F0919

D

Failure to Provide Functioning Call System for Two Roommates

Trenton, New Jersey Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

Surveyors determined that the facility failed to ensure residents had access to a functioning call system, as required by facility policy. During a tour on 2/5/26 at approximately 10:10 AM, a dependent resident with diagnoses including sciatica, depression, Parkinson’s disease, and peripheral vascular disease asked a surveyor to call the nurse. When the surveyor instructed the resident to activate the call bell, it was observed that there was no functioning call bell available. At 10:30 AM, this concern was shared with another surveyor, and at 10:45 AM both surveyors returned to the room and again observed that the residents in that room did not have a functioning call bell.

At 10:50 AM, one resident reported that they had been transferred from another facility on 2/3/26 and had not had a call device since the transfer, explaining that their roommate had to go into the hallway to call staff for assistance. The roommate, who reported needing only minimal assistance with care, confirmed that the other resident could not get out of bed and that she had to get out of bed and shout for staff to assist the dependent resident. In a subsequent interview at 12:30 PM, the DON acknowledged awareness that the room’s call device was not functioning and stated she had previously requested that a manual call device be provided, but neither resident had been given one. Review of the facility’s “Call bell Use Responsibility” policy dated 12/25 showed that it required all residents to always have access to a functioning call bell system and stated that failure to ensure access or timely response may place residents at risk.