Health inspection·December 20, 2024

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 ensure residents received services in the facility with reasonable accommodations of each resident's needs for 4 of 13 residents (Residents #2, #3, #4, & #5) reviewed for resident rights in that: Residents Affected - Some The facility failed to ensure Residents #2, #3, #4, & #5's call light was within reach on 12/20/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: 1.Record review of Resident #2's admission record dated 12/20/24 documented a [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses which included: acute cystitis with hematuria (a bladder infection that results with blood in the urine), major depressive disorder severe with psychotic symptoms (a mental illness that involves depression and a loss of touch with reality, or psychosis), anxiety disorder (a mental health condition that causes a person to experience excessive and intense feelings of fear, worry, and dread), acute respiratory failure with hypoxia (your lungs aren't able to get enough oxygen into your blood, leading to a dangerously low level of oxygen in your body), and lack of coordination (not being able to move your body smoothly and precisely, often resulting in clumsiness, stumbling, or jerky movement). Record review of Resident #2's Quarterly MDS assessment, dated 10/28/24, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also revealed Resident #2 required substantial/maximal assistance in the areas of Toileting hygiene, shower/bathe self, lower body dressing, and putting on /taking off footwear. Record review of Resident #2's care plan, dated 12/20/24, revealed Resident #2 was care planned for risk for fall and fractures and had an intervention of: Ensure call light is in reach and answer promptly. Observation and interview on 12/20/24 at 9:15 a.m., revealed Resident #2's call light was placed in her bottom drawer and out of her reach. Resident #2 stated her call light was always on the floor or out of reach. Resident #2 stated if she needed help, she would yell or wait till a staff to came in her room. Page 1 of 6 455591 455591 12/20/2024 Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2.Record review of Resident #3's admission record dated 12/20/24 documented a [AGE] year-old female admitted on [DATE]. Resident #3 had diagnoses which included: anxiety disorder (a mental health condition that causes a person to experience excessive and intense feelings of fear, worry, and dread), essential primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and multiple sclerosis (a chronic disease that affects the central nervous system, which includes the brain and spinal cord) Record review of Resident #3's admission MDS assessment, dated 09/06/24, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also revealed Resident #3 was dependent in the areas of Toileting hygiene and shower/bathe self. Resident #3 required partial/moderate assistance in the areas of upper body dressing, lower body dressing, and putting on/taking of footwear. Record review of Resident #3's care plan, dated 12/20/24, revealed Resident #3 was care planned for risk for complains of increase pain/discomfort and is at risk for injury from decrease in ADLs, functional bladder incontinence and is at risk for skin breakdown r/t incontinent of urine at times, on pain medication therapy, high risk for increased fall and fractures, and ADL self-care performance deficit r/t decreased functional mobility/terminal prognosis/generalized weakness. Observation and interview on 12/20/24 at 12:45 p.m., revealed Resident #3's call light was hanging toward the ground on the right side of her bed and out of her reach. Resident #3 stated she could not reach her call light. Resident #3 stated she has asked repeatedly for a clip for her call light so her call light could be clipped to her or her bedding. Resident #3 stated if she needed assistance, she would have to wait for staff to make rounds or go looking for staff. 3.Record review of Resident #4's admission record dated 12/20/24 documented an [AGE] year-old female admitted on [DATE]. Resident #3 had diagnoses which included: essential primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), lack of coordination (not being able to move your body smoothly and precisely, often resulting in clumsiness, stumbling, or jerky movement), cognitive communication deficit (having trouble communicating effectively due to problems with thinking skills like memory, attention, or reasoning), generalized anxiety disorder (constantly worrying about many different things in life even when there's no real reason) and muscle wasting and atrophy (when your muscles are shrinking and losing mass, making them weaker, usually due to lack of use, injury, or a medical condition). Record review of Resident #4's Quarterly MDS assessment, dated 12/06/24, revealed the resident had a BIMS score of 09 indicating the resident has moderate cognitive impairment. The MDS also revealed Resident #4 was dependent in the areas of oral hygiene, toileting hygiene, shower/bathe self, putting on /taking off footwear, and personal hygiene. Resident #4 required substantial/maximal assistance of lower body dressing. Record review of Resident #4's care plan, dated 12/20/24, revealed Resident #4 was care planned for risk for fall and fractures and had an intervention of: Ensure call light is in reach and answer promptly. Observation and interview on 12/20/24 at 1:05 p.m., revealed Resident #4's call light was hanging toward the ground on the right side of her bed and out of her reach. 455591 Page 2 of 6 455591 12/20/2024 Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #4 stated she could not reach her hanging call light because it was too far away. Resident #4 stated she was not sure of how long her call light was not within reach. Resident #4 stated if she needed help, she would have to wait until a staff came in her room to ask for assistance. 4.Record review of Resident #5's admission record dated 12/20/24 documented a [AGE] year-old male admitted on [DATE]. Resident #5 had diagnoses which included: schizoaffective disorder (a chronic mental illness that causes people to experience symptoms of both schizophrenia and a mood disorder at the same time), hyperlipidemia (a condition where there is too much fat lipids in your blood), and lack of coordination (not being able to move your body smoothly and precisely, often resulting in clumsiness, stumbling, or jerky movement). Record review of Resident #5's Annual MDS assessment, dated 09/20/24, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also revealed Resident #5 required supervision or touching assistance in the area of shower/bathe self. Record review of Resident #5's care plan, dated 12/20/24, revealed Resident #5 was care planned for risk for fall and fractures and had an intervention of: Ensure call light is in reach and answer promptly. Observation and interview on 12/20/24 at 1:15 p.m., revealed Resident #5's call light was hanging on his wall to the left side of is bed and out of his reach. Resident #5 stated that he could not reach is call light while in bed. Resident #5 stated he did not know how long his call light has been hanging on the wall. During an interview on 12/20/24 at 3:15 p.m., CNA A stated CNAs should make rounds at least every two hours or as needed. CNA A stated that CNAs should be looking to see if a resident needs assistance, ensuring call lights were within reach, and making sure all residents were comfortable. CNA A stated if a resident's call light was not within reach, then the resident could fall attempting to reach it or the resident would not receive assistance. During an interview on 12/20/24 at 6:25 p.m., the RN stated that anyone that entered the resident's room was responsible for ensuring the call light was within reach. The RN stated the purpose of a call light was for resident to notify staff when they need assistance. The RN stated if a resident's call light was not in reach, then the resident could have an unmet need. The RN stated her expectation was that all resident's call lights were always within reach so the resident can notify staff they need assistance. An interview on 12/20/24 at 7:05 p.m., the ADM stated the purpose of call light is for the residents to alert staff they need assistance. The ADM stated its everyone's responsibility to ensure call lights are always within reach. The ADM stated that if a call light was not within reach, then a resident desired need would not be met. The ADM stated that he expects for call lights to be always within reach and answered timely. Review of the facility's Answering the Call Light policy, revised September 2022, reflected, Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines 455591 Page 3 of 6 455591 12/20/2024 Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165

