F0558

E

Failure to Provide Accessible Call Systems and Alternatives for Two Residents

Waco, Texas Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences for calling staff, specifically by not ensuring functioning call systems or accessible alternative devices for two residents. Surveyors observed that the call light system in a shared room was not functioning and the entire call light box was out of the wall. Despite this, the non-functioning call buttons were still placed within reach for both residents. For one resident, a bell intended as an alternative call device was placed on the nightstand but out of the resident’s reach, and there was no visible bell available for the other resident.

One resident was an older female with osteoarthritis of the right shoulder and knee, COPD, muscle weakness, joint pain, a history of falls, poor balance, unsteady gait, and impaired physical functioning. Her MDS showed a BIMS score of 15 (no cognitive impairment), partial/moderate assistance needed for bed-to-chair transfers, and total dependence for toilet transfers. Her care plan documented pain related to impaired mobility and neuropathy, as well as an actual fall and impaired physical functioning. During interview, she reported that her room call system had been broken for about six months, that she could not reach the bell on the nightstand, and that when she needed help she would go into the bathroom and use the bathroom call button, even though she did not use the toilet there.

The second resident was an older female with repeated falls, muscle weakness, lack of coordination, abnormal gait and mobility, and a need for assistance with personal care. Her MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and her care plan noted impaired cognitive function/dementia, difficulty making decisions, impaired decision making, psychotropic drug use, and impaired physical functioning. She stated she did have a bell to call for help but sometimes yelled for assistance. The Maintenance Director reported the room call system had broken sometime the prior week and that he had ordered a replacement part and provided bells to both residents, and he stated he verbally informed staff of the broken system. The DON and Administrator both acknowledged awareness of the broken call system and that bells were to be used and kept within reach, and facility TELS work orders and an invoice documented call light malfunction and a completely broken call light station in that room over the preceding months.