Health inspection·April 18, 2024

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 relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside for one of twelve rooms (room [ROOM NUMBER]) reviewed for resident call systems. Residents Affected - Few The facility failed to ensure room [ROOM NUMBER] had a working call light. This failure could place residents at risk of not being able to have their needs met and call for staff assistance when they needed it. The findings include: Observation on 04/18/24 at 3:11 PM revealed the call lights in room [ROOM NUMBER] did not work. The State Surveyor pressed both bedside call light buttons in room [ROOM NUMBER], the light outside of the room illuminated but the phone did not ring at the nurse's station to indicate the resident in room [ROOM NUMBER] needed assistance. In an interview on 04/18/24 at 3:11 PM, with the resident who resided in room [ROOM NUMBER] stated, when he pressed his call light, the wall light inside of the room came on but no one would answer. The resident stated he wondered if his call light worked outside of his room. Observation on 04/18/24 at 3:24 PM revealed the DON and MND tested the call lights in room [ROOM NUMBER]. The MND reset the call light in the room and tested the call lights, but they did not notify the nurses station the call light had been pressed. In an interview on 04/18/24 at 4:56 PM, the MND stated residents should have working call lights at all times. The MND stated facility staff should report all maintenance needs in the maintenance binder at the nurse's station. The MND stated he was not aware room [ROOM NUMBER]'s call light was not working properly. The MND stated without the call light working in room [ROOM NUMBER], the residents were not able to call for assistance. The MND stated he was responsible for the maintenance of the call light system in the facility. The MND stated he would check all the call lights in the facility and make repairs as needed and would check the call lights weekly to ensure they were working properly. In an interview on 04/18/24 at 5:22 PM, the Admin stated it was expected for call lights to be fully functional at all times. The Admin stated he was not aware the call lights in room [ROOM NUMBER] were not working. The Admin stated the MND was to ensure the call light system functioned properly. Page 1 of 2 676453 676453 04/18/2024 Simpson Place 3922 Simpson Street Dallas, TX 75246

F 0919 Level of Harm - Minimal harm or potential for actual harm The Admin stated he had not received any reports of residents call lights not working or not being answered. The Admin stated if residents call lights did not function properly, they would not receive a response or care as needed. The Admin stated they contacted the call light system company and a technician would arrive at the facility for repairs on 04/19/24. The Admin stated staff would be in serviced on maintenance repair submission and call lights. Residents Affected - Few Record review of the facility's Maintenance binder on 04/18/24 at 5:05 PM, revealed no requests for any call light repair. 676453 Page 2 of 2