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F0919
E

Call Light System Not Accessible to Residents

San Rafael, California Survey Completed on 04-23-2025

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 system was accessible to four out of five sampled residents, as required by facility policy. During observations and interviews, it was found that one resident's call light was stored in a box on a dresser, and the resident was unaware of its location. Another resident was unable to reach her call light, which was clipped to a curtain out of her reach. A third resident did not know where her call light was, and it was confirmed to be attached to a curtain, making it inaccessible. The fourth resident's call light was found behind her, in a drawer on a dresser, and not within her reach while she was seated in a reclined chair. Staff members, including licensed nurses, the Social Services Director, and the Registered Dietician, confirmed during interviews that the call lights were not within reach of the residents and acknowledged that they should have been. The Director of Nursing also stated that it was her expectation for call lights to be easily accessible to residents and recognized that having them out of reach could pose a safety issue. A review of the facility's policy confirmed that call cords are to be placed within the resident's reach in their rooms.

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