F0919

E

Failure to Maintain Functioning Call Light System for Multiple Residents

Fresno, California Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a functioning resident call light system in multiple rooms and beds, including bathrooms and bathing areas, leaving residents without a reliable means to summon staff assistance. Surveyors observed that 11 of 59 beds (8A, 8B, 11A, 11B, 11C, 14A, 14B, 15A, 15B, 17B, 17D) had nonfunctioning or missing call lights. In one room, a resident reported that his call light had worked intermittently since admission and had stopped working again the day before the survey; when he pressed the button, there was no light above the door and no sound or light at the bed station panel. The panel had a splitter adapter with two cords plugged in, but the system did not activate. This resident stated he had previously gotten out of bed on his own and gone to the door to yell for help and that on one occasion he waited about an hour to be cleaned after a bowel movement because the call light was not working.

The same resident’s records showed diagnoses including mastoiditis, Bell’s palsy, muscle weakness, and repeated falls, and his MDS BIMS score indicated he was cognitively intact. He reported that the Director of Maintenance (DOM) had attempted to fix the call light about three weeks earlier but was unsuccessful, and that the DOM had said he ordered the wrong part or that parts were not coming in. During the interview, the DOM entered the room with a call light cord, stating he had a work order to replace the cord, but then left the room without replacing it. Later, the DOM stated there were five call lights not working in the facility and that he had received work orders for rooms 8, 11, and 14 on a recent Sunday, and he asserted it was the first time he had heard that the resident’s call light had been intermittently nonfunctional for approximately six weeks.

In another room shared by two residents, one resident stated she did not have a call light and believed it had been stolen; surveyors confirmed there was no call light near her bed. The other resident in the same room had a small silver bell on her overbed table instead of a call light, and she had partial deformity of her hands, making use of the bell difficult. Additional observations with the DOM showed that call lights in multiple rooms and beds did not activate when pressed, including beds 8A, 8B, 11C, 14A, 14B, 15A, 15B, 17B, and 17D, and that beds 11A and 11B had no call lights at all. In some cases, the DOM identified loose plugs or bad connections in the wall panels and noted that silver bells or portable call buttons had been used when the call lights were not working.

Staff interviews revealed inconsistent awareness and reporting of the call light problems. A CNA assigned to affected rooms stated she was unaware the call lights were not working and that the previous shift had not reported any issues. Another CNA reported that one room’s call light would not work at times because the cord would come slightly out of the panel and had to be pushed back in. An LVN stated she did not know that call lights in a particular room were not working, while another LVN reported that call lights in one room had not worked for about two months and that portable call buttons had been provided. The scheduler, who conducted Angel Rounds for certain rooms, stated that call lights in one room had not been working for approximately two months and that residents were initially given silver bells and later portable call buttons, but she was unaware that one resident in that room did not have a call light or bell. The DON stated that call lights in one room had not been working since January and that portable call lights were given due to connection issues, and she was unaware that a resident in another bed did not have a call light.

Review of maintenance request forms showed repeated reports of call light problems over several weeks, including nonworking call lights in room 14 for all beds, a bad wall connection in room 8B, a need for call lights for both beds in another room, and a missing call light in bed 11A. Some forms documented completion dates and comments that call lights were working again or that parts such as split connectors had been ordered. Angel Rounds documentation for certain dates noted a broken call light button in room 11. The facility’s call light policy stated that staff would be educated on proper use of the call system, ensure resident access to call lights, and report problems to a supervisor or maintenance director, and the maintenance director’s job description required maintaining the building and equipment in safe order and ensuring a safe and secure environment for staff, residents, and guests. Despite these policies, survey findings showed multiple nonfunctioning or missing call lights and inconsistent communication and follow-through regarding identified call light issues.