COLVILLE, WA - State inspectors found multiple violations at Prestige Care & Rehabilitation - Pinewood Terrace during a May 2025 inspection, including a non-functioning call light system that left residents unable to alert staff when they needed assistance and widespread gaps in mandatory staff training programs.
Critical Call Light System Malfunction Compromises Resident Safety
The most serious violation involved the facility's call light system, which had been non-audible for over a year according to staff members. During the inspection, surveyors repeatedly observed call lights that were visibly activated but produced no sound to alert staff members in the hallways.
The Maintenance Director described the system as "horrible," explaining that the annunciator component "constantly shorts out and goes out." This critical piece of equipment is responsible for converting visual call light signals into audible alerts that notify staff when residents need assistance.
Inspectors documented the malfunction across multiple days in May 2025, observing lit call lights at the nurses' station indicator board without corresponding audible signals. When maintenance staff attempted repairs during the inspection, the system continued to malfunction - producing only a single intermittent beep regardless of whether call lights were actually activated.
The Resident Council reported experiencing "excessively long call light wait times, sometimes waiting up to an hour" and acknowledged that "the call lights do not make a sound at all." This breakdown in communication between residents and staff creates significant safety risks, particularly for residents who may experience medical emergencies or falls.
Medical Impact and Safety Concerns
A functioning call light system serves as the primary lifeline between nursing home residents and their caregivers. When this system fails, residents face increased risks of:
- Delayed emergency response: Critical situations like heart attacks, strokes, or severe falls may go unnoticed for extended periods - Unmet basic needs: Residents requiring assistance with toileting, medication, or pain management may wait hours for help - Fall-related injuries: Residents who cannot summon help may attempt dangerous transfers or mobility without assistance - Psychological distress: The inability to call for help can create anxiety and feelings of abandonment
Industry standards require call light systems to be both visible and audible, with response times typically expected within 5-15 minutes for non-emergency situations. The facility's broken system potentially increased response times to over an hour in some cases.
Widespread Training Deficiencies Affect All Direct Care Staff
The inspection revealed systemic failures in mandatory staff training programs, with all 10 direct care staff members reviewed lacking required training in multiple areas including effective communication, Quality Assurance and Performance Improvement (QAPI), and compliance and ethics.
The facility failed to provide documentation that any of the reviewed staff - including licensed practical nurses, registered nurses, and nursing assistants - had received effective communication training. The Clinical Resource Nurse stated that while a previous administrator had conducted "lunch and learn" sessions on communication, no documentation or signature sheets existed to verify completion.
Similarly, none of the 10 staff members had received mandatory QAPI training, which is designed to help facilities recognize, assess, and implement quality improvement measures. The facility's QAPI plan, while outlining improvement processes, did not specify what type of training staff would receive or how frequently it would occur.
Nine of the 10 staff members also lacked compliance and ethics training, which is essential for maintaining regulatory standards and ensuring proper resident care protocols.
Training Requirements and Clinical Significance
Federal regulations mandate these training programs because they directly impact resident care quality:
- Effective communication training ensures staff can properly interact with residents, families, and healthcare team members, reducing medical errors and improving care coordination - QAPI training helps staff identify quality issues and participate in improvement initiatives, leading to better outcomes and reduced adverse events - Compliance and ethics training ensures staff understand their legal and ethical obligations, protecting both residents and the facility from violations
Research demonstrates that comprehensive staff training programs correlate with improved resident outcomes, reduced hospitalization rates, and fewer preventable complications. Facilities with well-trained staff typically experience lower turnover rates and higher resident satisfaction scores.
COVID-19 Vaccination Documentation Gaps
The facility also failed to maintain proper documentation of staff COVID-19 vaccination education and status. The infection preventionist position had been vacant until February 2025, and existing vaccination records had not been updated since 2023.
Staff members reported they had not been offered COVID-19 vaccines or annual declination forms "in several years," despite facility policies requiring annual education about vaccination risks and benefits. The Human Resources department was unsure who was responsible for tracking staff vaccination status or providing ongoing education about boosters.
This documentation failure places both staff and residents at risk of COVID-19 exposure, particularly concerning given that nursing home populations remain among the most vulnerable to severe COVID-19 outcomes.
Additional Issues Identified
The inspection documented several other operational concerns:
- Visual obstruction of call lights: Speaker boxes for the overhead paging system were positioned in ways that blocked visibility of some call lights from hallways and the nurses' station - Inadequate maintenance protocols: Despite ongoing call light system problems, maintenance staff had not received work orders or implemented more frequent monitoring - Administrative oversight gaps: The administrator acknowledged expectations for proper call light functionality but the facility had not implemented effective monitoring systems
Industry Standards and Regulatory Requirements
Federal nursing home regulations require facilities to maintain working call systems that are both audible and visible. Staff must be able to respond promptly to resident requests for assistance, and the call system must function reliably 24 hours per day.
Training requirements are similarly comprehensive, mandating that all direct care staff receive instruction in communication techniques, quality improvement processes, and ethical standards. These programs must be documented and updated regularly to ensure staff maintain current competencies.
The violations identified at Prestige Care & Rehabilitation - Pinewood Terrace represent fundamental breakdowns in safety systems that nursing homes must maintain to protect vulnerable residents. The combination of communication system failures and training deficiencies creates compounding risks that could significantly impact resident care quality and safety outcomes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prestige Care & Rehabilitation - Pinewood Terrace from 2025-05-23 including all violations, facility responses, and corrective action plans.
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