Failure to Ensure Working Call Lights for Multiple Residents
Summary
The deficiency involves the facility’s failure to ensure that residents had working call lights to reasonably accommodate their needs and preferences, as required by their care plans and facility policy. One resident, a cognitively intact female with multiple diagnoses including bilateral lower leg fractures, COPD, malnutrition, incontinence, and high fall risk, was admitted to her current room on 12/29/2025. Her care plan included multiple interventions requiring that the call light be placed within reach and that staff assess her ability to use it, particularly due to her functional deficits, incontinence, and fall risk. On observation, she was bedridden, unable to bear weight on her legs, and dependent on staff for all assistance, yet she reported that her call light had not worked since admission to the room. When she pressed the call light during the survey, there was no light at the panel, no light outside the room, and no audible sound. The same resident stated that when her roommate was present, the roommate would either press her own call light or walk to the nurses’ station to get help, but when the roommate was not present, the resident had to wait and became scared that no one would come when she needed help. The bathroom shared by these two residents had no call panel or pull switch. The roommate, also cognitively intact and with multiple medical and psychiatric diagnoses, confirmed that staff did not answer call lights consistently and that the other resident’s call light did not work. She demonstrated that her own call light functioned, while the bedridden resident’s did not, and she stated that if she needed help in the bathroom, there was no call light to pull. The Director of Nursing observed that the bedridden resident’s call light did not activate any lights and acknowledged that the resident was dependent on staff and required a working call light. The DON stated that if a call light was not working, the resident should have been given a bell, and that clinical staff do not check call lights, even though call lights should be working. A third cognitively intact male resident with a history of stroke, hemiplegia, incontinence, and high fall risk also reported that his call light did not work and that he relied on his roommate to get staff when he needed assistance. His care plan required that the call light be placed within easy reach to maintain his dignity related to incontinence and that he be educated to use the call light for assistance with ADLs as part of his fall prevention interventions. During observation, when he pressed his call light, there was no light at the wall panel, no light above the room, and no audible sound. The call light was not answered, and when an LPN entered to give medications, she did not acknowledge the call light because it was not functioning. When the LPN later tested the call light, it did not work until she unplugged and reinserted it several times, after which it began to function. She stated that nurses and CNAs are supposed to ensure call lights are working, keep them within reach, and submit work tickets for nonfunctioning call lights so they can be fixed immediately. Interviews with staff revealed inconsistencies between stated procedures and actual practice. The Assistant DON stated that call lights are checked every day and that frequent rounds are made to ensure residents are checked, while the Maintenance Director stated that rooms are checked daily by housekeeping and CNAs, that any nonworking equipment should be entered into the system to alert maintenance, and that every bed should have a functioning call light. The Maintenance Director acknowledged that the bedridden resident’s call light had been a “constant issue,” that management knew in morning meetings that the call light was not working, and that someone should have provided the resident with some type of communication device. The facility’s Preventive Maintenance Policy required monthly surveillance of all resident rooms for proper operation of equipment, and the Call Light Response policy required prompt reporting of defective call lights. The Maintenance Director’s job description required periodic rounds to check equipment and ensure it was working properly. Despite these policies and stated expectations, multiple residents had nonfunctioning call lights and lacked bathroom call devices, and staff either were unaware of the problems or did not ensure timely reporting and resolution, resulting in residents’ needs not being reasonably accommodated through access to working call lights.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Call Sensor Pad Not Within Reach: A resident with Parkinsonism, muscle spasms, seizures, and moderately impaired cognition was observed sitting in a wheelchair with his sensor pad left on his bed and out of reach. He stated he could not reach it and would have to yell for help, and CNA, RN, DON, and ADM interviews confirmed the device was not within reach and should have been accessible.
Call lights were not kept within reach for multiple residents who needed staff assistance. A resident with blindness, falls, and transfer needs was left at her table with the call light out of reach, another resident with cognitive impairment and extensive assistance needs had the light placed on the far side of the bed under a blanket, and a third resident with severe cognitive impairment and MS was found sleeping with the call light coiled on the wall out of reach. Staff interviews confirmed call lights should remain accessible even when residents do not always use them.
