F0558

D

Call Light Not Kept Within Reach for Dependent Resident

Bellflower, California Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in which staff failed to keep a resident’s call light accessible and within reach as care planned. The resident had diagnoses including generalized muscle weakness, acquired absence of multiple toes on both feet, UTI, and CKD, and an MDS dated 2/26/2026 showed intact cognition with a need for supervision to touch assistance for ADLs. The resident’s care plan, dated 11/20/2025, documented a risk for falls/injury related to impaired balance and included an intervention to place the call light within reach and encourage its use for assistance as needed.

During an observation and interview on 3/9/2026 at 2:45 p.m., the resident’s call light was found on the floor away from the resident, and the DSD acknowledged it was out of reach. At 2:55 p.m., the resident reported he needed the call light under his forearm so he could press it when needing assistance and stated he was looking for the call light every 20 minutes and needed it to get help to empty his urinal. In a 3:47 p.m. interview, the DON stated all residents must have accessible call lights within reach and that staff are instructed to check call lights every hour. At 3:55 p.m., CNA 1 reported that because the resident was large and his body covered the entirety of the bed, he had placed the call light on the bedside table at approximately 11 a.m., thinking it would fall off the bed, and acknowledged he should have placed it within the resident’s reach. Review of the facility’s “Call Light: Accessibility and Timely Response” policy dated 12/19/2022 indicated call lights must be within residents’ reach.