Failure to Accommodate Visually Impaired Resident’s Environmental and Accessibility Needs
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident with legal blindness and a right leg amputation by not individualizing his physical environment. The resident was cognitively intact, had highly impaired vision, and no behavioral issues. His care plan for impaired visual function only addressed arranging consultations with an eye care practitioner and did not include any interventions related to environmental modifications, accessibility, or low-vision supports in his room. Surveyors observed that the resident’s room furniture and electrical access were not arranged in a functional manner. There was only about two feet of space between the end of his bed and his chest of drawers, where his stereo was placed, requiring him to maneuver his powerchair backwards into the narrow space and lean forward to see the stereo dials. He had access to only one electrical outlet with two sockets on his side of the room, which were occupied by his laptop and phone charger, leaving his talking book machine unplugged. The resident reported frustration with the room setup, stating he felt like he was in a cage, could not charge and use his devices as desired, and was unable to use his braille writer or have adequate workspace. He stated he had repeatedly asked staff for a power strip and an LED bulb to reduce glare and adjust lighting, but reported that staff told him power strips were illegal and did not follow up on his requests. The resident also reported difficulty seeing the overhead light cord because it was white against a white wall, with only a small piece of glow-in-the-dark tape at the end, and he stated he needed contrast to see such items. He further reported that a bright yellow privacy curtain he could see well had been replaced without asking him, with a dull-colored curtain that appeared depressing and without a visible pattern to him. Documentation from a Caring Partners form showed he had voiced concerns about the accessibility and limited space in his room weeks earlier, and interviews with the unit manager and CNA confirmed he had complained about room layout, need for a larger room, and poor lighting. The facility’s own Accommodation of Needs policy required reasonable accommodation of residents’ physical environments based on individual needs to assist in maintaining independence, but the resident’s expressed concerns and needs for accessibility and low-vision modifications were not acted upon or incorporated into his care plan.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Call Sensor Pad Not Within Reach: A resident with Parkinsonism, muscle spasms, seizures, and moderately impaired cognition was observed sitting in a wheelchair with his sensor pad left on his bed and out of reach. He stated he could not reach it and would have to yell for help, and CNA, RN, DON, and ADM interviews confirmed the device was not within reach and should have been accessible.
Call lights were not kept within reach for multiple residents who needed staff assistance. A resident with blindness, falls, and transfer needs was left at her table with the call light out of reach, another resident with cognitive impairment and extensive assistance needs had the light placed on the far side of the bed under a blanket, and a third resident with severe cognitive impairment and MS was found sleeping with the call light coiled on the wall out of reach. Staff interviews confirmed call lights should remain accessible even when residents do not always use them.
A resident with severe cognitive impairment, wheelchair use, lower-extremity impairment, and dependence for most ADLs had her call light repeatedly observed on the floor out of reach while lying in bed. Her care plan directed staff to keep the call light within reach and encourage use of the bell for assistance, and multiple staff members stated call lights should always be within reach and that staff were responsible for placement. The resident's family member said she could use the call light, but survey observations showed it was not accessible during several checks.
A resident with bilateral knee replacements and difficulty walking could not independently access the closet in the room because the resident’s wheelchair would not fit between two beds placed footboard-to-footboard. The resident said staff had been told multiple times, but the room layout was unchanged; staff gave conflicting accounts of the resident’s mobility, and the Administrator and Maintenance Director confirmed the wheelchair could not fit between the beds.
A resident with seizures, aphasia, dementia, and a recent fall with injury did not have his call light within reach while in bed. The care plan directed staff to keep the call light in reach, but surveyors observed it wrapped around a wall-mounted switch box above the head of the bed and out of reach. The resident and an NA confirmed it could not be reached, and the record showed a prior fall after the resident tried to transfer without using the call light.
A resident with COPD, major depressive disorder, neuromuscular dysfunction of the bladder, and DM had intact cognition but needed extensive ADL assistance and had lower-body impairment. His care plan directed staff to keep his call light within reach, yet during observation it was found at the bottom of the bed and out of reach while he was lying in bed. Staff stated call lights should always be within the resident's reach and that residents should be told where they were placed.