A resident with severe cognitive impairment, wheelchair use, lower-extremity impairment, and dependence for most ADLs had her call light repeatedly observed on the floor out of reach while lying in bed. Her care plan directed staff to keep the call light within reach and encourage use of the bell for assistance, and multiple staff members stated call lights should always be within reach and that staff were responsible for placement. The resident's family member said she could use the call light, but survey observations showed it was not accessible during several checks.
A resident with bilateral knee replacements and difficulty walking could not independently access the closet in the room because the resident’s wheelchair would not fit between two beds placed footboard-to-footboard. The resident said staff had been told multiple times, but the room layout was unchanged; staff gave conflicting accounts of the resident’s mobility, and the Administrator and Maintenance Director confirmed the wheelchair could not fit between the beds.
A resident with seizures, aphasia, dementia, and a recent fall with injury did not have his call light within reach while in bed. The care plan directed staff to keep the call light in reach, but surveyors observed it wrapped around a wall-mounted switch box above the head of the bed and out of reach. The resident and an NA confirmed it could not be reached, and the record showed a prior fall after the resident tried to transfer without using the call light.
A resident with COPD, major depressive disorder, neuromuscular dysfunction of the bladder, and DM had intact cognition but needed extensive ADL assistance and had lower-body impairment. His care plan directed staff to keep his call light within reach, yet during observation it was found at the bottom of the bed and out of reach while he was lying in bed. Staff stated call lights should always be within the resident's reach and that residents should be told where they were placed.
Call Sensor Pad Not Within Reach
Penalty
Summary
The facility failed to provide reasonable accommodation for Resident #44 by not ensuring his call sensor pad was within reach. Resident #44 was a [AGE]-year-old male admitted on [DATE] with diagnoses including Parkinsonism, muscle spasms, and seizures. His quarterly MDS reflected that he was able to be understood and to understand others, had a BIMS score of 12 out of 15 indicating moderately impaired cognition, and required substantial assistance to total dependence for most ADLs. He used a manual wheelchair and required maximal assistance for locomotion and mobility. His care plan identified an ADL self-care performance deficit related to Parkinsons and muscle weakness and included an intervention to encourage him to use the call bell for assistance. During observation on 06/09/2026 at 10:45 AM, Resident #44 was sitting in a tall wheelchair in his room about 3 feet from his bed, and his sensor pad was lying on his bed. During interview, he stated he would use the sensor pad to call for help if needed, but he could not reach it and would have to yell if he needed help. CNA A stated she could not remember who helped him out of bed, but that he would not be able to reach the sensor pad if it was on his bed while he was in his chair a few feet away, and that he would not be able to get help in an emergency. RN B stated she did not notice the sensor pad placement that morning and that call lights or devices should be within reach. The DON and ADM also stated residents needed call lights or devices within reach so they had a way to get help.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for residents who were dependent on staff assistance. During observation, interview, and record review, call lights were found out of reach for 3 of 4 residents reviewed: R106, R24, and R9. Facility staff, including an RN, left R106 in her room at her dining room table without placing the call light within reach, even though she had moderately impaired cognition, blindness, multiple falls, and required staff assistance for transfers and toileting. Two call lights were present in her room, but one was on the bed about 7 feet away and the other was in the bathroom out of reach. R24, who had moderately impaired cognition, non-traumatic brain dysfunction, arthritis, and required substantial staff assistance for toileting, dressing, and transfers, was observed seated in her wheelchair with no call light within reach. The call light was on the other side of the bed and underneath a blanket. An RN later placed it within her reach and stated a volunteer may have brought her back to the room without placing the light. R9, who had severely impaired cognition, multiple sclerosis, dementia, muscle weakness, repeated falls, and dependence on staff for toileting and transfers, was observed sleeping in bed with the call light coiled up on the wall by the foot of the bed and not within reach. Interviews with nursing and activity staff confirmed that call lights should be within residents’ reach even when residents do not always use them or have cognitive impairment. The DON stated staff should ensure the call light is within reach before leaving a resident’s room, and if a resident cannot use the call light due to cognition, it should be removed as a care plan intervention. The facility policy stated all personnel must be aware of call lights, answer them promptly, and position them conveniently and accessibly for residents in bed or other sleeping accommodations.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure Resident #37 had her call light within reach. Resident #37 was a [AGE]-year-old female admitted most recently on [DATE] with diagnoses including vascular dementia with agitation, intermittent explosive disorder, muscle weakness, unsteadiness on feet, and cerebral infarction. Her quarterly MDS showed a BIMS score of 7, indicating severely impaired cognition, and she used a wheelchair with impairment to both lower extremities. She was dependent or needed partial/moderate assistance for all ADLs except eating, and she was always incontinent of bladder and bowel. Her care plan identified an ADL self-care deficit and included interventions to encourage her to use the bell to call for assistance and to be sure her call light was within reach. During observations on 06/03/26 at 09:01 AM, 11:11 AM, 12:19 PM, and 02:12 PM, Resident #37 was observed lying in bed and her call light was on the floor between her bed and the wall at the foot of her bed. During the 12:19 PM observation and attempted interview, she did not answer when asked if she had a call light or had ever used one. During interview, the resident's family member stated she was capable of using her call light and would sometimes push it just to mess with staff. Multiple staff members, including LVN, RN, CNA, DON, MDS RN, ADM, and HR, stated call lights should be in reach of residents and that staff were responsible for ensuring proper placement. HR stated she checked Resident #37's room twice a day and said the call light was in reach both times, which differed from the surveyor observations showing it on the floor.
