**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to successfully develop a plan and implement an accessible call system for all residents once an electronic call system became inoperable. These failures resulted in R1 being admitted from the hospital into a bed without a working call system on [DATE]. R1 was admitted with the diagnoses of Atrial Fibrillation, Repeated Falls, Acute and Chronic Right Heart Failure, Morbid Obesity, Hypertension, and Venous Insufficiency, and on [DATE] R1 was experiencing chest pain for over two hours without access to a working call system or staff response. These failures affect all 40 residents residing within the facility and resulted in R1 experiencing fear, chest pain, and shortness of breath for over two hours without staff intervention and R1 requiring emergency services for the treatment of a new onset of atrial fibrillation.These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on [DATE] when R1 was admitted to the facility from the hospital into a bed without a working call light. V1 (Administrator), V2 (Director of Nursing) and V17 (Regional Clinical Director) were notified of the Immediate Jeopardy on [DATE] at 1:20 PM. While the immediacy was removed on [DATE], the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include:The facility's Census Report dated [DATE] documents 40 residents reside within the facility.The facility's Call Light policy dated [DATE] documents, Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident rooms to respond to call system and promptly cancel the call light when the room is entered. 5. Hand bells will be provided for alert dependent residents when positioned out of reach of permanent call light when needed. 6. Call bell system defects will be reported promptly to the Maintenance Department for servicing. Check room frequently until system is repaired.The facility's Plan of Correction F919 dated as completed on [DATE] documents, Residents who need assistance with ADLs (Activities of Daily Living) will be provided increased/frequent rounding to aid the resident. If call light system is not audible, an alternate call light device will be provided by the facility. Education is provided to the residents who require an alternate call light device. All staff were in-serviced on the facility's Call Light policy including but not limited to respond to residents' request and needs in a timely and courteous manner, an alternate call light device will be provided to call for assistance, call bell system defects will be reported promptly to the Maintenance Director for servicing, and check rooms frequently until system is repaired by (V2) or (V1/Administrator).The facility's Resident Council Minutes dated 6/2025 and 8/2025 document, Call lights getting fixed. Order and waiting for them (call lights) to be installed.The facility's Resident Council Minutes dated 7/2025 document, Maintenance: Call lights.The facility's Inservice Form dated [DATE] documents V2 (Director of Nursing) provided an in-service to staff regarding the facility's call light system.R1's admission Record and current Physician's Orders document R1 is a [AGE] year-old admitted to the facility from the hospital on [DATE] at 4:26 PM with the diagnoses of Vertebra Compression Fracture, Morbid Severe Obesity, Atrial Fibrillation, Unsteadiness On Feet, Depression, Hypertension, Acute and Chronic Right Heart Failure, Venous Insufficiency, Neuralgia and Neuritis, Repeated Falls, and Acute and Chronic Diastolic Congestive Heart Failure (CHF).R1's MDS (Minimum Data Set) dated [DATE] documents R1 is cognitively intact, has impairments in functional range of motion to bilateral lower extremities, is dependent on staff for transfers and sitting to lying in bed, and does not ambulate.R1's Order Summary Report dated [DATE] documents R1 received oxygen at two liters per nasal cannula continuously for Shortness of Breath related to Acute and Chronic Right Heart Failure since [DATE].R1's current Care Plan documents R1 is dependent on staff for transfers, lying to sitting, sitting to lying, and transfers. This same Care Plan documents R1 is a full code and wants resuscitation and CPR (Cardio-Pulmonary Resuscitation), including intubation and mechanical ventilation.R1's current Care Plan documents, Started dated [DATE]: Focus: have altered cardiovascular status related to A-Fib Arrythmia, CHF, and Hypertension. Goal: I will be free from complication of cardiac problems through the review date. Interventions/Tasks: Assess for chest pain every shift. Enforce the need to call for assistance if pain starts.R1's Health Status Note dated [DATE] at 11:48 PM and signed by V7 (LPN/Licensed Practical Nurse) documents, At 10:15 (PM) I was approached by (V11/CNA/Certified Nursing Assistant) from 100-hall that (R1) was requesting her vitals to be checked due to not feeling right. I had not officially switched over from 200-hall over to 100-hall, so I did not have (R1's) full background of why (R1) was here or who (R1) was at that moment. When I went into (R1's) room, (R1) stated (R1) had chest pain and when (R1) initially hit her call light the pain was going into her left arm. The pain then went away in my arm. (R1) did stated that (R1) was d/c (discharged ) from cardiac unit with A-fib (Atrial Fibrillation) and arrived (at the facility) on Friday ([DATE]) afternoon. I obtained vitals- BP (Blood Pressure) 148/82 systolic/diastolic, SPo2 (saturation of peripheral oxygen) 94% (percent), R (respirations) 20, pain 4/5 (four out of five) on pain scale. (R1's) HR (heartrate) was tachy (tachycardia) & irregular initially. When I (V7) assessed (R1) apically it was 74, then I did obtain a radial at 73 with pulse regular rate. I reached out (V12/Physician) at 10:55 PM and (V12) stated I should send (R1) out to E.R. (Emergency Room) for assessment d/t (due/to) recent stay in cardiac unit for (R1's) A-fib. I called 911 at 10:57 PM. EMT (Emergency Medical Transport) showed up at 11:20 PM and left with (R1) at 11:28 PM. R1's EMS (Emergency Medical Services) Pre-Hospital Communication Form documents R1 was sent by ambulance to the hospital on [DATE] at 11:59 PM due to complaints of chest pain that started worsening 30 minutes prior and back pain. This same Form documents EMS administered an Intravenous Solution, gave R1 four baby aspirins, and increased R1's oxygen to four liters continuously. R1's Hospital History and Physical dated [DATE] document R1 was treated at the hospital emergency department for a new onset of Atrial Fibrillation with an irregular rate and rhythm and Congestive Heart Failure. R1's Census Report documents R1 was moved from the room she was admitted to on [DATE] to another room on [DATE].The facility's Outside Electrical Company Invoice dated [DATE] documents, [DATE] Nurse Call System: (V6/Maintenance Director) needed me (technician) to install a station in one of the residents' rooms (R1's) and test. Swapped bad station with one (V6) provided. Tested and works like other rooms.R2's admission Record documents R2 is an [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis of the Left Non-Dominant side, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease Hypertension, and Aphasia.R2's MDS dated [DATE] and current Care Plan documents R2 requires assistance of staff for transfers and sitting to lying.R2's current Care Plan documents R2 is at high risk for falls. This same Care Plan documents, Interventions: Be sure (R2's) call light is within reach and encourage (R2) to use if for assistance as needed. (R2) needs prompt response to all requests for assistance.R3's admission Record documents R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Hypertension, Depression, Traumatic Subarachnoid Hemorrhage, Orthostatic Hypotension, Retention of the Urine, Difficulty Walking, Unsteadiness on Feet, Mood Disorder, and Chronic Obstructive Pulmonary Disease.R3's MDS dated [DATE] and current Care Plan documents R3 requires assistance of staff for transfers and sitting to lying.R3's current Care Plan documents R3 is at risk for falls. This same Care Plan documents, Interventions: Be sure (R3's) call light is within reach and encourage (R3) to use if for assistance as needed. (R3) needs prompt response to all requests for assistance.R4's admission Record documents R4 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis affecting the Left Non-Dominant Side, Cerebrovascular Disease, Epilepsy, Acute Respiratory Failure with Hypoxia, Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, Hypertension, Acute Embolism, Acute Kidney Failures, and Abnormalities of Breathing.R4's MDS dated [DATE] and current Care Plan documents R4 is cognitively intact, is dependent on staff for transfers, toileting hygiene, and sitting to lying, and is unable to walk.R4's current Care Plan documents R4 has a potential for falls and has bowel incontinence. This same Care Plan documents, Interventions: Ensure (R4's) call light is within reach and answer promptly.On [DATE] from 9:15 AM through 9:30 AM a tour was done of the facility. The facility's electronic call light system was inoperable at both nursing stations and all resident rooms during this time. On [DATE] at 9:15 AM R1 was sitting in a wheelchair in her room. R1 was upset and stated, This facility is killing me. When I was admitted here, I was put in a room that did not have a call light. My roommate's (R6's) call light would work but mine never did. I was not given a bell or anything to get the staff's help when I needed it. I would either have my roommate use her call light or yell for help when I needed it. I would tell the nurses my call light was not working, and they would tell me it was working. I tried to explain to the nurses that the light outside of my room was only coming on when my roommate was using the call light, not when I was pushing mine. None of the nurses would listen to me. On [DATE] around 9:00 PM I started having chest pain that was going down my back and left arm. My roommate was out of the facility so I could not get her to use her call light to get me help from the staff. I tried to use my call light and kept yanking and yanking trying to get the call light to work. I yanked the call light completely out of the wall trying. I was short of breath and trying to concentrate. I was so scared. I had just been in the hospital due to my heart and for A-fib and found out the A-fib was causing my weakness and falls. About an hour later, I was able to get a staff member (unknown) to come to my room. I asked that staff member to get me help because I was having chest pain. Nobody came back for over an hour. I just kept concentrating trying not to pass out and control my chest pain. I asked that same staff member an hour later