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F0558
D

Call Light Accessibility Failure for Two Residents

The Woodlands, Texas Survey Completed on 06-20-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's call light was within reach, as required by facility policy and the resident's care plan. During an observation, the call light for a female resident with dementia, anxiety disorder, schizophrenia, and generalized muscle weakness was found on the floor while she was in bed. The resident attempted to retrieve the call light by rotating her body, which placed her at risk of falling. The care plan for this resident specifically indicated that the call light should be within reach to mitigate the risk of falls and injury, and staff interviews confirmed that call lights are expected to be accessible to residents at all times. A CNA reported that she had last checked on the resident 30 minutes prior and that the call light had been within reach at that time. Upon discovering the call light on the floor, the CNA returned it to the resident's bed. The DON also confirmed that call lights should be within reach and functional, as failure to do so could result in delayed care or failure to identify changes in condition. Facility policy requires that the call system be accessible to residents in their beds and that staff report and address any issues with the call system immediately.

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