The resident, identified as R5 in the inspection report, was lying in bed when inspectors arrived at 12:05 p.m. on September 8. His call bell was wrapped around the lower portion of the bed rail on his right side, completely out of reach.
When asked if he could reach the device, the resident tried to find it and told inspectors he didn't know where it was. He couldn't locate the call bell that was supposed to summon help when he needed to use the bathroom or transfer from his bed.
The resident told inspectors he normally used the call bell to get staff when he needed care, and they usually responded quickly. But on this day, the lifeline was useless.
Inspectors returned to check on the same resident's call bell placement later that afternoon at 1:49 p.m. and again at 2:37 p.m. Both times, they found the same problem. The call bell remained wrapped around the lower bed rail, out of the resident's reach.
The resident's most recent assessment, completed just two weeks before the inspection, showed he was cognitively intact and capable of making daily decisions. But he required substantial to maximal assistance for transfers and was completely dependent on staff for toileting hygiene. He had no limitations in upper body range of motion that would prevent him from using a properly placed call bell.
A certified nursing assistant interviewed the next day acknowledged that call bells should be placed within reach of all residents. She told inspectors this was necessary so residents could call when they needed something.
The nursing assistant said staff were supposed to check call bell placement every time they entered a room and again before leaving. She also said they checked placement when walking past rooms.
The facility's own policy, last revised in August 2020, specifically addressed this requirement. The policy stated that when residents are in bed or confined to a chair, staff must ensure the call light is within easy reach.
Yet for this resident who couldn't transfer independently and needed help with basic bathroom needs, the call bell spent at least six and a half hours wrapped uselessly around a bed rail.
The administrator, director of nursing, and assistant director of nursing were notified of the violation on September 9 at 1:44 p.m. The inspection report indicates no additional information was provided before inspectors completed their review.
Federal regulators classified this as a violation of requirements that nursing homes reasonably accommodate the needs and preferences of each resident. The violation carried a designation of minimal harm or potential for actual harm.
For a resident who depended on staff for basic bathroom needs and required substantial help moving around, an unreachable call bell represented more than a policy violation. It meant being unable to summon help when nature called or when pain struck or when something went wrong in the middle of the night.
The inspection was conducted in response to a complaint, though the report doesn't specify whether the call bell issue was the subject of that complaint or discovered during the investigation.
Winchester Health & Rehabilitation is required to submit a plan of correction addressing how it will prevent similar violations in the future. The facility has 14 days from receiving the inspection report to make its correction plan public.
The violation affects what inspectors described as "few" residents, though the report only identifies the one resident whose call bell was observed out of reach during multiple checks over two days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Winchester Health & Rehabilitation from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
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