Failure to assess residents’ need for siderails before removal
Summary
The facility failed to assess residents’ need for siderails for positioning and bed mobility before removing them from the beds of 4 of 16 residents reviewed. On 9/8/25, R42 was observed lying in bed without siderails or assist bars. R42’s father said the facility had removed the siderails about a week earlier, even though R42 used them to help turn in bed and as therapy. R42’s rehab data showed diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and that he required substantial/maximal assistance to roll from left to right in bed. The DON stated that siderails had been removed from everyone in the building because of entrapment risk, and that therapy was supposed to assess each resident’s need for siderails, but that this had not yet been done; she also stated she knew R42 needed siderails for positioning and mobility. R47 was observed in his room without siderails on his bed and stated the rails had been taken off and he was told he could not have them, leaving him with nothing to assist him in turning in bed. His functional assessment showed he required partial/moderate assistance to roll from left to right, and the DON stated he was able to use siderails for bed mobility. R26 also had no bedrails and said she was going to complain because the siderails had been removed and she could no longer use them to roll herself in bed; her assessment showed no ROM limitations and substantial/maximal assistance needed to roll, and her signed bed rail/enabler consent form showed she consented to the use of bed rails for her care. R23 reported that siderails had been removed from her bed and that she was not given the option to keep them, even though she said she needed them to turn or raise up in bed; her assessment showed she required supervision or touching assistance to roll left and right. The facility’s Bed Rails Policy stated that when a bed has a pre-installed rail, the facility must determine whether disabling the rail would pose a risk to the resident.
Penalty
Resources
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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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