Failure to Ensure Call Lights Were Within Reach
Summary
The facility failed to ensure that residents received services with reasonable accommodation of their needs, specifically regarding the accessibility of call lights. Observations revealed that five residents had their call lights out of reach, which could prevent them from calling for assistance when needed. For instance, Resident #54, who was totally dependent on staff for movement, had her call light on the floor and out of reach. Similarly, Resident #24, who required substantial assistance for transfers, also had his call light on the floor and out of reach while he was in bed with a wound vac attached to his left foot wound. Resident #52, who was legally blind and at risk for falls, was found in her bed with her call light on the floor, and she was unaware of its location. Resident #81, who was dependent on a manual wheelchair for indoor mobility, had his call light under his bed and out of reach. Lastly, Resident #69, who required substantial assistance for transfers and had a history of falls, was observed in his wheelchair with his call light on the floor. A CNA present in the room acknowledged that having call lights on the floor could create fall risks. Interviews with staff, including the ADON, Nurse Consultant, and Administrator, confirmed that the expectation was for call lights to be within reach of residents to prevent potential dangers such as falls or unmet needs. The facility's policy on answering call lights also emphasized the importance of ensuring call lights are within easy reach of residents when they are in bed or confined to a chair.
Penalty
Resources
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Surveyors found that two residents who required staff assistance for daily care and had cognitive and neurological conditions, including dementia, Parkinson’s disease, and stroke, did not consistently have their call pendants within reach as required by facility policy and their care plans. On observation, each resident was lying in bed with the call pendant placed on a nightstand out of reach, despite care plan directions to encourage call bell use and ensure pendants were in place. One resident later had both a pendant and a tap bell, but the tap bell was not within reach. Staff, including an aide and the DON, acknowledged that residents able to use call pendants should have them within reach, confirming that the observed situations did not meet facility expectations.
Surveyors found that staff failed to keep call lights within reach for two residents, contrary to facility policy requiring accessible call lights to ensure timely responses to needs. One resident with COPD and dementia was in bed with the call light hanging under the foot of the bed, out of reach. Another resident with a lumbar fracture and history of repeated falls was seated in a recliner while the call light was draped over an overbed table pushed against the bed on the opposite side of the room, also out of reach. A CNA and the RNC both acknowledged that call lights should have been within reach and were not in these cases.
A resident who required assistance with incontinence care activated a call bell and waited over an hour without receiving the needed help. A dietary staff member checked on the resident, learned that incontinence care was needed, and stated they would notify a nurse aide, but no staff responded during the period observed by the surveyor. The DON later acknowledged that a 15-minute wait for call bell response was considered too long, yet the resident’s call bell remained unanswered for a significantly longer period.
Surveyors found that the facility did not consistently provide hot foods at a palatable temperature, particularly for residents receiving in-room meal service. Multiple residents reported that cooked foods were lukewarm, sometimes cold, or not always cooked thoroughly when delivered to their rooms, and several residents at a Resident Council meeting echoed that food was not always warm during in-room dining. This occurred despite the facility’s policy and the Dietary Manager’s statement that all hot and cold food items must be served at an adequate, palatable temperature and that resident food preferences would be accommodated.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
A resident with an ADL self-care deficit and a care plan requiring assistance to the toilet/commode with maximum assistance of one staff was placed in a room where the bathroom was out of order due to renovation. During an incident involving alleged abuse/neglect, a GNA reported attempting to assist the resident to the bathroom, discovering it was under construction, and instead providing a bedpan. The DON later confirmed that the bathroom was nonfunctional at admission because the floor was setting and acknowledged that a commode should have been available, indicating the resident’s toileting needs and preferences for toilet/commode use were not reasonably accommodated.
Call Bells Not Kept Within Reach for Two Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call bells were within reach for two residents, contrary to facility policy and care plan interventions. The facility’s call system policy dated January 22, 2026, states that each resident must be provided with a means to call staff directly for assistance from the bed and other areas. Resident 32 had a quarterly MDS showing she was sometimes understood and sometimes able to understand others, required staff assistance for daily care, and had Parkinson’s disease and dementia. Her care plan, initiated in 2019 with an intervention added in 2021, directed staff to encourage her to use the call bell and to assure the call pendant was in place and functioning properly. On observation, she was found lying in bed with her call pendant placed on the nightstand out of reach. The DON stated at that time that the resident was unable to use the call pendant, then placed it around her neck. In interviews, the resident first indicated she would push the button on her pendant to call a nurse, and later stated she had been told there was a bell somewhere to use; at that later observation, she was wearing the pendant and had a tap bell on her overbed table that was not within reach. Resident 78’s annual MDS indicated he was usually understood and usually able to understand others, required staff assistance for daily care, and had dementia and a history of stroke. His care plan directed staff to encourage him to use the call bell for assistance. During observation, he was found lying in bed with his call pendant on the nightstand out of reach. At the time of this observation, a nurse aide acknowledged that the resident should have had his call pendant within reach. In a subsequent interview, the resident demonstrated his call pendant hanging around his neck when asked how he would call for a nurse. The DON stated that all residents who are able to use their call pendants should have them within reach, confirming that the observed placement of the pendants on the nightstands, out of reach, was inconsistent with facility expectations and policy.
