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F0558
D

Call Light Inaccessible to Resident with Limited Mobility

Duarte, California Survey Completed on 05-30-2025

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 and appropriate to the physical abilities of a resident with significant mobility limitations. The resident, who had muscle weakness and contractures affecting both hips, both knees, and the left elbow, was found lying on his left side and unable to locate or reach his call light. A CNA confirmed that the call light was positioned behind the resident's right backside, making it inaccessible, and handed it to the resident. The resident stated he was unable to reach the call light on his own. The resident's care plan and occupational therapy evaluation documented limited mobility, decreased strength, and the need for assistance with activities of daily living. Interviews with staff, including an LVN and the DON, confirmed that the call light should have been within the resident's reach to allow for timely assistance. The facility's policy also required that the call light be accessible to residents when in bed. The failure to ensure the call light was within reach had the potential to delay meeting the resident's needs for assistance.

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