Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an available call bell system for multiple Residents which was identified initially for one Resident (Resident #117), and secondarily as the sample was expanded, for three other residents (#118, #119, and #120) in a sample of 22 residents resulting in a finding of immediate jeopardy (IJ). Following the removal of IJ, the scope and severity was lowered to a level two pattern. The findings included.For Resident #117 and others, the call bell system was inoperable and no alternative means to call for assistance was in place for them in the facility. Resident #117 was most recently readmitted to the facility on [DATE]. …
F919 · Call system
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F919 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F919 finding.
The harm level
How severely F919 is cited
1.1% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J30.2% | K140.7% | L30.2% |
| Actual harm | G10.1% | H10.1% | I— |
| No harm, potential for more than minimal | D1,21063.2% | E55128.8% | F1266.6% |
| No harm, potential for minimal | A— | B50.3% | C— |
In the surveyor’s words
What an F919 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview and record review the facility failed to provide a functioning nurse call system in resident bathrooms for all facility residents. This failure resulted in four of four residents (R1, R2, R3 and R4) expressing fear and anxiety during toileting in their rooms due to a non-functioning nurse call system. Findings include: The facility policy, Call Lights, dated (revised) 2/2/18 documents, Purpose: To respond to resident's requests and needs in a timely and courteous manner. Resident call lights will be answered in (a) timely manner. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. …
Based on observation, medical record review, staff interview, review of call light records, review of written statements, and review of a facility policy, the facility failed to maintain an adequately equipped call system which relayed the call directly to a staff member or centralized staff work area from each resident's bedside toilet, and bathing facility. This deficient practice had the potential to affect all 39 residents residing in the facility. The facility census was 39.Findings include:Review of the medical record revealed Resident #49 was admitted to the facility from the hospital on [DATE]. …
Based on observation, interview and record review the facility failed to ensure that each resident room marked as available for new residents was adequately equipped to allow new residents to call for staff assistance through a communication system that would relay the call directly to a staff member or centralized staff work area for one room (215) of four observed that had a welcome sign and future resident listed outside of room.The facility failed on 3/22/2026 to ensure that the call light system was properly working for potential new resident rooms for room [ROOM NUMBER]. …
By state — 2025
Where F919 is cited more, and less, than expected
Each state is measured against its own expected share, not against other states.
- California1.73× · 122 citations
- Texas1.42× · 61 citations
- Pennsylvania0.85× · 25 citations
Co-occurrence
Cited alongside F919
Of the 2025 surveys that cited F919, these tags appeared in the same inspection more often than chance would predict.
- F7306.4% of F919 surveys · 4.5× chance
Observe each nurse aide's job performance and give regular training.
- F75611.8% of F919 surveys · 3.6× chance
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- F8146.4% of F919 surveys · 3.6× chance
Dispose of garbage and refuse properly.
- F92112.4% of F919 surveys · 3.5× chance
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F9086.4% of F919 surveys · 3.4× chance
Keep all essential equipment working safely.
Cited in the same inspection, not caused by one another.
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