Failure to Keep Call Light Within Reach of a Bedbound Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach as required by the resident’s care plan and facility expectations. The resident was a female with diagnoses including other recurrent depressive disorders, generalized muscle weakness, difficulty in walking, and cognitive communication deficit, and had a care plan focus of being at risk for falls due to a history of falls. The care plan, revised on 11/9/25, included an intervention to orient the resident to her surroundings and the use of the call light, initiated on 4/24/25. On multiple observations over two consecutive days, the resident was seen in bed with her call light not visible and hanging on the bottom of the bed frame behind the head of the bed near the floor, out of her reach. This positioning of the call light was documented at 9:27 AM, 11:07 AM, and 2:54 PM on 3/4/26, and again at 8:49 AM on 3/5/26. In interviews, CNAs and the ADON consistently reported that call lights were supposed to be within physical reach of residents, placed on or near their body so they could touch and activate them, and confirmed that it was not acceptable for the call light to be behind the resident on the bed frame near the floor. One CNA reported she had just found the resident’s call light in that inaccessible location and confirmed the resident did use her call light sometimes.
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