Failure to Accommodate Resident Needs and Preferences
Summary
The facility failed to reasonably accommodate resident needs and preferences by not ensuring overbed lights were accessible, call lights were within reach, and a requested bed preference was honored for several residents. The facility’s policy stated it would make reasonable accommodations for individual needs and preferences and individualize the resident’s physical environment, including the bedroom, to support independence, dignity, and well-being. Resident 40, who had chronic joint disease of the knees and morbid obesity and was dependent for mobility and transfers, moved rooms after stating the previous bed was larger and the current bed was too small. A maintenance request documented that the resident wanted the bed from upstairs because the current bed was too small. The resident stated the larger bed had been promised after the room move, but it was not moved. Staff confirmed the resident had previously been in a larger bed, that maintenance had been notified, and that the request had not been completed. Resident 21, who had diabetes and a left leg abrasion and was dependent for mobility, ambulation, and transfers, was observed reaching for the overbed light switch from bed and using a butter knife to turn it on because the switch was out of reach. The resident stated the switch could not be reached with the hands and that staff assistance was needed to turn the light on and off. Staff stated most residents had no way to operate the overbed light without calling for assistance, and leadership stated residents who were physically capable should have been provided a way to do so. Resident 49, who had a right hip fracture and was dependent for mobility, transfers, and ambulation, was observed over multiple days unable to turn on the overbed light without staff help. The resident stated there was a button for the light but it could not be reached and staff had to be called to turn it on and off. Staff stated some newer beds no longer had overbed light controls and that residents without a pull cord had to get out of bed or call staff for help. Resident 53, who had multiple fractures including the spine, pelvis, right lower leg, ribs, and neck and was dependent for bed mobility and unable to transfer or ambulate, was also observed unable to turn on the overbed light without staff assistance. The resident stated there was no way to turn on the light and no bed controls, and staff again confirmed that residents without pull cords had to call for help. Resident 48, who had Parkinson’s disease, memory loss, severe decision-making impairment, and bilateral upper and lower body impairment, had a pressure-activated call light wrapped around the upper bed rail near the left shoulder. The resident was observed reaching across the body with the right arm but unable to reach the call light. Staff stated the resident used the right arm more and that the call light needed to be positioned by the resident’s hand, with one staff member stating it should be placed in the resident’s lap to be accessible.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to provide requested enabler bars: A resident with HF, HTN, and renal insufficiency was assessed by OT as needing assist bars for bed mobility, but the resident remained without enabler bars despite stating she had requested them since admission. Nursing and OT staff confirmed the bars were not in place, and OT indicated the observation/order process likely was never entered.
Call lights were not kept within reach for five residents reviewed for residents' rights. Residents with diagnoses including bipolar disorder, stroke, TBI, Alzheimer's disease, schizophrenia, PTSD, diabetes, schizoaffective disorder, OCD, and unsteadiness on feet were observed with call lights placed under beds, hung on wall hooks out of reach, or coiled and pinned so they could not independently access them. An LPN and the DON stated the call lights should have been within the residents' reach.
A resident with a Right Femur Fracture, Anxiety Disorder, and moderate cognitive impairment was repeatedly observed in bed with the call light clipped onto itself at the head of the mattress, out of view and reach. The resident could not identify how to contact staff at times and stated they wanted the call light where they could see and reach it; the UM and DON confirmed call lights are to be kept within resident reach.
A resident with moderate cognitive impairment and significant care needs had ongoing difficulty using the standard call light, but the record had no formal assessment of call light ability and no adaptive call light was tried. The resident and family reported delayed responses and confusion about whether the call light had been activated, while an NA said the resident complained almost daily that staff did not answer. The DON confirmed the resident did not like a pancake call light, but no formal assessment had been completed.
A resident with intact cognition, generalized weakness, and COPD was found in bed on multiple observations with the call system device tucked inside the nightstand drawer and out of reach. The care plan directed staff to keep the call light within reach, and the DON confirmed it should have been placed within the resident’s reach.
A resident with paraplegia and bilateral above-the-knee amputations was observed in bed with his call light on the floor and out of reach on multiple occasions. He was alert and oriented, able to use the call light, and stated he could not reach it to ask for help with his menu, nasal cannula, or breakfast. Staff confirmed the call light should have been within his reach, and the facility policy required call lights to remain within reach for residents able to use them.
Failure to Provide Requested Enabler Bars
Penalty
Summary
The facility failed to reasonably accommodate Resident R105’s need and preference for enabler bars on the bed. The resident was admitted with diagnoses including heart failure, high blood pressure, and renal insufficiency. An OT evaluation dated 7/22/26 documented that the resident required assistance with bed mobility and could complete it with stand-by assistance if assist bars were present, but the resident’s clinical record on 8/5/26 did not include an observation for enabler bars. During an observation on 8/3/26, Resident R105 was lying in bed and stated she wanted enabler bars to help position herself in bed and had asked for them since admission but had not heard back. An RN confirmed the resident did not have enabler bars and said she would look into it. On 8/5/26, the resident was again observed resting in bed without enabler bars. An OT employee stated the process was for therapy to determine whether residents could use their upper extremities, then nursing would enter an observation for enabler bars and maintenance would be notified, and another OT employee stated the resident would benefit from enabler bars and that the observation probably never got entered into the computer.
