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F0919
D

Call Light Not Within Reach for Resident Requiring Assistance

San Gabriel, California Survey Completed on 04-10-2025

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

A deficiency occurred when the facility failed to ensure that a call light was within reach for a resident as required by the care plan and facility policy. The resident, who had diagnoses including metabolic encephalopathy, COPD, and cerebral infarction, was assessed as having moderately impaired cognitive skills and required supervision or assistance for activities such as toileting, bathing, personal hygiene, and transfers. The care plan specifically indicated that the call light should be within reach due to the resident's risk for falls related to impulsive behavior and poor safety judgment. During an observation, the call light was found on the floor, out of the resident's reach, while the resident was lying in bed. Staff confirmed that the call light should have been placed on the bed next to the resident. The DON also stated that call lights should be within reach to ensure residents can call for assistance. Facility policy required call cords to be placed within the resident's reach, but this was not followed in this instance.

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