F0558

D

Failure to Ensure Call Light Accessibility for Dependent Resident

Carbondale, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to reasonably accommodate a resident’s need for access to a call light. The resident had chronic atrial fibrillation, osteoarthritis, anemia, essential hypertension, a history of TIA, and sleep apnea, and was assessed with a BIMS score of 15 indicating intact cognition. The MDS documented that the resident was dependent on staff for sit-to-stand, chair/bed-chair transfers, and toilet transfers, and required substantial/maximal assistance for bed mobility. The care plan identified the resident as at risk for falls and included interventions to instruct the resident to call for assistance before getting out of bed or transferring, and to orient the resident to the room and use of the call light system.

On multiple observations, the resident was seen sitting in a wheelchair at the back of the room, several feet away from the call light, which was tied to the left bed rail and could not reach the resident’s preferred seating location. CNAs confirmed that the resident routinely sat in that spot, that the call light did not reach there, and that the resident pushed herself backward in the wheelchair but had difficulty moving forward. The DON acknowledged the resident sat in that location and was unsure if the call light would reach. The resident reported that she could push herself back but had trouble moving forward due to slick shoes, and that when she needed help she would try to get to the call light, call her daughter, or go to the doorway and yell for staff. The resident’s daughter confirmed the resident frequently sat by the window, struggled to propel herself forward, and often called her when she could not reach the call light, and stated she was concerned that the call light did not reach where the resident sat.