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F0558
D

Failure to Ensure Call Light Accessibility and Timely Response

La Verne, California Survey Completed on 04-04-2025

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 a call light was within reach for a resident with severe visual impairment and failed to answer a call light in a timely manner for another resident. In the first instance, a resident who was legally blind and dependent on staff for activities such as toilet hygiene and bathing was observed sitting in a wheelchair beside the bed, with the call light placed in the middle of the bed and out of reach. The resident expressed difficulty in locating the call light due to blindness and stated a desire to have it within reach. Staff interviews confirmed the resident's blindness and the expectation that the call light should be accessible, especially for residents with visual impairments. Facility policy also indicated that call lights should be accessible to residents. In the second instance, a resident with diagnoses including a stage 3 pressure ulcer, diabetes, and dysphagia, and who had intact cognition, activated the call light for assistance with treatment. The call light outside the resident's room and at the nursing station remained lit and unanswered for approximately 11 minutes before being addressed by a nurse. The resident reported dissatisfaction with the wait time. Staff interviews confirmed that call lights should be answered within three to five minutes, with a maximum of ten minutes, and that both licensed and unlicensed staff are responsible for responding. Facility policy supported the expectation for prompt response to call lights.

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