Based on observations, interviews and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for four residents (Resident #1, Resident #2, Resident #6, and Resident #7) of 83 residents reviewed for resident call system in that: The facility failed to ensure the call lights in Resident #1's and Resident #2's shared room were in working order. Resident #1 was not able to use her call light to call for help when she was physically assaulted by her roommate, Resident #2. On 07/25/25 at 11:20 AM an Immediate Jeopardy (IJ) was identified. …
F919 citations in Texas
Call system · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Texas cites F919 more often than its own record predicts
1.42 times the share F919 takes of citations nationally.
Of every deficiency written in Texas in 2025, this is the portion that was F919.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Texas surveyors wrote
F919 findings written in Texas, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview, and record review, the facility failed to ensure residents rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one of four residents (CR#1) reviewed for resident call system, in that: -CR #1's room did not have a properly functioning call system during an emergent change in condition. This failure could affect all residents and place them at risk of lack of staff assistance and help in the event of an emergency. Findings include: CR #1 Record review of the admission sheet for CR# 1 revealed a [AGE] year-old male admitted to the facility on [DATE]. …
Based on observation, interview, and record review, the facility failed to ensure rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 5 residents (Resident#85 ) reviewed for call lights. Resident #85's call light was observed to not have a red button inside the call light device to call for assistance on 8/11/2026. This failure could place residents at risk for delays in care and services, increased falls, and excessive waiting times, pain, and a decreased quality of life. …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 0.59% | 1.36× |
| 2024 | 0.66% | 1.49× |
| 2025 | 0.63% | 1.42× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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