Inadequate Wheelchair Sizing for Resident
Summary
The facility failed to provide an appropriately sized wheelchair for a resident, resulting in discomfort. The resident, who was admitted to the facility with diagnoses including mononeuropathies of bilateral lower limbs and chronic congestive heart failure, was observed sitting in a standard wheelchair with an 18-inch-wide seat. The resident's abdominal girth and thighs were resting directly on the metal parts of the wheelchair arms, indicating that the wheelchair was too small. The resident expressed discomfort, stating that the wheelchair was too tight and that her legs pushed against the sides. She spends most of her day in the wheelchair, including self-propelling to the dining hall for meals. The resident's care plan noted obesity and weakness, requiring moderate help with upper body tasks and substantial help with lower body activities of daily living. The therapy department, responsible for providing wheelchairs for new admissions, assessed the resident shortly after admission. However, the assessment did not result in the provision of a properly fitting wheelchair. Both a Licensed Practical Nurse and the Director of Nursing acknowledged the need for a wider wheelchair to accommodate the resident's size. The facility's policy on unit rounds, intended to monitor residents' needs throughout the day, was not effectively implemented in this case, as the resident's discomfort was not addressed in a timely manner.
Penalty
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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.
A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls, who required substantial assistance with ADLs and transfers, was observed lying in bed with the call light on the floor and out of reach, despite a care plan directing staff to keep it accessible. Staff, including CNAs, LVNs, the DON, and the Administrator, acknowledged that call lights must always be within residents’ reach and that all direct care staff are responsible for checking this, while the DON confirmed the facility had no written call light policy.
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.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences by not ensuring the call light was within reach. Record review showed the resident was an elderly male with dementia, hypertension, COPD, coronary artery disease, chronic kidney disease, and a history of falls. His annual MDS documented a BIMS score of 0, indicating severe cognitive impairment, and that he required substantial/maximal assistance with toileting hygiene, upper and lower body dressing, and transfers. The resident’s care plan directed staff to ensure the call light was within reach and to instruct him to use it for assistance as needed. During an observation in the resident’s room, the resident was found lying in bed with the call light on the floor toward his feet, out of his reach. The resident was confused, speaking incomprehensibly, and only the word "cold" in Spanish was discernible. Multiple staff members, including CNAs and LVNs, stated in interviews that call lights were required to be within residents’ reach so they could request help, and that all direct care staff were responsible for checking this. The DON and Administrator both confirmed that call lights had to be within reach and that all nursing staff were responsible for ensuring this, and the DON further confirmed via email that the facility did not have a written policy on call lights.
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