Health inspection·August 21, 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 two of ten residents (Resident #1 and Resident #2) reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Resident #1's room was in a position that was accessible to the resident on 08/21/2025.2. The facility failed to ensure the call light system in Resident #2's room was in a position that was accessible to the resident on 08/21/2025.These failures could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: 1. Record review of Resident #1's Face Sheet, dated 08/21/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia (decline in cognitive function that interferes with daily life), cognitive communication deficit (impacts how a person processes and conveys information), and difficulty in walking.Record review of Resident #1's Quarterly MDS (tool used to measure health status) Assessment, dated 08/11/2025, reflected severe cognitive impairment with a BIMS (tool used to measure cognitive status) score of 02. Resident #1 required staff assistance for transfers and acts of daily living. Record review of Resident #1's Comprehensive Care Plan, dated 06/21/2024, reflected Resident #1 was at risk for falls. One of the interventions was to ensure the call light was within reach and encourage the resident to use it to call for assistance as needed. During an observation and interview on 08/21/2025 at 11:33 AM, Resident #1 was lying in bed awake. Resident #1's call light cord was on the floor near the head of the bed. When asked if she could reach her call light, Resident #1 did not reply. The DON was in the hall and came into the resident's room. She attempted to pick up the call light from the floor but was unable to because it was under the wheel of the bed. The DON rolled the bed to the side and picked up the call light. The DON placed the call light on the bed within Resident #1's reach. She stated she would get a clip and secure the call light to ensure it did not fall off of the bed. 2. Record review of Resident #2's Face Sheet, dated 08/21/2025, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2 had diagnoses which included parkinsonism (condition that causes movement-related symptoms), schizophrenia (mental condition that affects how people think, feel, and behave), unsteadiness on feet, and other lack of coordination. Record review of Resident #2's Quarterly MDS Assessment, dated 06/11/2025, reflected moderately impaired cognition with a BIMS score of 08. Section GG (functional abilities) reflected Resident #2 needed assistance with toileting. Record review of Resident #2's Comprehensive Care Plan, dated 08/05/2025, reflected Resident #2 was at risk for falls related to an unsteady gait and weakness. One of the interventions was to ensure the call light was within reach and encouraged the resident to use it to call for assistance as needed. An observation on 08/21/2025 at 11:43 AM revealed Resident #2 lying in bed asleep. Resident #2's chair was Residents Affected - Few Page 1 of 2 676029 676029 08/21/2025 Westpark Rehabilitation and Living 900 Westpark Way Euless, TX 76040

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few approximately two feet to the right of the bed. Resident #2's call light was on the floor behind the chair. During an observation and interview on 08/21/2025 at 11:50 AM, CNA B stated she had moved Resident #1's bed a few minutes earlier to provide care and had not noticed the call light was on the floor. She stated Resident #2 might have moved his call light. She stated she rounded on all her residents at the beginning of the shift and made sure their call lights were within reach. She stated she also checked call light placement during her shift when rounding on the residents. She stated it was important for the residents to have their call lights within reach because that was their main source of communication to call for help. CNA B immediately went to Resident #2's room, picked up his call light, and placed it on the bed within the resident's reach. During an interview on 08/21/2025 at 2:53 PM, LVN C stated Resident #1 and Resident #2's call lights should have been in reach. He stated the call lights should be clipped to the side of the bed or bed sheet so the residents could reach them. He stated it was important for residents to have their call lights in case they needed water to drink, their television turned on or off, or needed to go to the restroom. He stated if residents attempted to get up without assistance, it could lead to an accident. He stated residents should have 24-hour access to their call light. He stated it was important to educate and remind residents what the call light was for and to use it when they needed help. During an interview on 08/21/2025 at 4:45 PM, the DON stated her expectation was for all residents to have their call lights in reach because that was how the residents communicated their needs to staff. She stated the facility started in-service training on call light placement. During an interview on 08/21/2025 at 4:50 PM, the Administrator stated the facility began in-service training about call light placement. He stated the nursing staff on the halls checked the call light placement when they completed their rounds. He stated when the department heads rounded daily on their assigned residents, one of the things they looked at was call light placement. He stated the facility also had customer service related audits of call lights for response time. Record review of the facility's policy Policy/Procedure - Nursing Clinical: Call Light/Bell, revised 08/03/2021, reflected It is the policy of this facility to provide the resident a means of communication with nursing staff . 3. Leave the resident comfortable. Place the call light within the resident's reach before leaving room. 676029 Page 2 of 2