F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
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 be adequately equipped to allow residents to
call for staff assistance through a communication system which relays the call directly to a staff member or
a centralized staff work area from each resident's bedside for 4 of 12 residents (Residents # 1, # 2, #3 and
# 4) reviewed for call lights.The facility failed to ensure Resident # 1 had an operating call light system. The
facility failed to ensure the call light system was accessible to Residents # 2, # 3 and # 4. These failures
could place residents at risk of not being able to call for staff assistance to meet care needs or at risk of
injury, pain, hospitalization, and a diminished quality of life.Findings include:Record review of a face sheet
dated 12/3/2025 indicated that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]
with diagnoses including: dementia (confusion due to aging with inability to remember), muscle weakness,
difficulty ambulating, and muscle wasting and chronic kidney disease stage 3 (the kidney's function has
been cut by half). Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated
that she had a BIMS score of 10, indicating that she had a moderate cognitive impairment. Resident # 1
needed supervision when transfers from bed to chair.Record review of Resident # 1's comprehensive care
plan with a revision date 11/10/2025, revealed the resident needed a safe environment with adequate,
glare-free light, a working and reachable call light, and the bed in low position at night. Resident # 1 was a
risk for falls.During an observation/ interview on 12/03/2025 at 9:34 a.m., Resident #1's call light did not
turn on when the button was pressed by Resident # 1. Resident stated that she did not know that the call
light was not working, and she would like to be sure that staff will respond to her calls for assistance.
Record review of a face sheet dated 12/3/2025 indicated that Resident #2 was a [AGE] year-old female
admitted to the facility on [DATE] with diagnoses including: Down Syndrome (a genetic disorder), dementia
(confusion due to aging with inability to remember), muscle weakness, and Dysphagia (difficulty
swallowing). Record review of a Quarterly MDS assessment dated [DATE] for Resident #2 indicated that
her BIMS score could not be determined. The MDS assessment of Resident # 2's mobility indicated she
required extensive assistance.Record review of the Care Plan dated 09/04/2025, for Resident #2 indicated
the resident's call light was to be within reach and staff were to encourage the residents to use it for
assistance as needed.During an observation and attempted interview of Resident # 2 on 12/03/2025 at
1:14 PM the resident was lying in her bed, and a flat call button was out of the resident's reach. It was
located under Resident #2's pillow. DON entered Resident # 2's room and resituated Resident # 2's call
light button from under the pillow to above the resident's blanket next to Resident # 2's left hand. Record
review of Resident # 3's face sheet dated 12/03/2025 indicated that Resident #3 was a [AGE] year-old
female admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease (form of dementia
that affects memory), congestive heart failure (heart unable to pump blood effectively) and Atherosclerotic
Heart Disease (hardening of the
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:
675897
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
675897
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Franklin Nursing Home
700 Hearne St
Franklin, TX 77856
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 0919
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
arteries). Record review of a Quarterly MDS assessment dated [DATE] for Resident #3 indicated a BIMS
score of 8 indicating she had moderate cognitive impairment. The assessment of Resident #3's mobility
indicated she was independent, and she needed no assistance from a helper. Record review of the Care
Plan dated 09/03/2024, for Resident # 3 indicated the resident's call light was to be within reach and
encourage the residents to use it for assistance as needed.In an observation and attempted interview of
Resident # 3 on 12/03/2025 at 9:34 am Resident # 3's call light button was resting on the arm of the easy
chair which was located over 3 feet way from the resident. Resident was sleeping and was not able to be
interviewed.Record review of Resident # 4 's Face sheet dated 12/03/2025 indicated that Resident #4 was
a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Dementia (confusion due
to aging with inability to remember), Diabetes (high levels of glucose in the blood), and Dysphagia (difficulty
swallowing).Record review of a Quarterly MDS assessment dated [DATE] for Resident #4 indicated a BIMS
score of 8 indicating he had moderate cognitive impairment. The assessment of Resident #4's mobility
indicated he needed partial/moderate assistance and the helper did less than half the effort.Record review
of the Care Plan dated 05/05/2025, for Resident # 4 indicated the staff was to be sure the resident's call
light was within reach and encourage the resident to use it.During an observation and interview of Resident
#4 on 12/03/2025 at 9:43 AM, the resident could not reach the call button due to the button hanging off the
right side of the bed. Resident said he was not sure how often the staff came into his room and checked on
him.During an interview on 12/03/2025 at 9:39 AM, CNA A said she did not know the last time she saw a
call light on for Resident # 4's room. During an observation, CNA A tested Resident # 4's call light button
and it was determined that the light was not working. CNA A stated, she did not know Resident # 1's call
light was not working. CNA A replaced Resident #4's call light button with another working call light button.
During an interview on 12/03/25 at 2:03 pm, the Maintenance Supervisor said the call lights in the
bedrooms needed to be working because if a resident were to fall, they needed to be able to use it to call
for help. He said he was responsible for making sure the call light system was working. He stated the call
lights were checked for functionality every week. He stated the senior staff did Champion Rounds daily. He
stated, Champion Rounds are when each member of the senior staff is assigned to check in on all the
residents on an assigned hallway and daily all departments got together, and they reported to him if
something was not working. He stated he checked the call light buttons in Resident #4's room and both
were functioning.During an interview on 12/03/2025 at 2:25 PM, the ADON said the call button was always
supposed to be within the resident's reach. She stated, CNAs, Nurses, everyone on staff is responsible for
making sure the resident can reach the call light button.During an interview on 12/03/2025 at 3:16 pm, the
DON stated, everyone on staff is responsible for checking the call light button locations. The DON stated,
even if the resident was not in the room at a given time, it was important to know where the call light was.
She stated, it may be wrapped up in the sheets and not visible so when they come back into the room, they
may not be able to find it. The DON stated, We don't test the call lights during the Champion Rounds. DON
stated her expectation was that her staff check to see that each resident had a call light button within reach.
She stated, she did not know why a resident's call light was not working, and they may have missed it. DON
stated, the ADM did most of the all-staff in-service training such as call light buttons were to be within reach
of the residents. During an interview on 12/03/25 at 11:41 am, the Administrator said a call light must be
within reach, wherever the resident was, in an easy chair or in their bed. The call light button was for a
resident to get assistance if there was an emergency. The Administrator said if a resident were to fall, they
needed to be able to reach the call light button to call for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675897
If continuation sheet
Page 2 of 3
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
675897
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/03/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Franklin Nursing Home
700 Hearne St
Franklin, TX 77856
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 0919
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
help. He said he would expect his staff to follow proper policy and procedure. Record review of an undated
facility policy titled Call Lights indicated a call light training involves the patient using the light to request
assistance and the staff responding promptly and courteously. Key components include placing the call light
within reach, demonstrating its use to patients, and establishing clear response protocols. For Staff promote
understanding: when a new resident arrives, explain what the call light is for and demonstrate how to use it.
Including the call button in the bathroom.Ensure Accessibility: Verify that the call light is plugged in and
positioned within the resident's easy reach. Systemic RequirementsFunctionality: All call systems must be
in operating order, with both visible and audible signals that are easy for staff to see and hear at the nurses'
station.Reporting: A procedure for reporting and correcting malfunctions is crucial to prevent common
problems like non- functioning equipment.Staffing and Training: Facilities should have clear expectations for
staff to ensure timely call light responses.Compliance: Regulations require functioning call system to
ensure resident safety, and response times are often monitored as a key performance indicator.
Event ID:
Facility ID:
675897
If continuation sheet
Page 3 of 3