Health inspection·December 3, 2025

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 Page 1 of 3 675897 675897 12/03/2025 Franklin Nursing Home 700 Hearne St Franklin, TX 77856

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 675897 Page 2 of 3 675897 12/03/2025 Franklin Nursing Home 700 Hearne St Franklin, TX 77856

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 675897 Page 3 of 3