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
observations, interviews, and record reviews, the facility failed to provide reasonable accommodations of
resident needs and preferences except when to do so would endanger the health or safety of 3 (Resident
#1, #2, and #3) of 7 residents reviewed for call lights.
Residents Affected - Few
The facility failed to ensure call light system was within reach and able to use if desired for Resident #1, #2,
and #3.
This failure could place the residents at risk of not maintaining or decreasing the resident's independence
and provide necessary assistance if needed.
Findings included:
Resident #1
Record review of Resident #1's face sheet, dated 9/14/23, revealed Resident #1 was an [AGE] year-old
female admitted to the facility originally on 1/24/23 and readmitted on [DATE]. Resident #1's diagnoses
include but are not limited to Alzheimer's Disease with late onset, Major Depressive Disorders, Delusional
Disorders, and repeated falls.
Record review of Resident #1's MDS, Section C (Cognition), dated 7/11/23, revealed a BIMS score of 08,
which indicated moderate cognitive impairment.
An observation and interview on 9/14/23 at 10:44 AM, Resident #1 was sitting in chair across from bed. The
resident was asked to press her call light, Resident #1's call light was in the floor between both Residents
beds out of reach.
An observation and interview on 9/14/23 at 10:46 AM, an interview with NA B verified the call light for
Resident #1 was on the floor and the call lights should have been clipped to the bed or to the person. NA B
stated a negative outcome could be the resident has an emergency and not able to reach the call light.
Resident #2
Record review of Resident #2's face sheet, dated 9/14/23, revealed Resident #2 was an [AGE] year-old
male who was admitted into the facility originally on 8/23/23, and readmitted on [DATE]. Resident #2's
diagnoses included, but are not limited to, abdominal hernia with obstruction, malnutrition, displaced
fracture of second cervical vertebra, and malignant neoplasm of prostate.
(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 2
Event ID:
676347
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
676347
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/14/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amarillo Center for Skilled Care
6641 W Amarillo Blvd
Amarillo, TX 79106
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Record review of Resident #2's MDS, dated [DATE], revealed no measurable score as resident has been in
the facility for less than 14 days.
Record review of Resident #2's care plan, dated 8/24/23, on Pg. 4, revealed a focus that the resident was a
risk for falls with an intervention stating to be sure the resident's call light is within reach and encourage the
resident to use it. Page 5 continues with same focus and a goal that the resident needs a safe environment
with a working and reachable call light.
An observation and interview on 9/14/23 at 10:55 AM, observed call light for Resident #2 was lying in
drawer next to bed. Observed Resident #2 unable to reach it.
An interview on 9/14/23 at 10:59 AM, LVN A revealed that Resident #2's call light was in the drawer. LVN A
stated the resident would not be able to reach it. LVN A stated a negative outcome could be the resident
would be in distress or could fall.
Resident #3
Record review of Resident #3's face sheet, dated 9/14/23, revealed a [AGE] year-old female, originally
admitted to the facility on [DATE], and readmitted on [DATE]. Diagnoses include btu are not limited to
hemiplegia affecting right dominant side, legal blindness, obstructive sleep apnea, and lymphedema.
Record review of Resident #3's MDS, Section C-Cognition, reveals a BIMS score of 15 which indicated the
resident is cognitively intact.
Record review of Resident #3's care plan, revised on 6/7/23, on page 6, indicated that the resident was a
risk for falls with an intervention that stated to be sure the resident's call light is within reach and encourage
the resident to use it for assistance as needed. On page 7, continued with same goal of the resident was
risk for falls, an intervention stated a working and reachable call light.
An observation and interview on 9/14/23 at 10:36 AM revealed Resident #3's call light wrapped around the
left side rail of the bed above Resident #3's head. Resident #3 was unable to reach the call light and stated
her roommate often must press the call light for them.
An interview on 9/14/23 at 11:17 AM, the ADON revealed that call lights are to not be on floors. They (call
lights), need to be clipped to the person or on the bed. She stated a negative outcome could be they can
fall, and no one would know.
An interview on 9/14/23 at 12:58 PM, the ADON indicated there was not a policy for call lights.
An interview on 9/14/23 at 3:54 PM, the DON revealed that call lights are to be on the chair, clothes, bed
linen, or pillowcase. The DON stated a negative outcome could be falls and ultimately someone can die.
The DON stated there was no policy for call lights.
Record review of in service completed on 8/21/23, revealed training on answering call lights promptly.
Second page, first paragraph states that call lights should be place where a resident can reach it even if
they cannot remember how to use it.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676347
If continuation sheet
Page 2 of 2