping noise each time staff entered or exited. The facility lacked an environmental policy, and the keypad had been broken for at least a couple of weeks, according to staff. The beeping occurred whenever staff held down the metal bar for 15 seconds to open the door and continued until a code was entered on the other side.

Multiple observations over several days showed frequent, loud beeping from this door as various staff, including maintenance, CNAs, laundry, and housekeeping personnel, repeatedly used the door throughout the day. Each observed use required holding the bar down for 15 seconds, triggering the loud alarm-like sound. This occurred many times in a short period on multiple days, demonstrating an ongoing and unresolved environmental issue affecting the sound level in the hallway.

Residents reported that the noise disturbed their rest and comfort. One resident stated the beeping came from the broken back door to the laundry room, reported that staff began arriving early in the morning, and said the noise often woke them up and made them feel "crazy." Another resident said the loud beeping sounded like a fire alarm, believed the door was broken, and reported being awakened in the mornings and hearing the sound periodically all day and sometimes at night, stating it bothered everyone. Staff interviews confirmed awareness of the broken keypad and frequent use of the door, while leadership interviews showed that the DON and administrator were not aware of the problem until the surveyors arrived, and that the maintenance director was waiting on invoices to be paid before ordering the needed part.