Health inspection·September 9, 2025

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 observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for three of five residents (Resident #1, #2, and #3) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, #2, and #3's rooms was in a position that was accessible to the residents on 09/09/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: Record review of Resident #1's Face Sheet, dated 09/09/25, reflected she was an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Acute Respiratory Failure (lack of oxygen) and unsteadiness on feet. Record review of Resident #1's Quarterly MDS assessment, dated 08/26/25, reflected he had a BIMS score of 9 (moderate cognitive impairment). For ADL care, it reflected the resident required total assistance. Record review of Resident #1's Comprehensive Care Plan, dated 08/26/2025, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident and to encourage the resident to use it. In an observation on 09/09/25 at 8:30 AM, Resident #1 was observed lying in bed and his call light was located under his bed, out of reach from the resident. Record review of Resident #2's Face Sheet, dated 09/09/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and unsteadiness on feet. Record review of Resident #2's Quarterly MDS assessment, dated 09/01/25, reflected she had a BIMS score of 5 (severe cognitive impairment). For ADL care, it reflected the resident required total assistance. Record review of Resident #2's Comprehensive Care Plan, dated 09/04/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident and to encourage the resident to use it. In an observation on 09/09/25 at 8:31 AM, Resident #2 was observed lying in bed and his call light was located approximately 3 feet away from his bed, out of reach from the resident. In an interview and observation on 09/09/25 at 8:33 AM, CNA Q was shown the call lights location for Resident #1 and Resident #2. She located the call lights and placed them alongside the residents. She stated the call light needed to be placed within reach of the resident so they could contact someone if they neededassistance. In an interview on 09/09/25 at 8:35 AM, LVN C was advised of the call lights for Resident #1 and Resident #2 not being within reach of the residents. She stated staff checked the resident rooms at least every 2 hours to ensure call lights were within reach of the resident. She stated if the resident's call light was not within reach, they could not contact anyone if they needed help. She stated Resident #1 and Resident #2 were fall risk. Record review of Resident #3's Face Sheet, dated 09/09/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and unsteadiness on feet. Record review of Resident #3's Quarterly MDS assessment, dated 07/12/25, reflected Residents Affected - Some (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 3 Event ID: 675611 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 675611 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Villages of Dallas 550 E Ann Arbor Ave Dallas, TX 75216 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)