Health inspection·January 20, 2026

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure all resident rooms had maintained and working call light/call light devices in one of two units and on three of three halls (100, 200, and 300) to include resident rooms 101, 102, 200, 202, 204, 209, 304, and 300.Findings include: On 1/20/2026 at 9:10 a.m. the following resident rooms were observed with the following concerns: *Resident room [ROOM NUMBER] call light was tested twice at 9:27 a.m. the light in the hallway above the room door did not illuminate, nor did it enunciate.*Resident room [ROOM NUMBER]a call light was tested twice at 9:13 a.m. the light in the hallway above the door did not illuminate, nor did it enunciate.*Resident room [ROOM NUMBER]a call light was tested three times at 9:28 a.m. the light in the hallway above the room door did not illuminate, nor did it enunciate.*Resident room [ROOM NUMBER]b call light was tested at 9:29 a.m the light in the hallway above the room door did not illuminate, nor did it enunciate.*Resident room [ROOM NUMBER]b call light was tested twice at 9:30 a.m the light in the hallway above the room door did not illuminate, nor did it enunciate.*Resident room [ROOM NUMBER]b call light was tested three times at 9:34 a.m. the light in the hallway above the room door did not illuminate, nor did it enunciate.*Resident room [ROOM NUMBER]b call light was tested twice at 9:47 a.m. the light in the hallway above the room door did not illuminate, nor did it enunciate.*Resident room [ROOM NUMBER]a and b call light was tested twice at 9:49 a.m. the call light would not reset by after initial activation. An interview was conducted with Staff A, Certified Nursing Assistant (CNA), on 1/20/2026 at 9:15 a.m. Staff A, CNA confirmed assignment included the 100 unit. Staff A, CNA confirmed resident room [ROOM NUMBER] call light above the door did not illuminate, nor enunciate at the nurse station. Staff A, CNA said in cases where the lights do not work, they will put in a work order through the electronic work order system, and the Maintenance Director will obtain the information and then fix the problem. Staff A said when the call lights are not working, they provide a small handheld bell for the residents to ring until the call light gets fixed. Staff A was not aware of any concerns with the call light system. An interview was conducted with the Director of Nursing (DON) on 1/20/2026 at 9:31 a.m. The DON stated there had been a problem on the North wing some time ago and it was fixed but did not believe there had been any issues on the current hall observed, South hall. The DON acknowledged the concern regarding the above resident room call lights. The DON said if a call light does not work, it should be brought to the attention of the maintenance department by way of the electronic work order system, and the maintenance staff are to work on the problem regarding call light repair immediately. The DON said all call lights should be in working order and placed within the residents' reach even if they do not or are not able to use them. The DON said if a call light is found not working, staff will provide a handheld bell for use until the call light is repaired. An interview was conducted with the Director of Maintenance (DOM) on 1/20/2026 at 9:37 a.m. The DOM confirmed the North unit had call light concerns a couple of months ago and they have since Residents Affected - Some Page 1 of 2 105780 105780 01/20/2026 Oaks at Avon 1010 US 27 N Avon Park, FL 33825

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some corrected the concern. The DOM said he had no idea there were issues on the South unit. The DOM said call lights in the building are to be functioning appropriately at all times. The DOM confirmed the resident room call lights noted above were not working. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 1/20/2026 at 11:40 a.m. Staff B, LPN said if there are any call lights that are not functioning properly, it is brought to the attention of the Maintenance Department by their electronic work order system. Staff B, LPN said if it is brought to her attention either by staff or residents, she will report concern immediately. Staff B, LPN said the resident would be provided with a handheld ball to use until the system is corrected. An interview was conducted with Staff C, LPN/unit nurse on 1/20/2026 at 11:48 a.m. Staff C, LPN said she was not aware of any call lights on the unit not working. Staff C, LPN said staff and residents would let her know and she would report it to Maintenance. The Maintenance Director did not have a specific Call Light Maintenance Policy and procedure for review. 105780 Page 2 of 2