Plan Of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Indiana Skilled Nursing INC dba Beacon Ridge agrees with the allegations and citations listed on the statement of deficiencies. Indiana Skilled Nursing INC dba Beacon Ridge maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Indiana Skilled Nursing INC dba Beacon Ridge written credible allegation of compliance. By submitting this plan of correction, Indiana Skilled Nursing INC dba Beacon Ridge does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Indiana Skilled Nursing INC dba Beacon Ridge reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding. The facility is unable to retroactively correct the observation for Resident 32 and 78; when it was identified it was corrected at that time. There were no ill effects noted. The Director of Nursing and/or designee will re-educate current facility staff, including agency staff, on assuring the call pendants and/or tap bells are within reach. New/agency Nursing staff will be educated upon onboarding, assuring the call pendants and/or tap bells are within reach of residents. The Director of Nursing and/or designee will complete random audits 3 times a week for 2 weeks, weekly for 2 weeks and then monthly for 2 months to assure the call pendants and/or tap bells are within reach. Audit results will be reviewed by the facility Quality Assurance Performance Improvement Committee to determine compliance or need for continuation of audits.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure residents’ call lights were within reach, as required by the facility’s “Answering the Call Light” policy, version 1.3, which states that call lights must be accessible to residents to ensure timely responses to their requests and needs. For one resident with COPD and dementia, the resident was observed lying in bed with the call light plugged into the wall and hanging down the wall under the foot of the bed, not within the resident’s reach. The resident was unable to independently reach the call light. A CNA later confirmed that this resident’s call light should have been within reach and had not been. Another resident, with a history including a stable lumbar vertebra fracture and repeated falls, was observed sitting in a recliner with the call light draped over an overbed table that had been pushed against the bed on the other side of the room, making it inaccessible. This resident reported that staff had pushed the table against the bed after removing the breakfast tray and that the call light could not be reached. The same CNA confirmed that this resident’s call light should have been within reach and was not. The RNC also stated that residents’ call lights should be within reach and acknowledged that they had not been in these instances.
Failure to Respond Timely to Resident Call Bell for Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s call bell was answered in a timely manner, as required for reasonable accommodation of resident needs and preferences. During an interview, the resident reported concerns about the length of time it took staff to respond to the call bell, stating that assistance was needed with incontinence care and that the call bell had been activated at approximately 11:00 a.m. At 11:17 a.m., a staff member identified by the resident as dietary staff knocked on the door to inquire about the call bell and, upon being informed that incontinence care was needed, stated that he or she would inform the nurse aide. When the surveyor left the resident’s room at 11:35 a.m., no staff had arrived to provide the requested incontinence care. Subsequent observations from the unit’s nurses’ station until 12:03 p.m. showed no staff responding to the resident’s call bell. In an interview with the DON and NHA, the DON stated that a 15-minute wait time for call bell responses was considered too long. The surveyor then informed the DON that the resident had been waiting for over an hour for assistance after activating the call bell.
Plan Of Correction
R1's call bell was responded to and incontinence care was provided on 4/14/2026. Facility wide education will be completed regarding call bell response expectations. DON/Designee will complete random facility wide call bell response time audits daily x30 days then 3 times per week for 4 weeks. DON/Designee will report findings to QA Committee for review/recommendation.
Failure to Provide Palatable-Temperature Meals to Residents, Especially During In-Room Dining
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to reasonably accommodate resident food preferences regarding temperature of cooked foods, particularly for residents receiving meals in their rooms. In individual interviews, one resident stated the cooked food was lukewarm, another reported that cooked food was sometimes cold when it arrived to their room, and additional residents indicated that cooked food was cold at times, sometimes cold, or cold and not always cooked thoroughly when they ate in their rooms. During a Resident Council meeting, three anonymous residents also reported that food was not always warm when they ate in their rooms. The Dietary Manager stated that food must be served at an adequate temperature and with palatable taste and that resident food preferences were accommodated, and the facility’s Food Temperatures policy indicated that all hot and cold food items would be served at a palatable temperature at the time the resident receives the food. These resident reports and policy statements formed the basis for the cited deficiency under 410 IAC 16.2-3.1-3(v)(1). No additional clinical history or medical conditions for the residents involved were documented in the report.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Provide Commode When Bathroom Was Out of Order
Penalty
Summary
Failure to reasonably accommodate a resident’s toileting needs occurred when a resident with an ADL self-care deficit and a care plan intervention requiring assistance to the toilet/commode with maximum assistance of one staff was admitted to a room whose bathroom was out of order due to recent floor renovation. During review of a facility-reported incident alleging abuse/neglect, a GNA documented that while attempting to assist this resident to the bathroom, it was discovered that the resident’s bathroom was under construction, and a bedpan was provided instead. The care plan, initiated two days after admission, specified assistance to the toilet/commode, but no commode had been made available in the resident’s room while the bathroom was nonfunctional. In an interview, the DON stated that at the time of the resident’s admission the bathroom was out of order because the floor needed time to set after renovation, and acknowledged that a commode should have been available for the resident’s use while the bathroom was out of commission. These findings, based on record review and staff interview, show that the resident’s identified need for assisted toileting to a toilet/commode was not reasonably accommodated when only a bedpan was provided in the absence of an accessible bathroom or commode.
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