A resident reported to a surveyor that the call system in their room was not working after pressing the call button and receiving no response. The surveyor observed that pressing the call button did not activate the call light above the door or the call station at the nurses’ station. An LPN confirmed that the system should provide visual hallway lights, an audible alert, and display the room number at the call station when used, but testing showed the call system in that room was not functioning properly.
Surveyors identified that two residents did not have accessible call light cords in their room, as the cords were found tied and curled on the floor against the wall, despite both residents being alert and ambulatory. In a separate case, a resident reported intermittent problems with a call light that, when tested by the resident, a GNA, and later the NHA, failed to illuminate in the room or hallway on two separate occasions, with staff attributing the issue to a loose wall adapter.
A resident was found to lack access to both a phone and a working TV remote in a semi-private room. Staff confirmed there was only one phone jack in the room, with the single phone line connected to the roommate’s phone, and that the resident did not have a personal or facility-provided phone. Staff reported the resident sometimes used the roommate’s phone for private communication with family. During observation, the Maintenance Director was unable to operate the TV with the resident’s remote and had to turn the TV on manually, confirming the remote was not functioning.
Inaccessible Bathroom Call Lights: Surveyors observed that two residents had bathroom call light issues on a station 2 unit, including one shared bathroom with a pull cord that was too short and another with no pull cord attached to the call light panel. The MDS stated resident bathrooms should have accessible call lights, and the residents were later observed with accessible pull cords.
Missing Bathroom Call Light Pull Cords: Surveyors observed wall-mounted call light devices in 5 resident bathrooms without accessible pull cords on the [NAME] Ground unit. The LNHA and VP of Facility Services/Maintenance were informed, and the VP stated there were issues with the durability of the pull cords.
Call System at Nurses' Station #3 Was Not Functioning Properly. The facility failed to ensure the resident call system was working properly at one nurses' station, where the panel continuously beeped every few seconds even when no resident calls were active and no room numbers appeared on the screen. RN staff stated the issue had been ongoing and maintenance had already looked at it, while the Maintenance Director later confirmed the abnormal beeping and noted other stations did not have the same problem.
Surveyors found that the facility failed to ensure a functioning call bell system on two nursing units, where call lights above resident rooms were illuminated but no audible alerts were heard by staff. On one unit, the call bell panel behind the nurse’s station had tape covering the enunciator speaker and was set to a low tone that was not audible to staff or residents. On the other unit, an illuminated call light corresponded with a panel that had tape over the enunciator speaker, a nonfunctional enunciator, and a missing low/high tone switch. The director of maintenance reported being unaware of these issues until informed by surveyors, and the administrator and DON were notified of the nonfunctioning systems during the survey.
Several residents who required assistance with ADLs and had limited mobility were found without access to a working call light system in their rooms and bathrooms. Despite facility policy requiring accessible call lights and prompt reporting of malfunctions, multiple work orders for broken call lights were left unresolved, and no manual call bells were provided. Staff and maintenance were aware of the ongoing issues, but residents remained unable to reliably summon help when needed.
Multiple residents were found to have nonfunctioning call bell systems, including cases where the alert signal could not be turned off or the call bell failed to signal staff. Some residents reported making repeated requests for repairs that were not addressed, and maintenance staff confirmed that no prior work orders had been submitted for certain rooms. The deficiency resulted in residents lacking reliable access to staff assistance.
The facility did not ensure that the call bell system on the second floor was fully functional, resulting in the absence of an audible alert for staff when a resident activated the call bell. A resident with a tracheostomy reported extended wait times for assistance, and staff confirmed they could not hear the call bell sound. The deficiency was confirmed through observations, interviews, and review of complaints.
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