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F0558
D

Failure to Ensure Call Light Accessibility for Dependent Resident

Hart, Michigan Survey Completed on 07-17-2025

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 occurred when staff failed to ensure that a dependent resident's call light was consistently left within reach, as required by the resident's care plan. The resident, who had diagnoses including diabetes, heart failure, and weakness, was dependent on staff for transfers and required the call light to be accessible when alone in the room. On multiple occasions, the resident was observed sitting in a recliner with the call light either out of reach or not visible, and the resident reported being unable to locate or use the call light to request assistance. Interviews with staff confirmed that the call light should have been left within the resident's reach after being assisted back to the room, but this was not done. One CNA acknowledged forgetting to place the call light within reach after assisting the resident, and another confirmed the resident's need for staff assistance and the importance of call light accessibility. These actions and inactions resulted in the resident being unable to call for help as directed by the care plan.

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