The facility operates under a special federal exception that allows them to use a wireless call light system instead of the standard hardwired version. But that exception comes with a critical requirement: staff must carry pagers at all times while working to ensure they receive emergency calls from residents.
Nobody was following that rule anymore.
During interviews on December 19, three separate staff members told inspectors the same story. The pagers had been abandoned sometime around last summer, with enforcement gradually fading away until almost no one carried them.
"He/she could not recall when it stopped, but it's been a while," one certified medication technician told inspectors during a morning phone interview. The technician said they hadn't worn a pager for at least three months, estimating staff stopped using them around the beginning of summer when administration stopped monitoring compliance.
An LPN interviewed the same morning was more specific about the timeline. The nurse said it had been "a couple of months ago when having the pagers became less of a focus." More troubling, the LPN admitted having no knowledge of the federal stipulation requiring staff to carry pagers due to the call light system exception.
That same nurse revealed another problem. Resident #1's call light hadn't functioned properly for months. The LPN had tried fixing it personally, but the repairs were only temporary. "It reverts to functioning improperly after some use," the nurse told inspectors, suspecting an electrical short in the device.
The maintenance director confirmed the call light's chronic problems during his afternoon interview. He said Resident #1's call light had been malfunctioning "for some time" and that he had fixed it several times. Each repair worked initially, but the device consistently broke down again.
"The call light will work properly after applying a fix but has reverted back to not functioning properly every time," the maintenance director explained.
The facility's monitoring system had significant gaps. The maintenance director told inspectors that while an outside agency monitors the call light system, there are no internal audits to ensure proper functioning throughout the facility. No alerts come to the facility if the system fails.
Instead, the responsibility falls on certified nursing assistants to monitor the lights for problems. But with CNAs not carrying the required pagers, the system's reliability becomes even more questionable.
The administrator, interviewed in the afternoon, acknowledged the facility's obligations under their federal exception. She confirmed that staff should wear pagers while working per the exception stipulation, but said she wasn't aware staff had stopped using them.
"The DON is responsible for monitoring nursing staff to ensure pagers are being used in accordance with the stipulation in their exception letter," the administrator told inspectors.
The facility has no internal audit system to verify the call light system works properly, the administrator confirmed.
The wireless call light exception exists as an alternative to standard hardwired systems, but federal regulators require the pager backup to ensure residents can always reach help in emergencies. When staff abandon the pagers, residents lose that critical safety net.
For Resident #1, the combination created a particularly dangerous situation. With a chronically malfunctioning call light and staff not carrying the pagers that might have provided backup communication, the resident faced potential isolation during medical emergencies.
The LPN's admission about lacking knowledge of federal requirements suggests the compliance breakdown went beyond simple negligence. Staff weren't just ignoring rules they knew about - some didn't understand the rules existed at all.
The facility's piecemeal approach to repairs, with individual staff members attempting temporary fixes rather than comprehensive maintenance solutions, left the fundamental problem unresolved. The maintenance director's repeated attempts to fix Resident #1's call light demonstrated awareness of the issue, but not systematic problem-solving.
Federal inspectors classified the violations as having minimal harm or potential for actual harm, affecting some residents. But for residents like #1, living with a broken call light and no staff pager backup, the risk was immediate and personal.
The inspection revealed a facility where safety systems had quietly deteriorated over months. Staff gradually stopped following federal requirements while administration failed to notice. Critical equipment malfunctioned repeatedly without permanent solutions.
Most concerning was the casual acceptance of the deteriorating conditions. Multiple staff members described the abandonment of required pagers matter-of-factly, as something that had just "fallen to the wayside" over time.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mary, Queen and Mother Center from 2025-12-19 including all violations, facility responses, and corrective action plans.
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