Resident #1's call light sat on the floor approximately two feet to the right of the bed. Resident #2's call light was on the floor behind a chair, completely out of reach.
The discovery came during a complaint inspection at the 676029-licensed facility. Call lights serve as residents' primary communication tool with nursing staff for everything from requesting water to needing bathroom assistance.
CNA B told inspectors she had moved Resident #1's bed just minutes earlier to provide care but hadn't noticed the call light had fallen to the floor. She suggested Resident #2 might have moved his own call light, though she couldn't explain how it ended up behind furniture.
"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 acknowledged to inspectors.
She immediately retrieved Resident #2's call light and placed it on the bed within reach when inspectors pointed out the violation.
CNA B claimed she checked all residents' call light placement at the beginning of her shift and during rounds throughout the day. The inspection findings contradicted this assertion.
LVN C explained the proper procedure to inspectors during a 2:53 PM interview. Call lights should be clipped to the bed side or bed sheet so residents can reach them, he said. Residents need access for basic requests like turning their television on or off, getting water, or using the restroom.
"If residents attempted to get up without assistance, it could lead to an accident," LVN C told inspectors.
He emphasized residents should have 24-hour access to their call light and stressed the importance of educating residents about when and how to use the emergency communication system.
The facility's own policy, revised August 3, 2021, requires staff to "place the call light within the resident's reach before leaving room" and provide residents "a means of communication with nursing staff."
Director of Nursing acknowledged during a 4:45 PM interview that her expectation was for all residents to have call lights within reach "because that was how the residents communicated their needs to staff."
She told inspectors the facility had started in-service training on call light placement in response to the violations.
Administrator confirmed the new training initiative during his 4:50 PM interview. He claimed nursing staff checked call light placement during their rounds and department heads looked for proper placement during daily resident visits.
The administrator also mentioned the facility conducted customer service audits related to call light response times, though this monitoring apparently failed to catch the placement violations inspectors discovered.
The violations occurred despite multiple layers of supposed oversight. CNA B claimed to check placement during rounds. Department heads supposedly verified placement during daily visits. The facility even audited response times.
Yet two residents sat without access to their primary means of requesting help.
For nursing home residents, particularly those with limited mobility, call lights represent a critical safety measure. Without them, residents may attempt to get up unassisted to meet basic needs, risking falls and injuries.
The inspection report classified the violations as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the consequences of inaccessible call lights can escalate quickly when residents face emergencies or urgent needs.
Westpark Rehabilitation and Living's response focused on training rather than addressing why existing policies and procedures failed. The facility's policy clearly required proper call light placement, yet staff either ignored the requirement or failed to implement it effectively.
The administrator's mention of response time audits highlighted another issue: the facility tracked how quickly staff responded to call lights but apparently didn't verify residents could actually reach them in the first place.
CNA B's immediate action to correct the placement when inspectors arrived demonstrated staff understood the importance of accessible call lights. The question remained why this understanding didn't translate to consistent practice before the inspection.
The incident revealed a gap between stated policies and actual implementation at the Euless facility. Despite written procedures requiring call light placement within reach, at least two residents were left without access to their primary means of communication with nursing staff.
Federal inspectors documented the violations as part of a complaint investigation, suggesting someone had raised concerns about care quality at Westpark Rehabilitation and Living that prompted the unannounced visit.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westpark Rehabilitation and Living from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Westpark Rehabilitation and Living
- Browse all TX nursing home inspections