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F0919
D

Call Light Accessibility Deficiency

St. Clair Shores, Michigan Survey Completed on 04-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that call lights were accessible to residents, as observed in the cases of three residents. For one resident, the call light was found on the floor by the side of the bed, out of reach, on two separate occasions. This resident, who had intact cognition but required substantial assistance for activities of daily living (ADLs), was unaware of the call light's location. Another resident's call light was observed on the floor under the bed and later next to the bed, both times out of reach. This resident had moderately impaired cognition and required moderate assistance for ADLs. A Licensed Practical Nurse (LPN) was observed picking up the call light from the floor and clipping it to the resident, indicating a lack of consistent adherence to call light placement protocols. A third resident's call light was also found on the floor by the bed, out of reach. This resident had moderately impaired cognition, was frequently incontinent of urine, and was dependent on staff for toileting. The facility's policy on call light accessibility, issued in August 2023, mandates that staff ensure call lights are within reach of residents. However, interviews with staff and the Nursing Home Administrator (NHA) revealed that the expectation for call light placement was not consistently met, as evidenced by the observations made during the survey.

Plan Of Correction

Residents R57, R106, and R152 currently reside in the facility. The facility failed to ensure that call lights are in reach. Element 2: Like Residents Residents who reside in the facility have the potential to be impacted by the identified deficiency. The facility completed a baseline audit to ensure residents had call lights in place. Element 3: Education Staff will be educated on the importance of ensuring the call lights are within reach for residents. Element 4: Audit An administrator or designee will complete a random audit on 10 residents a week for 4 weeks to ensure their call light is in place. Element 5: Compliance The facility Administrator will be responsible for assuring substance compliance is attained through this plan of correction by 5/13/25 and for sustained compliance thereafter.

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