The resident at Stone Cottage Care Center had negotiated an unusual arrangement with facility administrators. Rather than use the standard motion detector alarm system, he preferred calling the facility directly on his cellular phone when he needed assistance.
During the December 22 interview, the resident acknowledged a "rough start" when first admitted, citing hygiene care and wound care not always completed in a timely manner. He said conditions had improved and denied concerns with his cell phone call system.
But when inspectors asked for a demonstration the next day, the system failed repeatedly.
After several attempts, the resident was unable to use voice activation commands to unlock and operate his phone. Another person had to restart the device before the voice command system functioned properly.
The facility's Director of Nursing told inspectors that staff are expected to answer call lights within 15 minutes of activation. The administrator confirmed knowledge of the resident's preference for the cell phone system over traditional call lights.
Care plan documents revealed the resident was at increased fall risk but "refuses use of motion detector alarm, preferring to notify staff by calling the facility with his cellular phone." The plan included specific interventions: "Honor preference to use a cell phone to call the facility for assistance instead of a motion detector" and "Respond promptly to Resident #5's call to the facility when he asks for assistance."
Social services staff were directed to "support Resident #5's autonomy and document ongoing preference for alternatives to alarms."
The facility was simultaneously updating its call light system from pull-string levers to push buttons, according to the administrator. Another resident had requested a breath-activated call system upon admission and expressed concerns that the motion sensor alarm wasn't functioning properly.
Facility policy requires staff to explain and demonstrate call light use upon admission and periodically as needed. The policy states call lights must be "plugged in and functioning at all times" and "accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor."
Staff are directed to "report all defective call lights to the nurse supervisor promptly."
The resident's care plan also addressed behavioral concerns during personal care interactions, noting "potential risk for misinterpretation and emotional distress for both the resident and staff." Interventions required staff to explain each step before and during hands-on care, offer choices when possible, and maintain privacy with doors closed and curtains pulled.
All personal care tasks including transfers, hygiene, perineal care, dressing, bed baths, and repositioning required two staff members present. Staff were instructed to "validate concerns without arguing or escalating" and "avoid defensiveness if reports are made."
The inspection found the facility failed to ensure residents could reliably activate their call systems for assistance. While the resident expressed satisfaction with his alternative arrangement, the repeated technical failures during the demonstration highlighted the system's unreliability.
Federal regulations require nursing homes to provide call systems that allow residents to summon assistance at any time. The facility's willingness to accommodate the resident's preference for using his personal cell phone represented an attempt at person-centered care, but the malfunctioning device left him potentially unable to call for help during critical moments.
The resident's initial complaints about delayed hygiene and wound care, combined with the unreliable call system, raised questions about the facility's ability to provide timely assistance to residents who need help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stone Cottage Care Center from 2025-12-23 including all violations, facility responses, and corrective action plans.