F0919

D

Failure to Ensure Call Lights Were Accessible to Dependent Residents

Dover, Ohio Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a call light system that was readily accessible to residents in accordance with its policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. For one resident with Alzheimer’s disease, schizophrenia, and major depressive disorder, the care plan identified a risk for falls and included interventions to ensure the call light was within reach and a sign was in place to remind the resident to use the call light for assistance. The quarterly MDS showed this resident was moderately cognitively impaired and dependent on staff for ADLs. On two separate observations the resident was seated in a Broda chair next to the bed while the call light was found on the floor beside the bed, not within reach. A CNA confirmed the call light was not accessible and explained that a loop was placed around the call light cord to go around the resident’s wrist because the resident was blind.

A second resident, admitted with dementia, chronic kidney disease, and diabetes mellitus, also had a care plan identifying fall risk with an intervention to ensure the call light was within reach. The quarterly MDS indicated this resident was severely cognitively impaired and dependent on staff for ADLs. During observation, this resident was lying in bed while the call light was located behind the refrigerator, out of the resident’s reach. A CNA verified that the call light was not accessible to the resident. These findings were identified during the course of a complaint investigation and showed that, for two of three residents reviewed for call light accessibility, the facility did not ensure call lights were positioned so residents could use them as required by facility policy and care plan interventions.