F 0558 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and form the floor. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 455591 Page 4 of 6 455591 12/20/2024 Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 13 residents (Residents #1, and #5) reviewed for care plans. The facility failed to revise Resident #1's care plan to reflect an unwitnessed fall out of bed on 12/11/24 and 12/14/24. The facility failed to revise Resident #5's care plan to reflect interventions for nutritional impairment, behavior problem, and resistive to care that was initiated on 11/20/24. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: 1. Record review of Resident #1's admission record dated 12/20/24 documented a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: unspecified fall (sudden movement downward) type 2 diabetes (pancreas doesn't make enough insulin, and primary hypertension (high blood pressure). Record review of Resident #1's Quarterly MDS assessment, dated 11/29/24, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Record review of Resident #1's care plan, dated 12/20/24, revealed Resident #1 was care planned on 11/10/23 for falls. The care plan did not document unwitnessed fall out of bed for 12/11/24 and 12/14/24. 2.Record review of Resident #5's admission record dated 12/20/24 documented a [AGE] year-old male admitted on [DATE]. Resident #5 had diagnoses which included: schizoaffective disorder (a chronic mental illness that causes people to experience symptoms of both schizophrenia and a mood disorder at the same time), hyperlipidemia (a condition where there is too much fat lipids in your blood), and lack of coordination (not being able to move your body smoothly and precisely, often resulting in clumsiness, stumbling, or jerky movement). Record review of Resident #5's Annual MDS assessment, dated 09/20/24, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Record review of Resident #5's care plan, dated 12/20/24, revealed Resident #5 was care planned on 11/20/24 for nutritional impairment, behavior problem, and resistive to care. There were no interventions documented on the care plan for nutritional impairment, behavior problem, and resistive to care. The area for interventions was left blank and not completed. During an interview on 12/20/24 at 5:39 p.m., the ADON stated it was expected for the care plans to be accurate. The ADON stated the facility did not have a DON and it was her responsibility to make 455591 Page 5 of 6 455591 12/20/2024 Focused Care of Waxahachie 1413 W Main St Waxahachie, TX 75165

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sure that the care plans were updated. The ADON could not give a reason to why the care plans were not updated. The ADON expressed that it had been overwhelming for her lately. The ADON stated care plans not updated will lead to resident's needs not being met. During an interview on 12/20/24 at 7:08 p.m., the ADM stated it was expected for the care plans to be updated immediately when there is a change of condition. The ADM stated it was not a current DON at the facility and the ADON was responsible for making sure the care plans were accurate. The ADM stated if care plans were not updated the residents would not receive the needed service and their need would not be met. Record review of the facility's policy titled, Comprehensive Care Plan, dated 01/20/21 last revised 04/25/21, indicated, Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The Interdisciplinary Team will continue to develop the plan in conjunction with the RAI (MDS 3.0) and CAAS, after admission. The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. The resident's Care Plan will include participation from resident's representatives, external partners PASRR, Hospice, Therapy, Clinicians, and not as all-inclusive. 455591 Page 6 of 6