Health inspection·July 19, 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 interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 7 of 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for residents rights Residents Affected - Some The facility failed to ensure that staff were answering call lights in a prompt manner. This failure could place residents at risk of decreased feelings of self-worth. Findings include: Record review of Resident #1's electronic face sheet, dated 7/19/24 revealed he was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include iron deficiency anemia (is a common type of anemia. Anemia is a condition in which blood doesn't have enough healthy red blood cells to carry oxygen throughout the body), bipolar disorder (is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and post-traumatic stress disorder (A disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected he scored a 15 for her BIMS score which signified she was not cognitively impaired. During an interview on 7/19/24 at 2:35 AM Resident #1 stated that call lights are a big issue at the facility. She stated during the day call lights can take 30 minutes, but at night there are times where her call light is not even answered. She stated there was plenty of staff but the nurses and CNA's wont answer call lights at night. Record review of resident grievance/complaint investigation report dated 7/16/24 Resident #1 states that during all shifts, no one cares for her. She stated call lights go unanswered whenever she pushes call button. Record review of Resident #2's electronic face sheet, dated 7/19/24 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis following cerebral infraction (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he scored a 15 for Page 1 of 4 675910 675910 07/19/2024 Focused Care at Hogan Park 3203 Sage St Midland, TX 79705

F 0558 his BIMS score which signified he was not cognitively impaired. Level of Harm - Minimal harm or potential for actual harm During an interview on 7/19/24 at 1:25 pm Resident #2 stated call lights suck in this building. He stated that it was not great during the day but at night it is horrible. He stated that his average wait time at night on call lights is 45 plus minutes or they might not come at all. He stated the normal response by night staff was to come into the room, state they would be right back, turn off his call light and not return. Residents Affected - Some Record review of Resident #3's electronic face sheet, dated 7/19/24 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include function quadriplegia (s defined as the dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord), muscle weakness, and muscle spasm. Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected he scored a 11 for his BIMS score which signified he was moderately cognitively impaired. During an interview on 7/18/24 at 12:15 pm Resident #3 stated that due to his condition he did more help than other residents. He stated that staff are slow regarding call lights. He stated the biggest issue was the time it took staff to get to him. He stated that the staff could take 45 min or more to even come check on his call light, but then the staff would need to go get the mechanical lift, increasing his wait time. He stated for staff to get the Hoyer lift could be another 30 minuets to an hour. He stated at night, he would not get help unless his roommate went out into the hallway and made them come in and help him on a few occasions. Record review of Resident #4's electronic face sheet, dated 7/19/24 revealed he was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include hypothyroidism (deficiency of thyroid hormones can disrupt such things as heart rate, body temperature, and all aspects of metabolism), major depressive disorder, and hypotension (Low blood pressure, which can cause fainting or dizziness because the brain doesn't receive enough blood). Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected she scored a 15 for her BIMS score which signified she was not cognitively impaired. During an interview on 7/18/24 at 1:45 pm Resident #4 stated that she does not sleep in general. She stated walks the facility at night. She stated including last night 7/17/24 there has been multiple nights in which she will walk the facility and all staff will be sleeping. She stated they take their chairs and set them up in the hallway and go to sleep. She stated the nurses will sleep at the nurses' station. She stated that last night 7/17/24 when she went to walk around 3 am, there were 5 rooms with their call lights on, but all the staff were sleeping. Record review of Resident #5's electronic face sheet, dated 7/19/24 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include Dementia, lack of coordination, and ileus (is a bowel obstruction that occurs when the intestines stop moving normally, even though there is no blockage). Record review of Resident #5's quarterly MDS assessment dated [DATE] reflected he scored a 15 for his BIMS score which signified he was not cognitively impaired. During an interview on 7/19/24 Resident #5 stated that he does not use his call light anymore. He 675910 Page 2 of 4 675910 07/19/2024 Focused Care at Hogan Park 3203 Sage St Midland, TX 79705

