Health inspection·December 11, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 6 residents (Residents #1) reviewed for resident rights in that: Residents Affected - Few The facility failed to ensure Residents #1's call light was within reach on 12/11/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1's admission record dated 12/11/24 documented a [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses which included: vascular dementia (a type of dementia where thinking abilities are affected because of reduced blood flow to the brain), generalized anxiety (constantly worrying about everyday things), lack of coordination (not being able to move your body smoothly and precisely, often resulting in clumsiness, stumbling, or jerky movement), and unsteadiness of feet (your feet feel like they are not stable or balanced, making it difficult to walk steadily). Record review of Resident #1's Quarterly MDS assessment, dated 11/02/24, revealed the resident had a BIMS score of 03, which indicated severe impairment. The MDS also revealed Resident #1 was dependent in the area of eating. Resident #1 required substantial/maximal assistance in the areas of oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Record review of Resident #1's care plan, dated 12/11/24, revealed Resident #1 was care planned for a fall r/t dementia and had an intervention of: Keep call light in reach at all times. Observation on 12/11/24 at 10:47 a.m., revealed Resident #1 was lying in bed and call light was placed on a chair out of her reach. Observation on 12/11/24 at 2:04 p.m., revealed Resident #1 was lying in bed and call light was placed on a chair out of her reach. During attempted interview on 12/11/24 at 10:47 a.m., Resident #1 was not able to be interviewed due to her cognitive level. Page 1 of 2 675144 675144 12/11/2024 Avir at Burleson 600 Maple St Burleson, TX 76028

F 0558 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/11/24 at 11:20 a.m., CNA A stated that CNAs should make rounds at least every two hours. CNA A stated that CNAs should be looking to see if a resident needs assistance, ensuring call lights were within reach, and making sure all residents were comfortable. CNA A stated if a resident's call light was not within reach, then the resident could fall attempting to reach it or the resident would not receive assistance. Residents Affected - Few During an interview on 12/11/24 at 3:30 p.m., the DON stated that anyone that entered the resident's room was responsible for ensuring the call light was within reach. The DON stated the purpose of a call light was for resident to notify staff when they need assistance. The DON stated if a resident's call light was not in reach, then they would not be able to call for assistance. The DON stated her expectation was that all resident's call lights were always within reach and answered timely so the resident can notify staff they need assistance. An interview with the ADM on 12/11/24 at 3:45 p.m., the ADM stated that all resident call lights should be always within reach. The ADM stated that it's everyone's responsibility to ensure call lights are within reach. The ADM stated that the resident needs would not be met promptly if the resident's call light was not within reach. Review of the facility's Answering the Call Light policy, revised March 2021, reflected, Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 675144 Page 2 of 2