Health inspection·July 3, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 (Resident #1) of 7 resident rooms reviewed for environment. The facility failed to ensure the call light system in Resident #1's room (Room L080) was in good repair. This failure placed residents at risk of possible injury due to an unsafe environment. The findings included: Record review of Resident #1's face sheet, printed on 07/03/24, revealed a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses of cerebrovascular disease (conditions that affect blood flow and vessels to the brain), protein-calorie malnutrition, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (paralysis and partial weakness), encephalopathy (brain dysfunction), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Record review of Resident #1's annual MDS assessment, dated 12/21/23 revealed Resident #1 had a BIMS score of 15, which indicated Resident #1 was cognitively intact. Record review of Resident #1's care plan, revised on 04/23/24, revealed the following: Focus: At risk for falls r/t Hx of falls, muscle weakness, cognitive decline, poor mobility, seizure d/o, cardiac issues, CVA w/ hemiparesis and hemiplegia, confusion and forgetfulness, poor safety awareness and chronic UTI. Impulsive to do things by herself even if she is unable . Interventions: Be sure the call light is within reach and encourage to use it for assistance as needed. In an interview and observation on 07/03/24 at 1:47 p.m., Resident #1 stated she was well, and she had no concerns regarding the care she received at the facility. Resident #1 stated her only concern was the condition of the call light wall mount, which was observed to be hanging from the wall with electrical wiring exposed. Resident #1 stated the call light still worked but she was afraid to use (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: 675081 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 675081 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Acres Living and Rehabilitation Center 2525 Centerville Rd Dallas, TX 75228 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)