Health inspection·September 27, 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 resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 3 of 23 residents (Resident #73, Resident #25, and Resident #51) reviewed for resident rights; in that: Residents Affected - Some The facility failed to ensure Resident #73, Resident #25, and Resident #51 call lights were within reach. This failure could place residents at risk of needs not being met. Findings included: Resident #73 Record review of Resident #73's admission record, dated 09/27/23, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #73 had diagnoses which included: dementia (general decline in cognitive abilities), muscle wasting and atrophy (wasting [thinning] or loss of muscle), gross hematuria (visible blood in urine), need for assist with personal care, and acute myocardial infarction (heart attack). Record review of Resident #73's quarterly MDS assessment, dated 08/15/23, reflected Resident #73 had a BIMS score of 02, which indicated the resident was cognitively impaired. The resident required extensive assistance in various areas of activities of daily living such as bed mobility, transfer, toilet use. Resident #73 required limited assist for locomotion on unit, dressing, eating, and personal hygiene. Record review of Resident #73's care plan, initiated 05/24/23 and revised 07/07/23, reflected Resident #73 was care planned for has an ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance with a goal of [Resident #73] will demonstrate the appropriate use of adaptive device(s) to increase ability through the review date. and had an intervention of be sure [Resident #73's] Encourage the resident to use bell to call for assistance. In an observation on 09/25/23 at 1:30 PM, observed Resident #73's call light out of reach. Resident #73's call light was sitting on a recliner behind where Resident #73 was sitting in a wheelchair. Resident #73 attempted to stand and get the call light but was unable to reach call light. In an interview on 09/25/23 at 1:32 PM, Resident #73 stated he used a call light to call for help Page 1 of 3 675501 675501 09/27/2023 Legacy at Corsicana Rehabilitation and Healthcare 3300 W 2nd Ave Corsicana, TX 75110

F 0558 when he needed it. Resident #73 stated he could get up and get the call light if he needed to. Level of Harm - Minimal harm or potential for actual harm Resident #25 Residents Affected - Some Record review of Resident #25's admission record, dated 07/27/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #25 had diagnoses which included: type 2 diabetes mellitus (a chronic condition that affects the way the body processes the blood sugar), muscle wasting and atrophy (wasting [thinning] or loss of muscle), history of falling, need for assistance with personal care, and dysphagia (difficulty swallowing). Record review of Resident #25's quarterly MDS assessment, dated 09/07/23, reflected the resident had a BIMS score of 02, which indicated the resident was cognitively impaired. The resident required extensive assistance for dressing and supervision in various areas of activities of daily living such as bed mobility, transfer, locomotion on and off unit, eating, toilet use, and personal hygiene. Record review of Resident #25's care plan, initiated 02/21/20 and revised 09/24/23, reflected Resident #25 was care planned for at risk for falls r/t confusion, gait/balance problems, poor communication/comprehension, psychoactive drug use, unaware of safety needs, vision/hearing problems with a goal of [Resident #25] will be free of falls through the review date and had an intervention of be sure [Resident #25's] call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. In an observation on 09/26/23 at 11:59 AM, observed Resident #25's call light not in reach and on the floor beside his bed. In an interview on 09/26/23 at 12:01 PM, Resident #25 stated the staff come quick when needed. Resident #51 Record review of Resident #51's admission record, dated 09/26/23, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #51 had diagnoses which included: type 2 diabetes mellitus (a chronic condition that affects the way the body processes the blood sugar), dementia (general decline in cognitive abilities), muscle wasting and atrophy (wasting [thinning] or loss of muscle), need for assistance with personal care, cognitive communication deficit (difficulty thinking and using language) Record review of Resident #51's Annual MDS assessment, dated 07/21/23, reflected Resident # 51 required extensive assistance for dressing and supervision in various areas of activities of daily living such as bed mobility, transfer, locomotion on and off unit, eating, toilet use, and personal hygiene. Record review of Resident #51's care plan, initiated 02/21/20 and revised 09/24/23, reflected Resident #51 was care planned for at risk for falls r/t confusion, gait and balance problems, unaware of safety needs, wandering, Dementia with a goal of [Resident #51] will be free of falls through the review date and had an intervention of be sure [Resident #51's] call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. In an observation 9/25/23 1:41PM Resident #51 was lying in bed sleeping with call light on floor 675501 Page 2 of 3 675501 09/27/2023 Legacy at Corsicana Rehabilitation and Healthcare 3300 W 2nd Ave Corsicana, TX 75110

F 0558 rolled up next to head of the bed on the floor. Level of Harm - Minimal harm or potential for actual harm In an observation 09/26/23 10:22 AM Resident #51 observed resident lying in bed, call light remains rolled up next to the head of the bed on the floor Residents Affected - Some In an interview on 09/27/23 10:34 AM with Resident #51 she stated I do not know how to call for help if needed. Resident #51 appeared confused. In an Interview on 09/27/23 10:47 AM CNA B stated call lights needed to be within reach in case the resident's needed assistance. Everyone that works should have made sure the call light was within reach of the resident. Staff were educated to keep them within reach. Risk to the resident for not having call light in reach is the resident would not be able to get help if needed. In an interview on 09/27/23 10:38 AM LVN A stated call lights should be attached to beds and within reach for safety. Staff are educated on keeping the call lights within reach in the form of reminders and in-services from DON and ADON. The Certified Nurse's Aides were responsible for making sure the call lights are attached. The risk to the resident for not having access to their call light is the inability to obtain staff assistance when needed. In an interview on 09/27/23 11:41AM with DON stated all residents should have had access to a call light while in bed. All staff are responsible and should have placed call lights within reach of the residents . In an interview on 09/27/23 at 10:38 AM, the ADM stated the purpose of a residents call light was for residents to notify staff that they needed assistance. He stated if a residents call light was out of reach and the resident needed help, the time could be extended for staff to provide assistance to residents. He stated staff should have made sure residents call lights were in reach when they did their rounds because residents could knock it off the bed or something. He stated they did angel rounds every morning and they checked for the call lights being in reach. The ADM stated the staff has not been in-serviced since he had been there, and they had not had the need to in-service staff because there had been no issues with call lights. Record review of the facility's Answering the Call Light policy dated 10/2010 revealed General Guidelines bullet #5 When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 675501 Page 3 of 3