During an observation on November 14 from 1:10 p.m. to 1:40 p.m., inspectors found the call lights on Halls 100, 200, 300, and 400 were not working. Residents were using cow bells instead, and staff were making rounds to check if anyone needed assistance.
The Director of Nursing explained that when the system failed, the facility went out and purchased call bells for all residents who could physically use them. Staff began making rounds every 30 minutes for all residents, and every 15 minutes for residents who couldn't use the call bells.
"There have not been any injuries or illnesses since the call light system has been down," the DON told inspectors on November 14. She said the call bells were working until the main system could be fixed.
The maintenance director had been checking the call system weekly and said it had been functioning normally during his regular inspections. The entire system went out suddenly on November 11.
"I never had an issue with the call system going completely out," the maintenance director said. He called a technician immediately but didn't know when the system would be repaired.
By the next day, November 15, inspectors observed from 10:30 a.m. to 10:50 a.m. that call bells could be heard ringing throughout the facility. Staff were responding to the bells and continuing to make rounds.
A registered nurse told inspectors that staff were expected to answer the call bells immediately once the main system went down. She confirmed there had been no illnesses or accidents among residents since November 11.
The technician who examined the broken system determined that a chip needed to be replaced. The RN said repairs would take less than two weeks.
The facility's own policy, dated September 2022, states that residents must be provided with a means to call staff for assistance through a communications system that directly contacts a staff member or centralized workstation. The policy explicitly requires that "the resident call system remains functional at all times."
The breakdown affected residents across the entire 4-hall facility. Federal regulations require nursing homes to maintain working call systems so residents can request help from their bedside, bathroom, and bathing areas.
Staff told inspectors they were making rounds every 15 to 30 minutes to ensure residents' needs were met while the system remained broken. The DON said staff had been in-serviced on the new procedures to ensure adequate monitoring.
The maintenance director acknowledged it was expected for the call system to work at all times so residents could communicate their needs to staff. The sudden, complete failure of the system was unprecedented for the facility.
When inspectors returned on November 15, the main call light system was still not functioning. The cow bells and increased staff rounds continued as the primary means for residents to request assistance.
The violation placed residents at risk of not receiving necessary care and services to maintain their highest level of well-being, according to the inspection report. The facility's failure to maintain a working communication system lasted at least four days, from November 11 through the November 15 inspection.
No timeline was provided for when the chip replacement would be completed and the call system restored to full operation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mexia Ltc Nursing and Rehab from 2025-11-15 including all violations, facility responses, and corrective action plans.