to get me help. Finally, a nurse came in and could tell I was in A-fib and having chest pain. I was sent to the emergency room and was treated for A-Fib. Then I returned to the facility and was still not given a call light that worked or a bell. No one did anything about my call light until several days later. I was finally moved to a different room several days later that had a working call light.On [DATE] at 1:15 PM R4 was lying in bed. R4 had a bell at the bedside on the side table. R4 stated, They (facility staff) can shove this bell up their a***s! Using the bell is a joke! The staff do not respond to the bell and three days ago I laid in s**t in my pants for over three hours. I am tired of it. I had a stroke and cannot move my left side at all.On [DATE] at 1:20 PM R3 was lying in bed with a bedside table on the right side of R3's bed. R3 did not have a working call light or a bell at the bedside. R3 stated, I don't think I have ever had a bell to use. I just wait on the staff to come in and take care of me.On [DATE] at 1:30 PM R2's room did not have a working call light or bell.On [DATE] at 1:30 PM V13 (CNA) entered R2 and R3's room and searched R2 and R3's room for bells. V13 confirmed R2 and R3 did not have bells at the bedside or working call lights. V13 stated, I do not recall (R2) or (R3) ever having a bell. (R3) does try to get up and falls. (R2) struggles with speaking.On [DATE] at 12:08 PM V7 (LPN/Licensed Practical Nurse) stated, I have worked at the facility since March or [DATE]. I was working at 6:00 PM through 6:00 AM from [DATE] through [DATE]. Around 10:00 PM I was finishing up on another hallway when a newer CNA (unknown name) came over and said (R1) was not feeling well and wanted her vital signs taken. Around an hour or so later this same CNA came back and said she could not find the other nurse and stated (R1) thought something was wrong with her heart. I went to assess (R1), and I knew nothing about (R1). I took (R1's) vitals and I took (R1's) pulse and her heart was skipping beats, and I could tell (R1) was in A-Fib (Atrial Fibrillation). (R1) told me she came from the cardiac unit, and I was instantly concerned. (V8/LPN) assisted me. I decided to send (R1) to the emergency room. (R1) ended up being in A-Fib. (R1) said she was feeling off that day. At times call lights are not working right at the facility. I remember (R1) saying she was having chest pain for quite a while and (R1) said she had to wait for somebody to help her because her call light was not working, and she could not ask for help.On [DATE] at 12:00 PM V6 (Maintenance Director) stated, I know (R1's) call light was not working and had been pulled out of (R1's) wall but I did not document when that was reported to me. I contacted an outside company to fix the call light. I don't think (R1) was moved rooms until the day the company came and fixed (R1's) call light. We (the facility) have had trouble with our call light system and call lights not working ever since I have been here. We (the facility) currently have the call system out of service and a new call light system is being installed. The call light system has been out of service since last Tuesday ([DATE]).On [DATE] at 1:30 PM V13 (CNA) stated, When (R1) was admitted here, (R1's) room never did have a working call light. I am not sure if (R1) was given a bell.On [DATE] at 1:32 PM R5 was sitting on the edge of the bed in her room. R5 stated, When (R1) was my roommate, (R1's) call light never did work. My call light would work. I was on a home visit when (R1) was sent out to the hospital.On [DATE] at 1:35 PM V2 (Director of Nursing) stated, I gave an in-service to staff on [DATE] regarding the facility's call light system not working properly and all residents will be given hand bells to use in place of the call lights and all staff were to increase rounding on residents to check on all the residents care needs. The facility's call light system was put out of order last Tuesday ([DATE]). I announced the call light system not working in the dining room, in the morning of last Tuesday. The technicians are still working on putting in a new system. All residents should have a bell to use within reach and in every bathroom. We (the facility) did not develop a specific plan for the call light system being out except for the in-service of staff to do more frequent rounding of the residents and all residents are to have bells at the bedside and bathrooms.On [DATE] at 3:15 PM V11 (CNA) stated, I know (R1's) call light was not working in (R1's) room when (R1) was admitted here. I worked the next night ([DATE]) after (R1) had returned from the hospital and (R1) was still in the same room without a working call light. (V8/LPN) was livid that the facility would put (R1) in a room without a working call light, knowing (R1) had a heart condition. The facility has had a lot of problems with the call lights working properly.On [DATE] at 11:00 AM V2 (Director of Nursing) confirmed none of the residents' care plans had been updated with an alternate call system (bells) or to increase supervision/rounding for all residents while the electronic call system was inoperable.On [DATE] at 4:53 PM V14 (CNA) stated, On [DATE] I checked on (R1) around 10:00 PM. (R1) said she had been trying to use her call light for quite some time because (R1) was not feeling well and could not