Call Sensor Pad Not Within Reach
Penalty
Summary
The facility failed to provide reasonable accommodation for Resident #44 by not ensuring his call sensor pad was within reach. Resident #44 was a [AGE]-year-old male admitted on [DATE] with diagnoses including Parkinsonism, muscle spasms, and seizures. His quarterly MDS reflected that he was able to be understood and to understand others, had a BIMS score of 12 out of 15 indicating moderately impaired cognition, and required substantial assistance to total dependence for most ADLs. He used a manual wheelchair and required maximal assistance for locomotion and mobility. His care plan identified an ADL self-care performance deficit related to Parkinsons and muscle weakness and included an intervention to encourage him to use the call bell for assistance. During observation on 06/09/2026 at 10:45 AM, Resident #44 was sitting in a tall wheelchair in his room about 3 feet from his bed, and his sensor pad was lying on his bed. During interview, he stated he would use the sensor pad to call for help if needed, but he could not reach it and would have to yell if he needed help. CNA A stated she could not remember who helped him out of bed, but that he would not be able to reach the sensor pad if it was on his bed while he was in his chair a few feet away, and that he would not be able to get help in an emergency. RN B stated she did not notice the sensor pad placement that morning and that call lights or devices should be within reach. The DON and ADM also stated residents needed call lights or devices within reach so they had a way to get help.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for residents who were dependent on staff assistance. During observation, interview, and record review, call lights were found out of reach for 3 of 4 residents reviewed: R106, R24, and R9. Facility staff, including an RN, left R106 in her room at her dining room table without placing the call light within reach, even though she had moderately impaired cognition, blindness, multiple falls, and required staff assistance for transfers and toileting. Two call lights were present in her room, but one was on the bed about 7 feet away and the other was in the bathroom out of reach. R24, who had moderately impaired cognition, non-traumatic brain dysfunction, arthritis, and required substantial staff assistance for toileting, dressing, and transfers, was observed seated in her wheelchair with no call light within reach. The call light was on the other side of the bed and underneath a blanket. An RN later placed it within her reach and stated a volunteer may have brought her back to the room without placing the light. R9, who had severely impaired cognition, multiple sclerosis, dementia, muscle weakness, repeated falls, and dependence on staff for toileting and transfers, was observed sleeping in bed with the call light coiled up on the wall by the foot of the bed and not within reach. Interviews with nursing and activity staff confirmed that call lights should be within residents’ reach even when residents do not always use them or have cognitive impairment. The DON stated staff should ensure the call light is within reach before leaving a resident’s room, and if a resident cannot use the call light due to cognition, it should be removed as a care plan intervention. The facility policy stated all personnel must be aware of call lights, answer them promptly, and position them conveniently and accessibly for residents in bed or other sleeping accommodations.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure Resident #37 had her call light within reach. Resident #37 was a [AGE]-year-old female admitted most recently on [DATE] with diagnoses including vascular dementia with agitation, intermittent explosive disorder, muscle weakness, unsteadiness on feet, and cerebral infarction. Her quarterly MDS showed a BIMS score of 7, indicating severely impaired cognition, and she used a wheelchair with impairment to both lower extremities. She was dependent or needed partial/moderate assistance for all ADLs except eating, and she was always incontinent of bladder and bowel. Her care plan identified an ADL self-care deficit and included interventions to encourage her to use the bell to call for assistance and to be sure her call light was within reach. During observations on 06/03/26 at 09:01 AM, 11:11 AM, 12:19 PM, and 02:12 PM, Resident #37 was observed lying in bed and her call light was on the floor between her bed and the wall at the foot of her bed. During the 12:19 PM observation and attempted interview, she did not answer when asked if she had a call light or had ever used one. During interview, the resident's family member stated she was capable of using her call light and would sometimes push it just to mess with staff. Multiple staff members, including LVN, RN, CNA, DON, MDS RN, ADM, and HR, stated call lights should be in reach of residents and that staff were responsible for ensuring proper placement. HR stated she checked Resident #37's room twice a day and said the call light was in reach both times, which differed from the surveyor observations showing it on the floor.
Closet Access Blocked by Bed Placement
Penalty
Summary
The facility failed to ensure Resident 23 could independently access the closet in the resident’s room. Resident 23 was admitted with diagnoses of bilateral knee replacements and difficulty walking. The quarterly MDS identified intact cognitive function, use of a walker and wheelchair for mobility, and the need for set up and supervision with transfers and walking. The care plan stated the resident used a wheelchair and required one-person assistance with walking. Observations of the room showed the resident’s bed and the roommate’s bed were positioned directly facing each other, with the footboards approximately 20 to 24 inches apart and the closets located on the far wall corner. During observation, Resident 23 attempted to maneuver the wheelchair between the beds but the wheels caught on the footboards and prevented access to the closet. The resident stated the wheelchair could not fit between the beds and that staff had been notified multiple times, but no changes were made. Staff interviews reflected differing understandings of the resident’s mobility status, and the Administrator and Maintenance Director later confirmed the footboards were too close together for a wheelchair to fit between them.
Call Light Not Within Reach for Resident at Risk for Falls and Seizures
Penalty
Summary
The facility failed to ensure a call light was within reach for a resident with a history of epileptic seizures, aphasia, non-Alzheimer's dementia, and a recent fall with injury. The resident's MDS identified moderately impaired cognition, and the care plan directed staff to make sure the call light was in reach when the resident was in the room. The resident also had a history of needing partial/moderate assistance with standing and transfers, and the CAA identified fall risk related to body weakness and decreased muscle strength. During observation, the resident was in bed with the call light wrapped around the wall-mounted switch box above the head of the bed and off to the left, out of reach. On follow-up observation, the call light remained in the same position. The resident stated he would like his call light, and an NA confirmed he would not have been able to reach it and that it should have been within reach. The record also included a prior fall from bed after the resident attempted to transfer to his wheelchair without using the call light, and a later seizure episode in which the resident used the call light to alert staff. Staff interviews stated that all residents should have call lights within reach, and the facility policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Call Light Left Out of Resident's Reach
Penalty
Summary
The facility failed to ensure Resident 5's call light was within reach so he could call for staff assistance. Resident 5 had diagnoses of COPD, major depressive disorder, neuromuscular dysfunction of the bladder, and DM. His Significant Change MDS documented a BIMS score of 15, indicating intact cognition, and also noted impairment of the extremities on both sides of his lower body. The MDS further documented that he needed setup or cleanup assistance with eating and oral hygiene and was dependent on staff for toileting, bathing, and dressing. Resident 5's Falls CAA documented anxiety, antidepressant drug use, and assistance required for ADLs, placing him at risk for falls. His care plan stated that staff were to keep his call light within his reach so he could notify nursing when he needed to use the toilet or had an incontinence episode, and a later care plan entry stated staff were to keep the call light within his reach as he allowed. During observation, Resident 5 was lying in bed with his eyes shut, and his call light was found at the bottom of the bed on the left-hand side, out of his reach. Staff interviews stated that call lights should be placed within the resident's reach, on the bed rail or on the person, and that residents should be told where the call light was placed.
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