Inspection·January 19, 2024

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized work area for 1 of 27 (Resident #1) observed for call lights. Residents Affected - Few The facility failed to ensure Resident #1 had a call light installed in his room so Resident #1 could communicate to staff he needed assistance. This failure put residents at risk of not receiving ADL assistance and medical attention when needed. Findings include: Record review of Resident's #1 face sheet dated 1-18-2024, showed a [AGE] year-old male with an original admission date of 10-25-2023. Resident #1 has a primary diagnosis of epilepsy, and secondary diagnosis of gangrene (death of body tissue), sepsis, and acute respiratory failure. Record Review of Resident #1's Care Plan dated 11-10-2023, indicated Resident #1 has impaired visual function, has a seizure disorder, and is a fall risk. One of the Care Plan Interventions was Be sure my call light is within reach and encourage me to use it for assistance as needed. The date this was initiated was 11/08/2023. In an observation of Resident #1's bedroom, it was revealed that Resident #1 did not have a call light installed to the electrical outlet. The observation revealed that Resident #2, the roommate of Resident #1, had a call light installed and within reach. In an interview with Resident #1, on 1-18-2024, at 4:00 PM, it was revealed that Resident #1 did not know how to use a call light. Resident #1 did not realize he didn't have a call light. In an interview with the Administrator on 1-18-2024, at 4:05 PM, it was revealed that the Administrator thought Resident #1 had a call light installed for Resident #1's bed and did not realize Resident #1 was without a call light. In an interview with the Director of Maintenance, on 1-18-2024, at 4:15 PM, it was disclosed that he checked approximately 15 call lights a week. The Director of Maintenance did not know why Resident #1 did not have a call light installed. In an interview with the Administrator, on 1-19-2024, at 4:45 PM, it was revealed that the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675018 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675018 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Oaks Health and Rehabilitation Center 2416 NW 18th St Fort Worth, TX 76106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)