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated its rarely he needs help because he has gotten better but he might as well do things on his own because he would have to be waiting for a long to get the help anyway. He stated at night it was bad. He stated there was plenty of staff in the building, but it was night staff that were just lazy. He stated his roommate Resident #4 can barely get their help when he used the call light. Record review of Resident #6's electronic face sheet, dated 7/19/24 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include age-related nuclear cataract, glaucoma, and pain in the right hip. Record review of Resident #6's quarterly MDS assessment dated [DATE] reflected he scored a 13 for was BIMS score which signified he was moderately cognitively impaired. During an interview on 7/18/24 at 2:35 pm Resident #6 stated he was the roommate to Resident #3. He stated that almost every night those nurses are outside sleeping. He stated that there was multiple time in which his roommate will use the call light because he needs to be changed and they do not come. He stated that his roommate Was always waiting to be changed for at least an hour. He stated he Was not sure why. He stated when he does say something to staff and request them to help him, he was told to mind his own business. He stated it's not a lack of staffing it's the fact that the staff are not helping the residents. He stated last night 7/17/24 he even came out around 3 am and saw the employees sleeping in the hallway with call lights on. During an interview on 7/19/24 at 11:25 AM AD stated that overall, the number one complaint during the resident council meeting was call lights at night. She stated that it was bad for the past 3 months where the residents were complaining consistently. She stated the residents state that it Was slow at night or sometimes not answered at all. She stated the night staff also had been seen sleeping. She stated the process with resident council minuets was to present the concerns from resident council to all staff in the morning meetings the next day after resident council. She stated once she presents the minutes to the all-staff meeting, she keeps the minutes, and it was on the staff to fix the issues brought to their attention. She stated regarding complaints about call lights, the nursing staff, DON, and ADON were informed of the issues. She stated it would be on the nursing staff to fix the issue. Record review of resident council minutes dated 4/29/24 revealed: Clinical Services Department concerns. 1. Decline call lights if residents need help, 2. CNA come from other side to gossip about residents. Record review of resident council minutes dated 5/11/24 revealed: Clinical Services Department concerns. 1. No one responds at night to call lights, only check in the AM before they leave, 2. A lot of sitting not helping by 3rd shift (night staff). Record review of resident council minutes dated 6/28/24 revealed: Clinical Services Department concerns. 1. Night staff get mad when asking for help on both sides, residents don't want to bother night staff. During an interview on 7/19/24 at 2:15 AM CNA A stated she has been working at the facility for close to a year. She stated she has never not answered a call light. She stated she rounds every two hours and makes sure all residents are dry and taken care of. She stated she has no idea where all the residents got the idea that she would ever sleep at the facility. She stated she has never gossiped about any resident in the facility and was there to do her job and take care of the residents. 675910 Page 3 of 4 675910 07/19/2024 Focused Care at Hogan Park 3203 Sage St Midland, TX 79705

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 7/19/24 at 2:25 AM CNA B stated she has never slept on the job. She stated she will set up and sit in a chair in the hallway to keep an eye down the hallway but never fell asleep. She stated she has been told about the concerns with night shift and call lights but has no idea where that Was coming from. She stated she does her rounds every 2 hours and makes sure the residents are clean and dry. During an interview on 7/19/24 at 12:15 pm ADON stated that the facility was aware of the resident council complaints and grievance log complaints in the building regarding staff not answering call lights. She stated we have moved one nurse from the day shift to the night shift to fix this issue. She stated she has also done surprise visits at night to see if staff were sleeping or not answering call lights at night. She stated but she has never witnessed any staff sleeping or not answering call lights at night. She stated the cameras do not work in the hallways or she would be checking the videos. During an interview on 7/19/24 at 12:45 pm DON stated that residents have raised concerns about call light times and being helped by staff. She stated the primary concern by residents was the night staff. She stated that the ADON has done surprise night visits and never personally seen any employees sleeping or not answering call lights. She stated that she believes her staff was doing their job and the call lights are getting answered. She stated she believed that if her staff was not doing their job then they would have much more skin break down and other wound issues. She stated she Was not sure where all the residents are getting their concerns from but believes her facility has no issues. Record review of facility Residents Rights policy dated December 2016 indicated: Policy statement, employees shall treat all residents with kindness, respect, and dignity. A. a dignified existence. B. be treated with respect, kindness, and dignity. C. be free from abuse, neglect, misappropriation of proper, and exploitation. 675910 Page 4 of 4