Lone Star Rehab: Call Light Safety Violations - TX
Federal inspectors cited Lone Star Rehabilitation & Wellness Center in September after finding staff repeatedly failed to ensure call lights remained within reach of residents confined to their beds. The violation occurred despite facility policies requiring staff to place the devices where bedridden residents could easily access them.
Resident #6 became the focus of the inspection after complaints about call light accessibility. The man couldn't get out of bed safely, yet nursing assistants left his call light hanging on the cable where it exits the wall behind the head of his bed. From that position, he had no way to summon help during an emergency.
The facility's Director of Nursing acknowledged the problem during a September 3 interview with inspectors. She stated her expectation was that call lights should be within reach of residents when they were in bed. She confirmed that Resident #6 couldn't exit the bed to reach the call light in its wall-mounted position.
"Not having the call light in reach could interfere with residents calling for assistance," the nursing director told inspectors.
The administrator echoed these concerns the following day. During a September 4 interview, she confirmed that Resident #6 couldn't safely get out of bed to reach a call light hanging on the wall behind his head. She revealed that the resident had adapted to the situation by yelling for help instead of using the call system.
"Resident #6 would not use his call light and would yell out if he needed assistance but even so, she expected for him to have access to his call light," inspectors documented.
The administrator blamed a supervision breakdown for the violation. She explained that department heads were supposed to round the halls daily during the week to monitor nursing staff performance. However, the department head assigned to Resident #6's hall was on vacation, which "could have led to failure of call light not being in reach."
Both administrators placed responsibility for call light placement squarely on nursing assistants. The Director of Nursing stated that CNAs were responsible for ensuring call lights stayed within reach, with charge nurses monitoring compliance. The administrator confirmed this chain of responsibility during her interview.
Federal regulations require nursing homes to ensure residents can summon assistance when needed. Call lights serve as the primary communication link between residents and staff, particularly for those with mobility limitations who cannot leave their rooms independently.
The facility's own policies reinforced these requirements. A document titled "Strategies for Reducing the Risk of Falls" from December 2007 specifically listed "call light within reach" as a room safety requirement. The policy also reminded staff to encourage residents and families to "call as needed for assistance with transfer and ambulation."
A more recent policy from March 2021 outlined specific call light procedures. The "Answering the Call Light" policy required staff to explain and demonstrate call light use upon admission and periodically as needed. It mandated that residents demonstrate their understanding of the system.
Most importantly, the 2021 policy contained explicit instructions: "When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident."
Despite these clear guidelines, staff failed to follow basic safety protocols for Resident #6. The violation represented a fundamental breakdown in care that could have prevented the resident from getting help during a medical emergency or other urgent situation.
The inspection revealed systemic problems with supervision and accountability. While administrators knew their policies and could articulate expectations clearly to inspectors, these standards weren't being implemented consistently on the floor where residents actually lived.
For Resident #6, the failure meant relying on his voice rather than the facility's emergency communication system. His adaptation of yelling for help highlighted both his vulnerability and the staff's failure to provide basic safety measures that other residents could take for granted.
The citation carries minimal harm designation, affecting few residents. However, the violation underscores how easily fundamental safety measures can break down when supervision lapses and staff accountability systems fail to function as intended.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lone Star Rehabilitation & Wellness Center from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LONE STAR REHABILITATION & WELLNESS CENTER in STEPHENVILLE, TX was cited for violations during a health inspection on September 4, 2025.
The violation occurred despite facility policies requiring staff to place the devices where bedridden residents could easily access them.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.