Failure to Ensure Resident Call Lights Were Kept Within Reach
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach for three residents. During an observation on 03/10/26 at 10:52 a.m., Resident #25 was seen sitting in bed, appearing uncomfortable and calling out for staff, while his call light was on the floor behind the bed and out of his reach; he confirmed he could not reach it. At 10:54 a.m. the same day, Resident #26 was observed sitting in bed watching television with the call light on the floor under the bed and not accessible. On 03/11/26 at 12:47 p.m., Resident #27 was observed lying in bed with the call light located under the bed and not within reach. Certified Nursing Assistant (CNA) #3 confirmed that call lights should always be within reach of residents and acknowledged that the call lights for Residents #25, #26, and #27 were not within reach as they should have been, further stating that if a call light was not in reach, it could cause a resident to fall. The Unit Manager (UM) #1 stated that staff are responsible for ensuring call lights are within residents’ reach and agreed that the call lights for these three residents were not within reach as required. These observations and staff interviews show that, at the times noted, the facility did not maintain accessible call lights for the three residents, despite staff acknowledging the expectation that call lights be kept within residents’ reach.
