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F0919
D

Failure to Ensure Resident Access to Call Light in Bed

Houston, Texas Survey Completed on 11-19-2025

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

A deficiency was identified when a resident with severe cognitive impairment and multiple medical diagnoses, including vascular dementia, Alzheimer's disease, and mobility deficits, did not have access to a functioning call light while in bed. Observation revealed the call light was on the floor, out of the resident's reach, and the resident reported that staff had removed it from her room because she used it too frequently. The resident's care plan specifically required that the call light be within reach due to her risk for falls and need for staff assistance with activities of daily living. Interviews with staff confirmed that all personnel were responsible for ensuring call lights were accessible to residents, and that call lights should not be left on the floor. The nurse on duty acknowledged the importance of call light accessibility, especially for residents with confusion and mobility issues. The Director of Nursing stated that monthly in-services were conducted on call light procedures, but also confirmed that the facility did not have a specific written call light policy.

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