Federal inspectors discovered the malfunctioning call system during an October complaint investigation. The audible portion of the call bell system had failed completely on the second floor, leaving residents unable to alert staff to emergencies through sound.
Resident 216 told inspectors they had pressed their call button because they needed someone to suction their tracheostomy — a surgical opening in the windpipe that requires regular clearing to prevent breathing complications. The resident said response times were typically long, with waits of up to an hour before anyone answered their calls for help.
The inspection began after a complaint alleged call bells weren't answered in a timely manner. On October 7 at 9:47 AM, an inspector observed a call bell light illuminated outside a room next to the nurses' station. No audible sound accompanied the visual signal anywhere in the hallways or at the nursing station itself.
Staff member 11 had just finished changing Resident 216 when the inspector arrived to interview the patient. The staff member mentioned the resident needed help with their phone, which they couldn't provide.
During the interview, Resident 216 explained they had activated their call bell seeking assistance with tracheostomy suctioning. When asked about typical response times, the resident confirmed delays were routine, sometimes lasting an entire hour.
Later that afternoon at 1:00 PM, inspectors observed another call light flashing on the second floor. Three staff members stood talking at the nurses' station, apparently unaware of the silent emergency signal.
The inspector showed the Assistant Director of Nursing the illuminated call light and asked if she could hear any audible alert. She replied no, confirming she heard no call bell sound either at the nursing station or in the hallways.
When informed that call bell systems must provide both visual signals and audible alerts loud enough for staff to hear, the Assistant Director of Nursing said she would notify the maintenance director.
The administrator provided documentation the next day showing the facility had submitted a work order to an external company for call bell system repairs on the second floor.
During an October 9 interview, the Maintenance Director revealed that no one had reported the missing audible alerts to him. He acknowledged the second floor's call bell sound was "significantly lower" compared to the first floor but claimed this was a recent development.
The Maintenance Director said he had inspected the call bell system sound the previous month without identifying any problems.
A tracheostomy creates an opening in the trachea and inserts a breathing tube to help patients breathe. Regular suctioning removes secretions that can block the airway, making prompt response to calls for help potentially life-saving.
The silent call bell system affected all residents on the second floor, leaving them unable to summon help audibly during medical emergencies, falls, or other urgent situations.
Federal regulations require nursing homes to maintain functioning call systems in resident rooms, bathrooms, and bathing areas. The systems must provide both visual and audible alerts to ensure staff can respond promptly to resident needs.
The inspection found the facility failed to have a fully functioning call bell system, creating potential for actual harm to residents who depend on these devices to request assistance with breathing support, medical needs, and emergency situations.
Staff members working on the second floor had no way to hear when residents pressed their call buttons, relying solely on visual observation of corridor lights that could easily be missed during busy periods or when staff were focused on other tasks.
For Resident 216, the malfunctioning system meant potentially dangerous delays in receiving tracheostomy care. Blocked airways can quickly become life-threatening for patients dependent on breathing tubes, making rapid response to suctioning requests medically critical.
The facility's maintenance director claimed the problem was new, despite residents like 216 reporting lengthy response delays that suggested the audible system had been failing for an extended period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westgate Hills Rehab & Healthcare Ctr from 2025-10-09 including all violations, facility responses, and corrective action plans.
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