Complaint Investigation Report

Allegation: “Staff do not ensure that the facility has an appropriate auditory system for residents in care”

It was reported that the facility’s call system was non-operational and residents were given a whistle to utilize as a replacement. A physical plant tour conducted on 07/01/2026 confirmed that the call system was not functional. Interviews revealed that the call system was on and off operational for approximately two (2) months. The ED reported that towards the end of May, the system had worsened and the facility acted by inquiring with third parties regarding a system replacement. The ED expressed that the project would take awhile due to the building’s old system in addition to the approval process. Residents were reportedly given a whistle to utilize due to the inoperable call system. Prior to providing the whistles, staff stated that each resident tested the whistles to ensure they could successfully utilize it.

Residents reported no concerns regarding the call system and expressed that they do not often utilize the system. Instead, the residents typically use their personal phones to call the nurses’ station or will walk to find staff for assistance. Residents confirmed that they were provided bracelets with whistles attached to utilize in lieu of the call system.

Review of the facility’s communications revealed that on 05/19/2026, the ED contacted the Information Technology (IT) team on the status of the call light system. The IT team reported that the call lights were presumed to be operational stating, “The IT team has restored the Newman Nurse Call system twice in the last week.” On 05/22/2026, the facility’s Maintenance team contacted IT reporting that the pull cords were not communicating with the base station and were inoperable.

The LPA determined that although the call system is inoperable, the facility took immediate action to rectify the situation and provided residents with a temporary alternative solution. Additionally, the violation did not present an immediate risk to residents in care; therefore, the allegation is deemed SUBSTANTIATED and considered a TECHNICAL VIOLATION . No citation was issued.

The LPA discussed the importance of maintaining an efficient and functional call system to maintain compliance. The ED agreed to streamline the call system replacement project and to provide the Department with the facility’s project plan and estimated completion date.

No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.