Santa Rosa Center For Rehabilitation And Healing

Make sure that a working call system is available in each resident's bathroom and bathing area.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observations, interviews and policy and record review, the facility failed to ensure accommodation of needs in 6 out of 20 residents rooms related to call lights being in reach of the residents. (Rooms 416, 502, 412, 505, 513, and 515)The findings include:On 9/24/25 at 10:15 AM, a tour of the facility was conducted, and the following observations were made on the 400-500 nursing care units concerning call lights being out of reach of the residents while in their rooms: In room [ROOM NUMBER], a resident was lying in their bed and the call light was positioned hanging on the wall above his bed, out of his reach.In room [ROOM NUMBER], the resident call light was hanging on the wall in between the A and B beds while the residents were in their room laying in their beds, out of reach.In room [ROOM NUMBER], the call light was positioned at the head of bed and tucked under the resident's pillow, out of reach of the resident laying on her right side facing the window.In room [ROOM NUMBER], the call light for the resident residing in the B-bed was observed hanging on the wall out of reach of the resident lying in their bed.In room [ROOM NUMBER], the A-bed call light was observed clipped to a call light box on the wall in between the A and B beds, out of reach of the resident while lying in his bed.In room [ROOM NUMBER], a call light was observed at the top of the bed hanging on the bedrail, out of the resident's reach while the resident was lying in bed. An observation was made at 2:00 pm on the same unit and the same rooms. In every case, the call lights were still placed out of the residents' reach. An interview was conducted with Staff Member A (Social Services Assistant) on 9/24/25 at approximately 2:00 pm, who revealed all the managers do a call light audit at least once a month.

That is something the Administrator put in place a while back to ensure the lights are being monitored and answered timely and appropriately. An interview was performed with the Social Services Director on 9/24/25 at around 2:30 pm.

She stated that there have been concerns voiced in regard to call lights not being answered in a timely manner and all the department head managers are asked to complete call light audits monthly at random periods of time to ensure they are being answered and promptly and to ensure call bells are placed within the reach of residents. An interview was conducted with the Administrator on 9/24/25 at 3:00 pm, who states call light audits were implemented due to concerns voiced by residents and family representatives.

The department head managers are asked to perform call light checks on a weekly and monthly basis to ensure call lights are being answered timely.A follow up interview was conducted with the Director of Nursing on 9/24/25.

She revealed that education in-services are completed with staff on call lights and answering call lights in a timely manner.

When she has conducted her audits, she has not visually seen call lights deliberately placed out of reach of residents but voiced the only ones that she has seen has been clipped to privacy curtains when housekeeping has been in the room cleaning. A review of the facility call light policy was conducted and revealed under section key procedural points include when the resident is in bed or confined to a chair be sure the call lights is within easy reach of the resident.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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