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F0558
D

Call Light Not Accessible to High Fall Risk Resident

Grand Rapids, Michigan Survey Completed on 08-18-2025

Penalty

51 days payment denial
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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 resident's call light was within reach, as required by facility policy. The resident, who had diagnoses including lack of coordination, epilepsy, muscle weakness, and difficulty walking, was dependent on staff for toileting, personal hygiene, and required substantial assistance with dressing. During an observation, the resident was found sitting at the edge of his bed, appearing weak and shaky while attempting to stand up unassisted. The resident repeatedly stated he needed help but was unable to use his call light because he did not know where it was. It was observed that the call light was under the bed and out of the resident's reach. In an interview, a registered nurse confirmed that the resident was a high fall risk and had recently experienced unwitnessed falls in the facility. The nurse also stated that the resident typically used his call light for assistance. Review of the facility's call light policy indicated that staff are responsible for ensuring call lights are plugged in, functioning, and within reach of residents. The failure to provide the resident with access to the call light resulted in the resident's inability to call for staff assistance.

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