The resident, identified as R103 in the inspection report, had been admitted to the facility with difficulty walking and was described as "alert and oriented to self with confusion to time, place, and situation." His admission assessment noted he arrived by medical transport in a manual wheelchair.
When the inspector visited R103's room on December 16 at 10:40 a.m., the resident was sitting in his wheelchair next to the right side of his bed. Asked if he could locate his call bell, R103 looked around and said he didn't know where it was.
The call bell was draped over the left side of the headboard, completely out of his reach.
The inspector pointed out the call bell's location and asked if R103 could access it. The resident tried to propel his wheelchair to the opposite side of the bed but couldn't maneuver alongside the left side to reach the device. "I could not reach the call bell," R103 told the inspector.
Fifteen minutes later, Licensed Practical Nurse #5 entered the room, removed the call bell from the headboard, and clipped it to R103's shirt while he sat in his wheelchair. The nurse acknowledged to the inspector that the call bell "was not within his reach and should have been where R103 could access it."
She explained that call bells are used by residents to summon assistance when needed.
The violation represents a failure to accommodate a resident's basic needs, particularly concerning given R103's physical limitations and cognitive impairment. Federal regulations require nursing homes to reasonably accommodate each resident's individual needs and preferences.
For a resident who uses a wheelchair and experiences confusion about time, place, and situation, having immediate access to a call bell becomes critical for safety and care. The device serves as the primary means for residents to alert staff when they need help with medical issues, falls, or other emergencies.
The inspection occurred as part of a complaint investigation at the 23226 Forest Avenue facility. The deficiency was classified as causing minimal harm or potential for actual harm, affecting few residents in the facility's survey sample of 12.
R103's situation illustrates how seemingly minor oversights can create significant safety risks for vulnerable residents. A person with mobility limitations and cognitive impairment who cannot reach their call bell faces potential delays in receiving necessary care or assistance during medical emergencies.
The facility's administrator and director of nursing were notified of the findings on December 17 at 2:00 p.m. The inspection report notes that no additional information was provided before the survey team's exit.
This violation occurred despite standard nursing home protocols that require call bells to be positioned within easy reach of all residents, regardless of their physical or cognitive abilities. The requirement becomes even more critical for residents with multiple impairments that limit their mobility and awareness.
The incident raises questions about staff training and routine room checks at Westport Rehabilitation and Nursing Center. Licensed Practical Nurse #5's immediate recognition that the call bell placement was inappropriate suggests staff understood the proper protocol but failed to implement it consistently.
Federal inspectors found R103 during a routine room observation, indicating the improper call bell placement wasn't a temporary oversight but had persisted long enough for an unannounced inspection to document it.
The facility must now submit a plan of correction detailing how it will prevent similar accommodation failures. However, the inspection report provides no timeline for when R103's situation was resolved or what immediate steps were taken to ensure his safety.
For residents like R103, who depend on staff assistance for basic needs and emergency situations, an unreachable call bell represents more than an inconvenience. It creates a barrier to receiving timely care that could prove dangerous if a medical emergency or fall occurred when no staff member happened to be nearby.
The violation adds to ongoing concerns about nursing home care quality, particularly for residents with multiple impairments who require individualized accommodation strategies to maintain their safety and dignity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westport Rehabilitation and Nursing Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Additional Resources
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