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F0558
D

Failure to Ensure Call Light Accessibility for Residents with Physical Limitations

San Rafael, California Survey Completed on 05-16-2025

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 the call light was within reach for two residents with significant physical limitations. One resident, admitted with hemiplegia, paraplegia, and multiple contractures, was observed lying in bed with both hands and neck contracted. The call light was placed by her collar bone, above her right hand, but she stated she was unable to move her hands or call for assistance because the call light was not within her reach. Her roommate confirmed that she often had to press her own call light for this resident, as the call light was frequently not placed within reach. A CNA confirmed the call light was not within reach and acknowledged it should have been. Another resident, admitted with hemiplegia of the left side, need for assistance with care, and aphasia, was observed lying in bed with her call light dangling off the bed, out of reach. An LVN confirmed the resident was unable to reach her call light and stated it should always be within reach. The Director of Nursing also confirmed that call lights should always be accessible to residents. The facility's policy and procedure on answering call lights indicated that staff should ensure the call light is accessible to the resident.

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