Health inspection·November 24, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five (Resident #1, #2, #3, #4, and #5) of fifteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, #2. #3, #4, and #5's rooms was in a position that was accessible to the residents on 08/12/2025. 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 included: Resident #1 Record review of Resident #1's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness, hemiplegia (paralysis of one side of the body), and hemiparesis (weakness on one side of the body). Record review of Resident #1's Quarterly MDS Assessment (assessment used to determine functional capabilities and health needs), dated 09/01/2025, reflected the resident had a severe impairment (the resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 05. The Quarterly MDS Assessment indicated that the resident required maximal assistance for dressing, bed mobility, and transfer. Record review of Resident #1's Comprehensive Care Plan, dated 09/23/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and interview on 10/09/2025 at 9:32 AM revealed Resident #1 was in her bed, awake. It was observed that the resident's call light was on the resident's side table and was not within reach. When asked where her call light was, the resident looked at her side and said she could not find her call light. Resident #2 Review of Resident #2's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting. Review of Resident #2's Quarterly MDS Assessment, dated 07/14/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 13. The Quarterly MDS Assessment indicated that the resident required moderate assistance for dressing, bed mobility, and transfer. Review of Resident #9's Comprehensive Care Plan, dated 09/10/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and interview on 10/09/2025 at 9:36 AM revealed Resident #2 was in his wheelchair, awake. It was observed that the resident's call light was on the floor behind his side table. He said the call light was behind his side table for some time. Resident #3 Review of Resident #3's Face Sheet, dated 10/09/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting. Review of Resident #3's Quarterly MDS Assessment, dated 08/14/2025, reflected the resident had severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated that the resident required moderate assistance for dressing, bed Page 1 of 3 675783 675783 11/24/2025 The Villa at Mountain View 2918 Duncanville Rd Dallas, TX 75211

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mobility, and transfer. Review of Resident #3's Comprehensive Care Plan, dated 09/30/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. An observation on 10/09/2025 at 9:39 AM revealed Resident #23 was in his bed with eyes closed. It was observed that the resident's call light was on the floor under his bed. Resident #4 Review of Resident #4's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and muscle wasting. Review of Resident #4's Quarterly MDS Assessment, dated 09/26/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that the resident required maximal assistance for dressing, bed mobility, and transfer. Review of Resident #4's Comprehensive Care Plan, dated 09/23/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and an attempted interview on 10/09/2025 at 9:43 AM revealed Resident #4 was in her bed, awake. It was observed that the resident's call light was on the floor. When asked where her call light was, the resident did not answer. Resident #5 Review of Resident #5's Face Sheet, dated 10/09/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and abnormalities of gait. Review of Resident #5's Quarterly MDS Assessment, dated 09/01/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that the resident required supervision for dressing, bed mobility, and transfer. Review of Resident #5's Comprehensive Care Plan, dated 09/24/2025, reflected the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and an attempted interview on 10/09/2025 at 9:47 AM revealed Resident #5 was sitting at the side of her in her bed. It was observed that the resident's call light was on the floor under a walker. When asked where her call light was, the resident did not reply. During an observation and interview on 10/09/2025 at 9:57 AM, CNA C stated the call lights should be with the residents at all times because the call lights were used by the residents to call the staff if they needed something or if they needed help. She said without the call lights, the residents might fall if they tried to do things by themselves or might get mad because they cannot get hold of anybody. She said the call lights were for all the residents, whether independent or dependent residents. She went inside Resident's #1's room, took the call light from her side table, and placed it where Resident #1 could reach it. She then went to Resident #2's room and pulled his call light from behind the resident's side table and placed it where the resident could reach it. She then went to Resident #3's room and took the call light from the floor. She also did the same for Resident #4 and Resident #5. She said she went to the residents' rooms to change them but did not made sure that the call lights were with residents when she left their rooms. She said she would a round on her assigned hall to check the call lights. In an interview on 10/09/2025 at 10:31 AM, LVN B stated call lights should be with the residents in case they needed to call the staff because they needed to be changed, needed pain medications, or needed a refill of water. She said the CNAs and herself were responsible in making sure the call lights were with the residents. She said she did not notice the call lights were not with the residents when she checked on them. In an interview on 10/09/2025 at 11:19 AM, ADON A stated call lights should be with the residents at all times because the call lights were their lifeline. He said the residents used the call lights to call the staff if they were in distress or just needed a refill of water. He said the call lights were for independent or dependent residents. He said an independent resident might be having a heart attack and no one would know because the call light was not within reach. He said all the staff were responsible in checking if 675783 Page 2 of 3 675783 11/24/2025 The Villa at Mountain View 2918 Duncanville Rd Dallas, TX 75211

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the call lights were with the residents and the expectation was for the staff to make sure the call lights were with the residents every time they left the rooms. He said an in-service had been going around and that he would coordinate with the DON to randomly check if the call lights were with the residents. In an interview on 10/09/2025 at 11:28 AM, the DON stated the expectation was for the staff to make sure the call lights were with the residents at all times. She said the call lights were used by the residents to call the staff if they needed something. She said residents might try to go to the bathroom by themselves because she had no way to call the staff that might result to a fall and injuries. She said all the staff were responsible for the call lights, including her. The DON said an in-service was already initiated and she would monitor the staffs' compliance about call lights. In an interview on 10/09/2025 at 11:48 AM, the Administrator stated the staff should make sure the call lights were with the residents before they leave the room. She said, for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said without the call light the residents might feel helpless. She said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said the DON already started an in-service about call lights. Record review of the facility's In-Service Training Report, dated 10/09/2025, reflected Call lights should be always be withing residents' reach/ability to push button/activate call light. Use clip for positioning. Everyone has the ability/responsibility to pick up call light and make sure it is in residents reach at all times. Record review of the facility's policy entitled Answering the Call Light 2001 MED-PASS, Inc. revised October 2010 reflected Purpose: The purpose of this procedure is to respond to the resident's requests and needs . General Guideline . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 675783 Page 3 of 3