Failure to Ensure Accessible Call Lights and Timely Repair of Shower
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were accessible and by not repairing a shower in a timely manner. One resident with severe cognitive impairment, Alzheimer’s disease, osteoarthritis, and insomnia was care planned as being at risk for falls and encouraged to use the call light for assistance with transfers. Multiple observations over several days showed this resident seated in a recliner while the call light was wrapped around the bed rail at the top of the bed or under the pillow, consistently out of reach. The resident stated a desire to go to bed but reported the call button was not within reach. A CNA and an LPN both confirmed the resident was able to use the call button and that it should have been within reach. Another resident with severe cognitive impairment, dementia, heart disease, and heart failure was dependent on staff for personal and toilet hygiene and was care planned to have the call light kept within reach at all times due to fall risk related to impaired mobility and altered mental status. On two separate observations, this resident was lying in bed while the call light was positioned on the floor behind the headboard, not accessible to the resident. A CNA and the DON both stated that call lights were to be positioned within residents’ reach at all times, regardless of cognitive status, which was inconsistent with the observed placement of the call lights for these residents. The facility also failed to provide reasonable accommodation by not repairing a shower in the 200 hall shower room for approximately a month. A cognitively intact resident with arthritis and spinal stenosis, who did not have a bathroom in the room, reported self-propelling in a wheelchair to the 200 hall shower room to use the bathroom but was unable to shower there because it was broken. The resident stated the shower had been broken for over a month, requiring use of another shower room located further down the hall and often needing staff assistance to reach it. Observations on multiple days showed a sign posted in the 200 hall shower room stating, "Please do not use shower." The maintenance associate and maintenance director both acknowledged the shower had been broken for about a month, with the maintenance director stating he had not gotten around to fixing it, while the administrator reported being unaware of the issue.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.