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F0919
D

Inaccessible Call Bell in Resident Room

West Haven, Connecticut Survey Completed on 08-20-2025

Penalty

Fine: $26,685
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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 with chronic obstructive pulmonary disease, asthma, and respiratory failure was found in bed with the call bell lying on the floor, out of reach. The resident, who was cognitively intact but dependent for bed mobility and transfers, was unaware of the call bell's location and could not access it when needed. During the surveyor's observation, the resident was seen facing away from the call bell, which was on the opposite side of the bed and not accessible. Shortly after the initial observation, the resident began yelling for help due to difficulty breathing and was visibly short of breath. The surveyor responded by alerting an LPN, who attended to the resident. The call bell remained on the floor until the LPN placed it back on the bed after being notified by the surveyor. When interviewed, the nursing assistant assigned to the resident was unaware of why the call bell was out of reach and stated that call bells are typically clipped or wrapped onto the bed. Facility policy requires that call bells be positioned so residents can easily access them.

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