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F0558
E

Failure to Maintain Call Devices Within Easy Reach for Dependent Residents

South Pasadena, California Survey Completed on 07-24-2025

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 call devices were maintained within easy reach for two residents with significant physical and cognitive impairments. For one resident with encephalopathy, cerebral palsy, and bilateral hand contractures, the call pad was observed hanging below the bed and out of reach, despite the resident's dependence on staff for all activities of daily living and the need for the call pad to be positioned near the chest area due to hand contractures. Both a CNA and an LVN confirmed that the call pad was not accessible and should have been placed within easy reach to allow the resident to request assistance. For another resident with epilepsy, dysphagia, and Alzheimer's disease, the call pad device was found on the floor near the head of the bed, making it inaccessible. This resident had severe cognitive impairment and required substantial to maximal assistance with daily care. An LVN confirmed that the call pad was not within easy reach and should have been accessible to ensure timely care. The facility's policy requires that call lights be within easy reach for residents in bed or confined to a chair, but this was not followed in these cases.

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