Health inspection·October 17, 2023

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 5 residents (Residents #1, #2, #3 & #4) reviewed for call lights in that: Residents Affected - Some Residents #1, #2, #3, & #4's call lights were not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Resident #1 Record review of Resident #1's admission record dated 10/17/23 documented a [AGE] year-old female admitted on [DATE]. Resident #1's documented diagnoses included: Unspecified Dementia (loss of thinking abilities), Disorder of bone density (thin fragile bones), Weakness, Essential hypertension (elevated blood pressure), Fracture of the third cervical vertebra (broken vertebra in the neck region) Record review of Resident #1's Significant change MDS assessment dated [DATE] revealed the resident had a BIMS score of 99 indicating severe cognitive impairment. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as bed mobility, dressing, and personal hygiene. Record review of Resident #1's care plan dated 08/25/22 revealed Resident #1 was care planned for falls and requires monitoring for safety. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as bed mobility, dressing, and personal hygiene. Observation of Resident #1 on 10/17/23 at 10:20am revealed Resident #1's call light is lying on the floor around bedside table leg out of reach of resident. Resident #1 was not interviewer able. Resident #2 Record review of Resident #2's admission record dated 10/17/23 documented a [AGE] year-old male admitted on [DATE]. Resident #2's documented diagnoses included: Unspecified Dementia (loss of thinking abilities), Type 2 Diabetes Mellitus (elevated blood sugar), Repeated falls, Essential Hypertension (elevated blood pressure) Page 1 of 3 675096 675096 10/17/2023 Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #2's annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 08 indicating Resident #2 is moderately cognitive impaired. The MDS also revealed the resident required limited assistance in various areas of activities of daily living such as bed mobility, transfer, dressing, eating and toilet use. Record review of Resident #2's care plan dated 07/25/23 revealed Resident #2 was care planned for falls, uses a wheelchair for mobility, and had an intervention of Keep call light in reach at all times. Observation of Resident #2 on 10/17/23 at 10:28 A.M. revealed Resident #2's call light was behind his wheelchair and bedside table on the floor out of reach. In an Interview with Resident #2 on 10/17/23 at 10:28 A.M. Resident #2 stated he uses the call light to call for assistance from staff when help is needed. He stated if he were to fall, he would not be able to reach his call light. Resident #3 Record review of Resident #3's admission record dated 10/17/23 documented a [AGE] year-old male admitted on [DATE]. Resident #3's documented diagnoses included: Alzheimer's Disease (a brain disease that slowly destroys memory and thinking), Essential Hypertension (elevated blood pressure), Muscle weakness, Difficulty walking. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 05 indicating Severe cognitive impairment. The MDS also revealed the resident required limited assistance in various areas of activities of daily living such as bed mobility, transfer, dressing, eating and toilet use. Record review of Resident #3's care plan dated 09/18/23 revealed Resident #3 was care planned for self-care deficit. Resident #3 had an intervention of Keep call light within reach and encourage to use it for assistance. Respond promptly to all requests for assistance. Observation of Resident #3 on 10/17/23 at 10:42 A.M. revealed Resident #3's call light was clipped together hanging on the wall in the middle of the room out of reach from the resident. In an Interview with Resident #3 on 10/17/23 at 10:42 A.M. Resident #3 stated he would just yell if he needed assistance from staff. Resident #4 Record review of Resident #4's admission record dated 10/17/23 documented an [AGE] year-old female admitted on [DATE]. Resident #4's documented diagnoses included: Type 2 Diabetes Miletus (elevated blood sugar), Dysphagia (difficulty swallowing), Paroxysmal atrial fibrillation (abnormal heartbeat), Major depressive disorder. Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 07 indicating severe cognitive impairment. The MDS also revealed the resident required extensive assistance in various areas of activities of daily living such as bed mobility, dressing, and personal hygiene. 675096 Page 2 of 3 675096 10/17/2023 Avir at Hillsboro 411 Old Brandon Rd Hillsboro, TX 76645

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #4's care plan dated 08/25/22 revealed Resident #4 was care planned for self-care deficit. Resident #4 had an intervention of Keep call light within reach and encourage to use it for assistance. Respond promptly to all requests for assistance. Observation of Resident #4's call light on 10/17/23 at 10:58 A.M. revealed the call light was wrapped over back of bed hanging down with red button between headboard and wall out of reach from Resident #4. In an Interview with Resident #4 on 10/17/23 at 10:58 A.M. Resident #4 stated she was not sure how to call for help she would start yelling until someone comes in the room. In an Interview with LVN #A on 10/17/23 at 11:10 A.M. LVN #A stated it was her expectation that all call lights should be in place within the residents reach. All staff are responsible for ensuring the call lights are within the residents reach. The risk to the resident of not having their call light within reach would be a fall if they are not able to get assistance when needed. In an Interview with LVN #B on 10/17/23 at 11:20 A.M. LVN #B stated It was the Expectation that all residents have their call light in reach even if the resident has dementia. Everyone should make sure all residents have their call light. In an Interview with CNA #C on 10/17/23 at 1:33 P.M. CNA #C stated Call lights should be in reach. Everyone is responsible for call lights being within the residents reach. CNA #C stated the risk to the residents for not having their call lights would be getting up by themselves and falling. In an Interview with CNA #D on 10/17/23 at 1:45 P.M. CNA #D stated call lights should be in residents reach; everyone is responsible for call lights being within residents reach. The risk to the residents for the call light not being in reach include falls and residents not being able to obtain help if needed. An interview with ADM on 10/17/23 at 3:24P.M. ADM stated that the purpose of the call light for the residents to ask for assistance. ADM stated that call lights should always be in reach of residents. ADM stated if a call light is not in reach, then a resident would not be able to call for assistance. The ADM states it is all staff's responsibility to ensure the call light is within reach. Record review of the facility's Policy Answering call Light dated October 2010 General guidelines #5 is written When resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 675096 Page 3 of 3