Closet Access Blocked by Bed Placement
Penalty
Summary
The facility failed to ensure Resident 23 could independently access the closet in the resident’s room. Resident 23 was admitted with diagnoses of bilateral knee replacements and difficulty walking. The quarterly MDS identified intact cognitive function, use of a walker and wheelchair for mobility, and the need for set up and supervision with transfers and walking. The care plan stated the resident used a wheelchair and required one-person assistance with walking. Observations of the room showed the resident’s bed and the roommate’s bed were positioned directly facing each other, with the footboards approximately 20 to 24 inches apart and the closets located on the far wall corner. During observation, Resident 23 attempted to maneuver the wheelchair between the beds but the wheels caught on the footboards and prevented access to the closet. The resident stated the wheelchair could not fit between the beds and that staff had been notified multiple times, but no changes were made. Staff interviews reflected differing understandings of the resident’s mobility status, and the Administrator and Maintenance Director later confirmed the footboards were too close together for a wheelchair to fit between them.
Call Light Not Within Reach for Resident at Risk for Falls and Seizures
Penalty
Summary
The facility failed to ensure a call light was within reach for a resident with a history of epileptic seizures, aphasia, non-Alzheimer's dementia, and a recent fall with injury. The resident's MDS identified moderately impaired cognition, and the care plan directed staff to make sure the call light was in reach when the resident was in the room. The resident also had a history of needing partial/moderate assistance with standing and transfers, and the CAA identified fall risk related to body weakness and decreased muscle strength. During observation, the resident was in bed with the call light wrapped around the wall-mounted switch box above the head of the bed and off to the left, out of reach. On follow-up observation, the call light remained in the same position. The resident stated he would like his call light, and an NA confirmed he would not have been able to reach it and that it should have been within reach. The record also included a prior fall from bed after the resident attempted to transfer to his wheelchair without using the call light, and a later seizure episode in which the resident used the call light to alert staff. Staff interviews stated that all residents should have call lights within reach, and the facility policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Call Light Left Out of Resident's Reach
Penalty
Summary
The facility failed to ensure Resident 5's call light was within reach so he could call for staff assistance. Resident 5 had diagnoses of COPD, major depressive disorder, neuromuscular dysfunction of the bladder, and DM. His Significant Change MDS documented a BIMS score of 15, indicating intact cognition, and also noted impairment of the extremities on both sides of his lower body. The MDS further documented that he needed setup or cleanup assistance with eating and oral hygiene and was dependent on staff for toileting, bathing, and dressing. Resident 5's Falls CAA documented anxiety, antidepressant drug use, and assistance required for ADLs, placing him at risk for falls. His care plan stated that staff were to keep his call light within his reach so he could notify nursing when he needed to use the toilet or had an incontinence episode, and a later care plan entry stated staff were to keep the call light within his reach as he allowed. During observation, Resident 5 was lying in bed with his eyes shut, and his call light was found at the bottom of the bed on the left-hand side, out of his reach. Staff interviews stated that call lights should be placed within the resident's reach, on the bed rail or on the person, and that residents should be told where the call light was placed.
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