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 4 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 03/22/2025.
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 03/22/2025 documented an [AGE] year-old female
admitted on [DATE]. Resident #1 had diagnoses which included: hypertensive heart disease with heart
failure(high blood pressure damage the heart and blood vessels), hyperlipidemia(high levels of fat particles
in the blood),hypokalemia(blood level that s below normal that result in fatigue, muscle cramps, and
abnormal heart rhythms),parkinsonism(cause tremors and slow movements, and depression(sadness).
Record review of Resident #1's Quarterly MDS assessment, dated 02/05/2025, revealed the resident had a
BIMS score of 12 indicating the resident had moderate cognitive impairment. The MDS also revealed
Resident #1 required partial/moderate assistance in the areas of Toileting hygiene, shower/bathe self, lower
body dressing, and putting on /taking off footwear.
Record review of Resident #1's care plan, dated 03/22/2025, revealed Resident #1 was care planned for
ADL self-care performance deficit r/t impaired balance, stroke, and PD. Resident # 1 had an intervention of:
Encourage Resident #1 to use call light for assistance.
Observation on 03/22/2025 at 12:50 PM., revealed Resident #1's call light was under her bed, in the
middle, not in reach.
During an interview on 03/22/2025 at 12:50 PM, Resident #1 stated it had been out of reach since early
morning. Resident # 1 was not able to recall how long the call light was not in reach or the last time staff
had come in to assist her. Resident # 1 stated she needed to be changed and was waiting on staff to pass
by her room to call out for staff to assist her. Resident # 1 stated when the call light was not in reach, she
would just wait for staff to come to her room. Resident # 1 stated she really didn't want to say too much
because she had to stay there and did not want the facility to retaliate against her
(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:
675581
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
675581
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Village at Heritage Oaks
3002 W 2nd Ave
Corsicana, TX 75110
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
Residents Affected - Few
During an interview on 03/22/2025 at 2:29 PM, CNA A stated CNAs should make rounds at least every two
hours or as needed. CNA A stated that CNAs should be checking to see if call lights were in reach. CNA A
stated she had left Resident # 1's room around 12:30 PM, and the call light was in place when she had
entered the room (time entered not recalled). CNA A stated the call light may have fell of when she made
Resident #1's bed. CNA A stated she could not recall if the call light was tied to the bed rail when she had
left Resident #1's room. CNA A stated if a resident's call light was not within reach, then the resident needs
would not have been met.
During an interview on 03/22/2025 at 3:10 PM, 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 needed assistance. The DON stated if a resident's call light
was not in reach, then the resident could have an unmet need. The DON stated her expectation was that all
resident's call lights were always within reach so the resident could notify staff they need assistance.
During an interview on 03/23/2025 at 1:45 PM, the ADM stated the purpose of call light was for the
residents to alert staff when they needed assistance. The ADM stated it was everyone's responsibility to
ensure call lights were always within reach. The ADM stated that if a call light was not within reach, then a
resident desired need would not be met. The ADM stated that she expected for call lights to be always
within reach and answered timely.
Review of the facility's Call Lights: Accessibility and Timely Response policy, implemented 05/01/2024 and
revised 05/01/2024, reflected, Purpose: The purpose of this policy is to assure the facility is adequately
equipped with a call light to allow residents to call for assistance.
Policy Explanation and Compliance Guidelines
1.
All staff will be educated on the proper use of the resident call system, including how the system works and
ensuring resident access to the call light.
5.
.Staff will ensure the call light is within reach of the resident and secured, as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675581
If continuation sheet
Page 2 of 2