Call Lights Not Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for 5 of 18 residents reviewed for residents' rights: Residents #29, #50, #51, #56, and #57. The facility's policy, "Answering the Call Light," revised September 2022, stated that call lights should be accessible to residents when in bed, from the toilet, from the shower or bathing facility, and from the floor. Resident #51, who had diagnoses including acquired absence of the left leg below the knee, bipolar disorder, and anxiety disorder, was observed with the call light button under the bed against the wall and not accessible. Resident #56, who had diagnoses including stroke, traumatic brain injury, and Alzheimer's disease, was observed lying in bed without the call light button, which was hanging on a wall hook about five feet high and out of reach; she was unable to self-ambulate, could not get out of bed, and did not verbally communicate. Resident #29, who had diagnoses including schizophrenia, PTSD, and diabetes, was observed with the call light plugged into the wall above the bed, hanging down to the floor under the bed and not within independent reach. Resident #57, who had diagnoses including schizophrenia, anxiety, and unsteadiness on feet, was observed with the call light plugged into the wall above the bed with the cord coiled and pinned to itself and not within independent reach. Resident #50, who had diagnoses including schizoaffective disorder and OCD, was observed with the call light plugged into the wall near the foot of the bed, coiled and pinned to itself and not within reach. Staff interviews confirmed the call lights for these residents should have been within reach and were not.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure that R15’s call light was kept within reach. On 07/28/2026, R15 was observed lying in bed with the call light hanging over the top left edge of the head of the bed and clipped onto itself at the side of the mattress, out of view and reach. When asked how they would contact staff for assistance, R15 could not provide a response, and when asked about the call light, stated that sometimes it was with them but not always. R15’s EMR showed admission to the facility with diagnoses including Right Femur Fracture and Anxiety Disorder. The MDS indicated moderate cognitive impairment and maximum assistance with most self-care tasks, and the ADL care plan included the intervention to encourage use of the call light and keep it within reach. On 07/29/2026 and 07/30/2026, R15 was again observed with the call light clipped onto itself on the left side of the mattress at the head of the bed, out of the resident’s view and reach. R15 stated they did not know where the call light was and said they would prefer to be able to see and reach it. The UM and DON both confirmed that call lights are to be kept within resident reach, and the facility policy for unit rounds included checking that the call light was placed appropriately.
Failure to Assess Call Light Use and Provide Adaptive Call Light
Penalty
Summary
The facility failed to assess a resident’s ability to independently activate the call light and did not provide a reasonable accommodation, such as an adaptive call light, after staff became aware of ongoing difficulty using the standard call system. The resident had a quarterly MDS identifying moderate cognitive impairment and diagnoses including chronic kidney disease, a sacral pressure ulcer, atrial fibrillation, and hypertension. The resident required substantial to maximal assistance with bathing and was dependent on staff for all other care areas, with a care plan directing staff to respond promptly to toileting requests, provide a bedpan when safely possible, and keep the call light in reach. During interview, the resident stated she could push the call button but staff did not come for over two hours, while a family member said the resident had difficulty pushing the call light at times and sometimes believed it had been activated when it had not. The resident’s record contained no assessment of call light ability. A nursing assistant reported the resident complained almost daily that she had turned on the call light and staff did not answer, and said this had been reported to nursing without change. The DON stated the resident had complained of long wait times, but call light logs showed the resident had not turned on the call light; the DON also stated the resident did not like a pancake call light, yet no formal call light assessment had been completed and no different adaptive call light had been tried.
Call Light Not Kept Within Resident’s Reach
Penalty
Summary
The facility failed to ensure that a call system was accessible for one resident who had diagnoses including high blood pressure, prostate cancer, generalized muscle weakness, and COPD. The resident’s MDS assessment dated May 11, 2026, showed intact cognition and dependence on staff for activities of daily living, including toileting, dressing, and personal hygiene. The care plan identified the resident as at risk for falls and directed staff to keep the call light within reach for assistance as needed. However, on multiple observations, the resident was found in bed with the call system device tucked inside the top drawer of the nightstand, out of reach. The DON confirmed that the call system device should have been placed within the resident’s reach.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure that Resident 121’s call light was within reach so he could summon staff assistance. Resident 121 had diagnoses of paraplegia, left above-the-knee amputation, and right above-the-knee amputation. His baseline care plan documented that he was a fall risk, that staff should anticipate and meet his needs, and that he did not have cognitive impairment. A daily skilled note documented that he was oriented to person, place, time, and situation but required supervision for safety. During observations, Resident 121 was found lying in bed with his call light on the floor and out of reach on two separate occasions. On one observation, he had his breakfast tray on the over-bed table with a pencil and paper to complete his menu, but he stated he could not reach the call light to ask for help because it was on the floor. On another observation, he again could not reach the call light and stated he could not use it to ask for help with his nasal cannula or to ask about breakfast before leaving for an appointment. Staff interviews confirmed that he was able to use his call light and that it should have been within his reach at all times. The facility policy stated that staff would ensure call lights were within reach of residents who were able to cognitively use them each time staff left the room.
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