Observations:
Based on observations of the resident rooms, and interviews with staff, it was determined that the facility failed to maintain the Resident call bell system in working condition for two out of 10 residents' rooms observed for call bell functioning.
Findings Include:
On January 28, 2026, a tour of the fourth floor of the facility was conducted, and at 11:53 a.m., observations in Room 404, Bed D, revealed the call bell device was non-functioning. Resident R2 of Room 404, Bed D, stated that the call bell was not functioning for a few days.
On January 28, 2026, a tour of the fourth floor of the facility was conducted, and at 11:57 a.m., observations in Room 426, Bed B, revealed the call bell device was non-functioning.
On January 28, 2026, at 11:57 a.m., the findings were confirmed with E 3, a Licensed Nurse.
28 Pa Code 207.2(a) Administrator's responsibility
| | Plan of Correction - To be completed: 03/16/2026
Tag F0919
The facility immediately notified the maintenance director upon identification of the non-functioning call bells in rooms 404D and 426B. The call bell batteries were replaced, and both call bells were tested to ensure proper functionality the same day the issue was identified. The nursing staff and affected residents were notified of the call bells functionality after the repairs and were instructed to immediately report any issues/concerns involving resident call bells and to provide tap bells until the issues are resolved. Staff with PCC access were reminded to submit work orders into TELs, allowing maintenance to track and resolve any maintenance issues that may arise.
All residents have the potential to be affected by the deficient practice.
To ensure other resident were not affected, the maintenance director conducted a facility wide audit of all resident call bells to ensure proper functionality and to identify any potential defects/call bell concerns.
The maintenance director will provide re-education to all direct care staff on the importance of resident call bells functionality and reporting non-functioning call bells immediately to ensure resident safety. The in-service education will require all staff with PCC access to submit work orders in TELS if/when a call bell is found to not be working properly and to immediately provide a tap bell until the issue is resolved.
The maintenance director or designated designee will conduct weekly audits for 4 weeks and then monthly audits for 2 months to ensure proper call bell functionality for all residents. Audit results will be submitted and reviewed in QAPI to identify any concerns and to determine if corrective action is needed.
Expected date of compliance: March 16th, 2026
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