F0558

D

Failure to Ensure Functionally Accessible Call Light for Dependent Resident

Bell Gardens, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not providing an appropriate and usable call light. The resident, who had diagnoses including muscle weakness and hypertension, was care planned to have a call light within reach and answered promptly. The resident’s H&P documented that he did not have the capacity to understand and make decisions, while the MDS indicated he was usually able to understand and be understood, and was dependent for most ADLs and mobility, including transfers and toileting. During interview, the resident reported not knowing where his call light was, being unable to press it because he could not move his arms and hands, and stated he sometimes felt powerless and ignored, resorting to yelling or waiting until someone entered the room, and that when he called, he would be dirty and wanted to be cleaned.

On observation with a CNA, the resident’s call light was found not within reach, and the CNA then placed it within reach. The resident reiterated he could not use the call light due to inability to move his arms and hands. The CNA acknowledged she had not asked the resident if he could use the call light and stated that not being able to use and access the call light could lead to feelings of neglect, delay in care, and in assisting the resident’s needs. The MDS nurse stated he was not aware the resident could not use the call light. The facility’s policy on call lights required that each resident be evaluated for unique needs and preferences to determine any special accommodations needed to utilize the call system and that the facility be adequately equipped with a call light at each resident’s bedside, toilet, and bathing area to allow residents to call for assistance.