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.
(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:
675144
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
675144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avir at Burleson
600 Maple St
Burleson, TX 76028
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)
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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675144
If continuation sheet
Page 2 of 2
