Surveyors found that the facility failed to ensure call lights were accessible and appropriate for several residents, including one with hemiplegia, aphasia, functional quadriplegia, and severe cognitive impairment who could not operate a standard call bell and did not have an adapted device in place. Observations on multiple occasions showed call lights wrapped around bed rails, wedged between the mattress and rail, lying on the floor at the foot of the bed, placed on top of a mini fridge, or hanging on the wall, all out of residents’ reach. Staff, including CNAs, LPNs, the DON, and a corporate RN, acknowledged that call lights were not within reach despite care plans identifying fall risk and specifying that call lights should be kept within reach.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
A resident with severe cognitive impairment and no functional impairment to the upper or lower extremities was observed in bed with the call light on the floor and out of reach on more than one occasion. Staff confirmed the call light should have been within the resident’s reach, and the roommate reported calling for help when the resident yelled out.
A resident with quadriplegia, intact cognition, depression, low BMI, and a stage 4 sacral pressure ulcer required assistance with all ADLs but repeatedly did not have an accessible call light. Surveyors observed the call bell placed between the bed and side rail and later on a dresser, both out of the resident’s reach. The resident reported being unable to use the call system and sometimes relying on a roommate to call for help, and stated they would not have been able to summon assistance over a weekend if needed. A hospice RN noted that although the call bell was placed within reach during her visit, she did not believe the resident could effectively use it, and the administrator later confirmed the call bell was not within reach.
Surveyors found that staff failed to keep call lights within reach for two residents whose care plans required accessible call systems. One resident with moderate cognitive impairment and multiple conditions, including osteoarthritis and prior cerebral infarction, was observed with her call light on the floor, out of reach, despite being able to use it. Another resident with severe cognitive impairment, mobility issues, and diabetic polyneuropathy was observed in a geri-chair with the call light rolled up on a bedside table, also out of reach, even though she could use it to request help. Staff, including a CNA, a supervisor, and the DON, confirmed that both residents were capable of using their call lights and that facility policy requires call lights to be easily reachable at all times.
A resident with quadriplegia, central cord syndrome, edema, and intact cognition, who relied on a wheelchair for mobility and required extensive assistance with ADLs, repeatedly reported that her wheelchair was too small and causing hip discomfort. CNAs confirmed the complaints and notified the administrator, and staff observed that the resident had gained weight and sometimes had edema. Surveyors observed the resident seated with her hips tightly pressed against the wheelchair sides and later noted redness and indentations on both hips after transfer, which an LPN confirmed were from the wheelchair. Therapy staff reported they had not been informed by nursing that the wheelchair was too small, and despite awareness of the issue, no effective action was taken to provide an appropriately sized wheelchair.
Surveyors found that staff failed to keep call lights within reach for three dependent residents with conditions such as hemiplegia, muscle weakness, gait abnormalities, and a history of falls. In each case, the call light was observed hanging off the side of the bed or lying on the floor, and the resident reported being unable to locate it. CNAs and an LPN acknowledged that call lights were supposed to be on the bed and within residents’ reach at all times, consistent with facility policy, but this was not done for these residents.
The facility did not ensure that call light systems were functional and accessible, resulting in a resident's calls for assistance going unanswered due to a non-working call light, and a hall bathroom lacking an emergency call light cord. Staff interviews and observations confirmed these deficiencies, with maintenance unaware of the issues and no designated staff to monitor the call system.
A resident with chronic pain and limited mobility requested a geri chair to improve comfort, but the request was not communicated to management or acted upon by staff. Multiple staff members were either unaware of the request or believed someone else had reported it, resulting in the resident not receiving the requested accommodation.
A resident with severe cognitive impairment and a history of falls did not have their walker accessible as required by their care plan. Observations showed the resident ambulating without the walker, and staff confirmed the device had not been present for at least a week, contrary to facility policy and the resident's assessed needs.
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