F0558

D

Failure to Keep Call Light Within Reach for Dependent Resident

Reseda, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to the facility’s failure to ensure a resident’s call light was within reach, as required for reasonable accommodation of resident needs and preferences. The resident had been admitted with diagnoses including unspecified severe sepsis and Parkinson’s disease. According to the History and Physical, the resident was able to speak in full sentences, make her own needs known, and make simple medical decisions. The MDS documented that the resident usually made herself understood, usually understood others, and required substantial assistance with upper and lower body dressing, personal hygiene, and putting on and taking off shoes.

During an observation in the resident’s room, the resident was seated in a wheelchair with a bedside table in front, positioned between the bed and the entrance door. The resident lifted an empty cup and gestured for more, but the call light, located on the bed, was out of reach. In a concurrent interview, the CNA assigned to the resident stated she had forgotten to place the call light next to the resident and acknowledged that the call light should be within reach so the resident could communicate with staff, including to request water. The DON later stated that all call lights should be within each resident’s reach so staff can attend to their needs timely, and the facility’s “Answering the Call Light” policy indicated staff must ensure the call light is accessible to the resident.

Plan Of Correction

F-558 Corrective Action for Affected Residents: On 3/10/2026, Certified Nursing Assistant (CNA 1) immediately placed Resident 72's call light within reach.

Identifying other Residents having the Potential to be Affected: RN Unit Managers conducted facility-wide room checks of current residents to ensure that call-lights were within reach and accessible to residents based on their individual needs and preferences.

Out of 62 residents with limited mobility while in their room, 3 were found to not have the call light within reach. Any residents found with call lights out of reach had immediate corrective action taken to place call lights within reach by education to the responsible nurse 3/31/26.

Measures put into place or Systemic Changes: The DON and/or Director of Education in-serviced Licensed nurses and Certified Nursing Assistants on the facility policy and procedure titled "Answering the Call Light," with emphasis on ensuring call lights remain within reach and accessible to residents at all times, including when residents are repositioned, moved to wheelchairs, or transitioned between locations.

The in-service included education on assessing individual resident needs and preferences for call light placement based on physical limitations, mobility status, and cognitive abilities.

Attendance records and lesson plans were maintained.

Plan to Monitor Performance: Beginning 4/6/2026, the RN Unit Manager or designee will conduct random room audits of a minimum of 5 rooms per floor per week for four consecutive weeks, to verify that call lights are within reach and accessible to residents based on their individual needs and positioning.

If deficiencies are identified during audits, immediate corrective action will be taken and the responsible staff member will receive re-education and supervisory intervention as appropriate.

The DON or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee.

The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.