Failed call light system: The facility did not maintain a working call light system for resident bathrooms and bathing areas. A CNA observed a call light on for an extended period, and when multiple call lights were activated, they flashed but did not trigger an alarm or notification at the nursing station; the panel showed an error message. An RN, Maintenance Director, DON, and Administrator all confirmed the unit-wide system was not functioning properly.
A resident dependent on staff assistance with ADLs had a nonfunctioning call device after the cord was found wrapped on the siderail. When the resident activated it, neither the wall box nor the overhead indicator light illuminated, and the ADON and Maintenance Director both confirmed the device was not working. The resident had COPD, morbid obesity, HTN, and moderately impaired cognition, and the care plan directed staff to keep the call light within reach for toileting and incontinence assistance.
A facility failed to ensure working call lights were available and within reach for multiple residents. Residents with documented weakness, ADL dependence, and other medical conditions were observed with missing, disconnected, or nonworking call lights, and some were given bells instead. Residents and staff reported that bells were hard to hear and that call lights were not always answered, while leadership acknowledged ongoing problems with the call light system and rooms without functioning devices.
A facility failed to keep the resident call light system working for multiple residents. Two residents in a shared room reported their call lights had not worked for weeks or longer, and testing showed their bedside and bathroom call lights did not activate the nurse station monitor. Another resident reported her call light had not worked overnight, and when tested, the monitor again did not show activation. An LPN stated the system probably did not work and that a new call light system was needed.
A facility failed to ensure call lights were within reach and functioning for 4 of 8 residents reviewed. Several residents had call lights placed on the floor, draped over furniture, or tied to bedposts or bedside tables so they could not reach them, and one resident stated she had been told the call lights were not working and never received a wireless call light. CNAs stated call lights should always be within reach, and the ADM acknowledged issues with call lights not working or not being within reach.
Nonfunctioning Call Light System and Resident Call Lights: The facility failed to maintain a working call system in resident bathrooms and bathing areas, and two residents had call lights that were not operating properly. Staff reported the system often had no audible alarm at the nurses’ station and required physically checking hall lights. One resident said the call light had been broken for weeks and reported repeated unanswered calls for help, while another resident with significant medical issues said the call light worked only intermittently and was observed with a disconnected electrical box missing a battery.
Call Light Not Within Reach for Two Residents: A facility failed to ensure a working call system was available in resident rooms and bathing areas. Two cognitively intact residents who needed assistance with ADLs reported they had no call light or bell to summon staff, and observations confirmed no call light or bell was present in their rooms. The facility policy required call lights to be within the resident’s reach at all times.
Call Light Not Functioning Properly: A cognitively intact resident dependent on staff for ADLs reported that the call light was not working correctly and had been an ongoing issue. During observation, the light above the door did not illuminate when activated, and a CNA stated not all call lights alert at the nurses' station. The resident said staff sometimes could not see the call light and that they had to yell out or wait longer for help.
Missing and Nonfunctioning Call Light System: Two residents, both cognitively intact and requiring assistance with ADLs/toileting, were found without a working call light or alternate call device in reach. Surveyors observed the wall jack hanging and not in working condition, with no cords plugged in, and both residents said they would have to rely on their roommate to call for help. The Maintenance Director acknowledged the call lights had been missing for at least two weeks, and a repair quote for the 3rd floor and shower room had not yet been approved or scheduled.
The facility failed to maintain a functional call system for three residents on one hallway, resulting in non‑working call lights in bedrooms and bathrooms and, in one case, the complete absence of a call light. One resident, care planned to use a call light, instead received a drum she could not effectively use, requiring her to yell or wait for staff checks. Another resident with a traumatic brain injury and convulsions reported having no call light or alternative device and having to walk to the nurses’ station for help. A third resident with diabetes and anxiety also reported a non‑functioning call light and no alternative call system, stating he had to search for staff. The Administrator and a CNA confirmed the south hallway call lights had been inoperative for an extended period, and the acting Maintenance Director acknowledged awareness of the problem and the importance of a working call system.
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