get the call light to work. (R1) stated she had to jerk the call light completely out of the wall to get the light to work. When I went into (R1's) room the call light was completely out of the wall. (R1) said she was feeling funny and needed her vitals checked. (R1) said she was admitted from the cardiac unit. I went and told (V15/LPN) and (V15) never did check on (R1). I went around a half an hour to 45 minutes later and told (V7/LPN). (V7) took over and I know (R1) was sent out to the hospital. I know there have been several issues with the call lights not working within the facility.Immediate Jeopardy Removal Plan On [DATE] from 10:00 AM through 10:25 AM a tour was done of the facility with V1 to confirm the facility's actions to remove the Immediate Jeopardy. During this tour R1, R4, R7, R8, R9, R10, and R11's bathroom call lights were tested by V1 and did not work. R1, R4, R7, R8, R9, R10, and R11's bathrooms did not have bells in them as alternatives to the call lights not working and as stated in their abatement plan to be completed as of [DATE]. V1 stated, I was told by (V6/Maintenance Director) that all call lights were working except for the hallway that does not have residents residing. I had no idea (R1, R4, R7-R11's) bathroom call lights were not working. I will have to go somewhere and get bells to put in those bathrooms.On [DATE] at 10:45 AM V2 (Director of Nursing) stated, I did an audit of all resident rooms yesterday to ensure all rooms had bells at the bedside in case the call light system was not working. I did not check any of the residents' bathrooms to ensure there were bells.On [DATE] at 10:45 AM V6 (Maintenance Director) confirmed that no one had informed him that R1, R4, R7, R8, R9, R10, and R11's bathroom call lights were not working so therefor he did not have a record in the service repair/work order binder to document when the call lights were out of service and when repairs will be made. V6 stated, I will have to call the call light installers and see if I can get them back out here to fix this.On [DATE] at 10:48 AM V17 (Regional Clinical Director) stated the Immediate Jeopardy abatement plan was supposed to be completed by [DATE] and V2 should have done an audit of all resident rooms and resident bathrooms to ensure there were bells as a back up to the call light system and V6 should have been informed that the call lights were not working in R1, R4, R7, R8, R9, R10, and R11's bathrooms. V17 stated, I will be re-in servicing all staff today to ensure all staff are notifying (V6) immediately of any call lights that are not working, and I will make sure (V2) audits all rooms and bathrooms to ensure there are bells.On [DATE] this surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1. All resident care plans were updated by V2 on [DATE] to ensure residents receive frequent rounding every 30 minutes to ensure needs are met and bells within reach if a call light is found to be inoperable. Staff will complete a work order and submit to the Maintenance Department for service or repairs. The Maintenance Director will keep all work orders which will document what type of repair was conducted, with date and time of said repair. The Administrator and/or Director of Nursing will be responsible for overseeing and maintaining plan until call light system is back online and operating appropriately.2. On [DATE] V1, V2, and V17 in-serviced all staff on the facility's Call Light policy including reporting call bell system defects promptly to the Maintenance Department for servicing and checking rooms frequently until the call light system is repaired, providing dependent residents with a hand bell whenever a call light is found to be inoperable, and answering call lights promptly. 3. On [DATE] V17 educated V2 on the facility's Comprehensive Care Plan policy, including but not limited to developing a comprehensive care plan within seven days after completion of the comprehensive assessment that includes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, resident's goals for admission and desired outcomes, resident's preference and potential for future discharge, including the resident's desire to return to the community and any referrals to local contact agencies.4. On [DATE] V1 and V17 educated V6 (Maintenance Director) to document when call lights were out of service, when repairs were made, and keeping a service repair/work order binder to document when call lights are out of service and when repairs are made.5. On [DATE] at 2:30 PM V1 ensured all resident bathrooms were provided with hand bells.6. V2 completed daily audits to ensure all call lights were operational and hand bells were within reach of all residents that did not have working call lights with the exception of 300 hall which closed and does not currently have residents. These audits will continue for six weeks.7. On [DATE] V17 re-in serviced all staff including V1 and V17 on ensuring V17 receives a work order whenever call lights are not working and ensuring V17 documents in the maintenance binder when the call lights are inoperable and are repaired.8. On [DATE] the new call system was fully operational and working on all of 100 and 200 hallway bathrooms and resident rooms. All resident rooms and bathrooms had bells as back up call devices. These bells were within reach of all residents.Completion Date: [DATE]