Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
Surveyors determined the facility failed to ensure residents’ call lights were within reach, as required by the facility’s undated “Call System, Residents” policy, which states each resident must be provided a means to call staff directly for assistance from the bed, toileting/bathing areas, and from the floor. Resident #35, admitted with diagnoses including atrial fibrillation and high blood pressure, was observed on 2/17/26 at 10:27 AM sitting in a recliner placed on the left side of her bed while her call light was lying on the nightstand on the right side of the bed, out of her reach. At 10:30 AM, LPN #1 confirmed the call light should have been within Resident #35’s reach and was not. Resident #30, admitted with diagnoses including end stage renal disease, diabetes, and repeated falls, was observed on 2/17/26 at 1:25 PM sitting in a recliner on the right side of his bed while his call light was pinned to the room curtain on the left side of the bed, also out of his reach. At 1:42 PM, LPN #1 acknowledged that Resident #30’s call light should have been within reach and was not, and at 2:52 PM the Administrator likewise stated that resident call lights should be within residents’ reach and had not been in these instances. These findings, based on policy review, observation, record review, and staff interview, showed that for 2 of 12 residents reviewed for residents’ rights, the facility did not reasonably accommodate residents’ needs and preferences by ensuring their call lights were accessible.
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