Health inspection·October 28, 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, record review and interviews the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of resident needs and preferences for 5 (Residents #1, #2, #3, #4, #5) of 30 residents observed for accommodation of needs. Residents Affected - Some The facility failed to ensure Residents #1, #2, #3, #4, and #5 had call lights within reach. This failure could place the residents at risk of not being able to request assistance when needed. Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old male who had been admitted to the facility on [DATE] with diagnoses that included muscle wasting, depression and anxiety. Review of Resident #1's annual MDS, dated [DATE], revealed a BIMS score of 4, indicating severe cognitive impairment. His Functional Status revealed he required limited assistance with his ADLs. Review of Resident #1's care plan, dated 08/30/23, revealed he had an ADL deficit related to impaired cognition. Review of Resident #2's undated admission Record revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, depression, anxiety, and cognitive communication deficit. Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 1, indicating severe cognitive impairment. Her Functional Status revealed she required limited assistance with her ADLs. Review of Resident #2's care plan, dated 09/13/23, revealed she was dependent on staff for activities and interactions. Review of Resident #3's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included muscle wasting, bipolar disorder, and contractures. Review of Resident #3's yearly MDS, dated [DATE], revealed a BIMS score not calculated. Her Functional Status indicated she required extensive assistance with her ADLs. Page 1 of 2 675817 675817 10/28/2023 FT Worth Southwest Nursing Center 5300 Alta Mesa Blvd Fort Worth, TX 76133

F 0558 Level of Harm - Minimal harm or potential for actual harm Review of Resident #3's care plan, dated 08/23/23, revealed she was dependent on staff for activities and social interactions. She has communication problems related to dementia. Review of Resident #4's undated admission Record revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Stroke, Parkinson's and muscle weakness. Residents Affected - Some Review of Resident #4's quarterly MDS, dated [DATE], revealed a BIMS score not calculated, His Functional Status indicated he required limited assistance with his ADLs. Review of Resident #4's care plan, dated 09/13/23, revealed he had behavioral problems but he enjoyed playing games and socialization. Review of Resident #5's undated admission Record revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included muscle wasting, Parkinson's, dementia, and stroke. Review of Resident #5's yearly MDS, dated [DATE] revealed a BIMS score of 1 indicating severe cognitive impairment. His Functional Status indicated he required limited assistance wit his ADLs. Review of Resident #5's care plan, dated 10/04/23, revealed he had sexually inappropriate behaviors, likes large social groups, and smoking. Interview and observation on 10/28/23 at 8:20 AM Resident #1 stated his call light was not where he could find it. Resident #1 stated that when staff get tired of answering the call light they would take it away and put it where it could not be reached. Resident #1's call light was curled up in his bedside drawer. Observations on 10/28/23 from 8:20 AM - 9:00 AM of the 30 residents on 300 Hall revealed a total of five residents (Residents #1, #2, #3, #4, #5) with call lights out of reach. Call lights were located on the floor at the foot of the bed, between the bed and the wall, behind dressers, and at the foot of the bed. Interview on 10/28/23 at 10:15 AM, the DON stated call lights were required to be placed easy reach of the resident, even if the resident was believed incapable of using the call light. The DON stated family and other staff needed to be able to easily call for help if they were in the room. Review of the facility's Communication-Call System policy, revised October 2022, reflected: .I. The Facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities. II. If a resident is physically incapable of actuating a call system, the resident shall be physically housed in a resident room close enough to the nursing station to allow for line-of-sight supervision at a frequency identified by a thorough individualized nursing assessment 675817 Page 2 of 2