F0919

E

Malfunctioning Call Light System Affecting Multiple Residents

Grants Pass, Oregon Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that resident call lights functioned properly and independently in resident rooms and bathrooms. For one resident admitted in January 2021 with pain, a CNA tested the call light and found that when this resident’s call light was turned off, the roommate’s call light also turned off. Similar testing was done for two other residents, one admitted in January 2024 with stroke and diabetes and another admitted in January 2023 with heart disease, and in both cases, when each resident’s call light was turned off, the roommate’s call light also turned off. The facility administrator confirmed that the call lights should operate independently.

Another resident, admitted in June 2024 with pain and repeated falls and documented as cognitively intact on a quarterly MDS, reported that it took staff about 20 minutes to answer call lights and believed the call light was malfunctioning because it would shut off by itself. This resident stated that these concerns had been reported to staff without follow-up. A CNA acknowledged that the resident had reported multiple times that the call light was not working but initially believed the resident was mistaken. Upon testing, the CNA confirmed the call light was not functioning properly and that turning off this resident’s call light also turned off the roommate’s call light.