Health inspection·March 19, 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 the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 7 residents (Residents #1 & #2) reviewed for resident rights. Residents Affected - Few The facility failed to ensure Resident #1 & Resident #2's call lights were within reach on 03/19/2025. This failure could place residents at risk of their needs not being met. Findings include: 1. Record review of Resident #1's admission record, dated 03/19/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: unspecified dementia (neurological condition affecting the brain that worsen over time), chronic obstructive pulmonary disease with acute exacerbation (a chronic lung disease that cause air flow limitation and breathing-related symptoms), acute diastolic congestive heart failure (when the left heart ventricle stiffens and can't relax properly between beats, leading to less blood filling it), and acute respiratory failure with hypoxia (when your lungs are suddenly failing to get enough oxygen into your blood, leading to dangerously low oxygen levels.). Record review of Resident #1's Quarterly MDS assessment, dated 03/062025, reflected the resident had a BIMS score of 10, which indicated moderate cognitive impairment. Resident #1 required substantial/maximal assistance in the areas of toileting hygiene, shower/bathe self, and personal hygiene. Resident #1 was dependent in the areas of lower body dressing and putting on/taking off footwear. Record review of Resident #1's care plan, dated 03/19/2025, reflected Resident #1 was care planned for communication and had an intervention of call light in reach and answer in a timely manner. During an observation on 03/19/2025 at 9:24 AM., Resident #1's call light was observed hanging towards the floor on the right side of Resident #1's bed. During an observation on 03/19/2025 at 11:37 AM., Resident #1's call light was observed hanging towards the floor on the right side of Resident #1's bed. During an observation and interview on 03/19/2025 at 12:44 PM., Resident #1's call light was observed hanging towards the floor on the right side of Resident's #1's bed. Resident #1 stated she could Page 1 of 3 676047 676047 03/19/2025 Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not reach her call light. Resident #1 stated if she needed assistance, she would have to wait on staff to come in her room. 2. Record review of Resident #2's admission record, dated 03/19/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: unspecified dementia (neurological condition affecting the brain that worsen over time), lower back pain, shortness of breath, and essential primary hypertension (high blood pressure without a known underlying cause.) Record review of Resident #2's Quarterly MDS assessment, dated 03/06/2025, reflected the resident had a BIMS score of 05, which indicated severe cognitive impairment. Resident #2 required substantial/maximal assistance in the area of shower/bathe self. Resident #2 was dependent in the area of putting on/taking off footwear. Record review of Resident #2's care plan, dated 03/19/2025, reflected Resident #2 was care planned for risk communication, high risk for falls, and had an intervention for Resident #2's call light to within reach and answered in a timely manner. During an observation on 03/19/2025 at 12:46 PM., Resident #2's call light was observed tied to the lower left part of her bed rail. Resident #2's call light was not within her reach. Resident #2 stated she could not reach her call light if she tried too. Resident #2 was not sure how long her call light had been out of reach. Resident #2 stated she would have to wait on staff to enter her room or call for assistance if she needed help. During an interview with the CNA A on 03/19/2025 at 2:05 PM, CNA A stated she and CNA B both were working the D hall where Residents #1 & #2 resided. CNA A stated CNAs made round's every two hours or as needed. CNA A stated it was everyone's responsibility for ensure resident's call lights were within reach. CNA A stated when making rounds CNAs checked to see if residents needed assistance and ensured the residents were safe. CNA A stated the purpose of a call light was a resident to call for assistance. CNA A stated she was not aware Resident #1 or Resident #2's call light was not within reach. CNA A stated if a resident could not reach the call light the resident would not be able to call for help if they need something. During an interview with CNA B on 03/19/2025 at 2:10 PM, CNA B stated she and CNA A both worked the D hall where Residents #1 & #2 resided. CNA B stated CNAs made rounds at least every two hours unless there was a resident who may require more frequent checks. CNA B stated that it's the CNAs and anyone who enter the resident's room to ensure the call lights was in reach. CNA B stated during rounds, CNAs were taught to ensure the resident call lights were in reach. CNA B stated she was not aware Resident #1 or Resident #2's call light was not within reach. CNA B stated if a residents call light was not in reach the resident would not be able to call for assistance. During an interview with the DON on 03/19/2025 at 3:05 PM, the DON stated all residents call lights should be always within reach. The DON stated it was everyone's responsibility to ensure residents call lights were always within reach. The DON stated if a resident's call light was not within reach the resident would not be able to receive assistance if they needed it. During an interview with the ADM on 03/19/2025 at 4:10 PM, the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call light were within reach. The ADM stated if a resident call light was not within reach, then the resident may not be 676047 Page 2 of 3 676047 03/19/2025 Town Hall Estates Keene, Inc. 207 S Old Betsy Rd Keene, TX 76059

F 0558 Level of Harm - Minimal harm or potential for actual harm able to call for assistance. The ADM stated her expectation was for all resident's call lights to always be within reach. A record review of the facility's Answering the Call Light policy, revised September 2022, reflected The purpose of this procedure is to ensure timely response to the resident's requests and needs. Residents Affected - Few General Guidelines 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor 676047 Page 3 of 3