PUEBLO, CO - Inspectors discovered that Rock Canyon Respiratory and Rehabilitation Center failed to provide adequate call light systems for residents in its memory care unit, leaving vulnerable residents without a reliable way to summon help during emergencies or routine care needs.
Memory Care Residents Left Without Call Lights
During a July 2024 inspection, state surveyors found that two residents with cognitive impairments and physical limitations were unable to call for assistance when needed. The violations occurred in the facility's memory care secure unit, where residents with dementia and other cognitive conditions require enhanced safety monitoring.
Resident #24, a 70-year-old stroke survivor with severe cognitive impairment, was observed yelling for help while lying in bed without access to a call light. The resident had limited movement on one side of his body and was completely dependent on staff for basic activities including toileting, bathing, and transfers. When surveyors returned the next day, the resident still lacked a call light system in his room.
Similarly, Resident #8, who had moderate cognitive impairment and was dependent on staff for eating, hygiene, and mobility, was also found without a working call light despite being able to communicate her needs effectively.
Malfunctioning Emergency Systems in Shower Areas
The inspection revealed critical safety gaps in the facility's shower rooms on the memory care unit. Both men's and women's shower areas lacked functioning call light systems, creating dangerous situations where residents could fall or experience medical emergencies without being able to alert staff.
A red emergency button existed in the men's shower room, but testing revealed it was completely non-functional - a remnant from an old call light system that had been disconnected. When pressed, the button failed to activate any alert panel or notification system.
"During that time there had never been call lights in the shower rooms on the memory care unit," the maintenance supervisor told inspectors, revealing that the safety violation had persisted for at least four years.
Medical Risks and Safety Implications
Call light systems serve as critical safety tools in nursing homes, particularly for residents with cognitive impairments who may not be able to seek help independently. The absence of functional call lights creates multiple medical risks including delayed response to falls, medication reactions, choking incidents, or other emergencies.
For residents like #24, who experienced weakness and contractures following a stroke, the inability to summon assistance could result in prolonged discomfort, injuries from attempting unsafe transfers, or complications from unmet basic needs. Stroke survivors often face challenges with mobility and communication, making reliable call systems essential for their safety and dignity.
Shower areas present particularly high-risk environments where residents face increased fall potential due to wet surfaces and the physical demands of bathing. Without working emergency call systems, residents experiencing falls, dizziness, or other medical events in these areas could face dangerous delays in receiving help.
Inadequate Assessment and Response Procedures
The facility's call system assessment process revealed significant deficiencies in evaluating residents' ability to use call lights effectively. Staff assessments had incorrectly determined that both residents were unable to use call bells, despite evidence suggesting otherwise.
"She said she was able to use it when she needed to call for staff," Resident #8 told inspectors after finally receiving a call bell following reassessment.
The social services director acknowledged taking over call bell assessments and discovered that previous evaluations had been insufficient. When residents were properly reassessed during the inspection, both were found capable of using call systems effectively.
Staff Awareness and Training Gaps
Staff interviews revealed concerning gaps in understanding call light requirements. A certified nursing aide stated that "none of the residents who resided on the memory care unit had a call light," indicating that the absence of these safety devices had become normalized rather than recognized as a serious deficiency.
Another aide expressed safety concerns about providing call lights to residents with cognitive impairment, citing strangulation risks from cords. However, this perspective overlooked the availability of alternative call systems designed specifically for residents with cognitive limitations, such as the yellow service bells ultimately provided to both residents.
Additional Issues Identified
The inspection also revealed problems with the facility's quality assurance program. The nursing home administrator acknowledged that "the facility clearly did not have an effective process to ensure resident tube feedings were being appropriately monitored and managed," though tube feeding concerns had not been addressed by the quality improvement team in the previous 90 days.
The facility's maintenance supervisor was able to install working call lights in the shower rooms during the inspection period, demonstrating that solutions were readily available but had not been previously implemented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rock Canyon Respiratory and Rehabilitation Center from 2024-07-12 including all violations, facility responses, and corrective action plans.
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