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F0550
D

Call Light Inaccessibility Compromises Resident Rights and Safety

Torrance, California Survey Completed on 08-14-2025

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 was identified when a resident's call light, an essential communication tool for requesting staff assistance, was found on the floor behind the resident's bed and not within reach. The resident, who had diagnoses including schizoaffective disorder, major depressive disorder, and failure to thrive, was documented as having a fluctuating capacity to understand and make decisions and required supervision or touching assistance for activities such as toileting hygiene, showering, and personal hygiene. During an observation and interview, a CNA confirmed that the call light was not accessible to the resident and acknowledged responsibility for ensuring call lights are within reach. The CNA also stated that the resident would not be able to pick up the call light from the floor independently and relies on it for assistance. Further interviews with an LVN and the DON confirmed that facility policy requires all staff to ensure call lights are always accessible to residents before leaving the room. Both staff members reiterated that the resident depends on the call light for help and that its inaccessibility creates a safety risk. Review of facility policies supported the expectation that call lights be positioned for easy access and that resident dignity and rights be maintained. The failure to ensure the call light was within reach compromised the resident's ability to request assistance and did not align with facility policy or resident rights.

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