Resident #5 at Stone Cottage Care Center had negotiated an unusual arrangement with staff. Instead of using the facility's motion detector alarm system, he preferred calling the facility directly on his cell phone when he needed assistance.
The facility documented this preference in his care plan on December 4, with revisions made December 17. Staff agreed to "honor preference to use a cell phone to call the facility for assistance instead of a motion detector" and promised to "respond promptly to Resident #5's call to the facility when he asks for assistance."
But when inspectors asked the resident to demonstrate the system on December 22, the technology failed him. After several attempts, he could not use voice activation to unlock and operate his phone. Another person had to restart the device before the voice command system functioned.
The resident told inspectors he "had a rough start when first admitted to the facility due to hygiene care and wound care not always completed in a timely manner but felt this had improved." He reported no concerns with his cell phone call system, despite the demonstration problems.
His care plan revealed other complications. Staff were required to work in pairs for all personal care tasks including transfers, hygiene, perineal care, dressing, bed baths and repositioning. The plan noted potential for "misinterpretation and emotional distress for both the resident and staff" during interactions.
Interventions included explaining each step before and during hands-on care, offering choices when possible, and maintaining privacy with doors closed and curtains pulled. Staff were instructed to "validate concerns without arguing or escalating" and "avoid defensiveness if reports are made."
The facility's call light policy, undated, required staff to demonstrate proper use of call systems to residents upon admission and periodically as needed. The policy mandated that call lights remain "plugged in and functioning at all times" and be "accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor."
Staff were directed to report defective call lights to nurse supervisors promptly.
Director of Nursing told inspectors on December 23 that staff were expected to answer call lights within 15 minutes of activation. The facility administrator confirmed the nursing home was updating its call light system from pull string levers to push buttons.
The administrator acknowledged knowing that another resident, Resident #2, had requested a breath-activated call system upon admission and had concerns about a malfunctioning motion sensor alarm.
Federal regulations require nursing homes to ensure residents can easily summon assistance. The inspection found Stone Cottage Care Center's accommodation of Resident #5's preference created a system that failed when tested.
The resident's care plan classified him as having "increased fall risk" and documented his refusal to use the standard motion detector alarm. Social services were tasked with supporting his "autonomy and document ongoing preference for alternatives to alarms."
During the inspection, the facility could not demonstrate that its customized call system worked reliably. The resident required technical assistance from another person to operate the device he depended on for emergency communication.
The violation carried minimal harm designation, affecting few residents. But for Resident #5, the malfunctioning system represented his primary means of summoning help when staff were not present.
His care plan acknowledged the complexity of his needs, requiring paired staffing for routine care and careful communication to avoid escalating situations. The cell phone system was meant to provide him autonomy while ensuring safety.
Instead, inspectors found a resident whose emergency communication method failed repeatedly, leaving him dependent on others to restart the very device meant to preserve his independence.
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.