F0558

E

Failure to Provide Accessible and Reachable Call Lights for Dependent Residents

West Sacramento, California Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The facility failed to reasonably accommodate residents’ needs and preferences related to call light accessibility for multiple residents. Two residents with significant physical limitations, including one with bilateral hand contractures and another with quadriplegia, were assessed as dependent in activities of daily living. During observation, both residents had standard call lights placed on their chests despite their mobility issues, and a licensed nurse acknowledged not knowing how they would be able to use the call lights if they needed help. The DON confirmed that these residents were not provided with accessible call light systems and stated that the facility did not conduct assessments for accessible call lights, asserting that such residents could not press them anyway. The facility did not provide a policy or procedure for call light accessibility when requested, although its Resident Rights policy referenced residents’ right to a dignified existence.

Additional deficiencies were identified for three other residents whose call lights were not within reach. One resident with respiratory failure and another with an anoxic brain injury were observed lying in bed with their call lights on the floor; the licensed nurse present confirmed the call lights were not within reach and acknowledged that call lights on the floor were a safety issue. Another resident with Parkinson’s disease was also observed in bed with the call light on the floor, and the respiratory therapist confirmed the call light was out of reach and that the resident would not be able to use it to get help. These observations were inconsistent with the facility’s written policy on answering call lights, which required that call lights be accessible to residents when in bed.