Health inspection·May 17, 2024

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents had the right to reasonable access to the use of a telephone, and a place in the facility where calls can be made without being overheard for 9 of 99 (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9) residents reviewed for Resident Rights. Residents Affected - Some Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9 stated they did not have access to a telephone to make private calls. This failure could place residents at risk of increased social isolation and decreased psychosocial well-being. Findings Included: Resident #1 In an interview on 5/17/24 at 8:49AM Resident #1 stated he had been at the facility about a year and when he arrived, he had a personal cell phone to use to communicate with friends and family outside of the facility. The cell phone would not hold a charge and he was without cellular communication, beginning in August of 2023. Resident #1 had spoken to the SW regarding his cell phone and was told that documents indicating his financial need to purchase a new cell phone had been submitted to an outside entity who provides provided cell phones for those in need, but the request had been denied. Since August of 2023, Resident #1 has been without a communication device to make a private call. He stated if he wanted to make a personal call, he had to go to the Nurse's Station or to one of the offices of facility staff. He stated there are always nurses at the Nurse's Station, so no call made from there was completely private. He stated that he could use the phone in a staff member's office between the hours of 8AM and 5PM, but after those hours, there was no way for him to place a private call outside of the facility. Record review of Resident #1's admission Record on 5/17/24 at 8:54AM revealed a [AGE] year-old male with a BIMS of 12, indicating moderate cognitive impairment, who was admitted to the facility on [DATE] with a diagnosis of, but not limited to Unspecified Symbolic Dysfunctions (social impairment); Cognitive Communication Deficit (trouble participating in conversations); Limitation of Activities Due to Disability; Depression, Unspecified; Other Specified Anxiety Disorders and Unspecified Sequelae of Cerebral Infarction (psychological distress and neuropsychiatric disturbance after a Stroke). An interview on 5/17/24 at 9:19AM with the Ombudsman revealed residents had complained to her about the lack of a portable phone in the facility, which they could use for personal communication. She Page 1 of 5 676010 676010 05/17/2024 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0576 Level of Harm - Minimal harm or potential for actual harm stated she had tried to call Resident #1 on 5/16/24 and had spoken with the receptionist, who transferred her to the phone at the Nurse's Station on Resident #1's hall. The phone at the Nurse's Station had rung for about 10 minutes and had not been answered. She instead drove to the facility to speak with Resident #1 face-to-face. Residents Affected - Some Resident #2 In an interview on 5/17/24 at 9:57AM Resident #2 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He would like to have a cell phone of his own but cannot afford one. Record Review of Resident #2's admission Record on 5/17/24 at 10:00AM revealed a [AGE] year-old male with a BIMS of 15, indicating he was cognitively intact, who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Dysphagia (difficulty swallowing); Cognitive Communication Deficit (trouble participating in conversations); Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety (a mental disorder in which a person loses the ability of think, remember, learn, make decisions, and solve problems); Personal History of Transient Ischemic Attack, and Cerebral Infarction without Residual Deficits (a short period of symptoms similar to those of a stroke). Resident #7 In an interview on 5/17/24 at 10:02AM Resident #7 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call, which was difficult due to her declining eyesight. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record Review of Resident #7's admission Record on 5/17/24 at 10:07AM revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS of 11, indicating moderate impairment and a diagnosis of, but not limited to Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure (a combination of the ventricles of the heart not producing enough pressure to push blood circulation and no relaxing enough to fill with blood), Presence of a Cardiac Pacemaker, and Legal Blindness as Defined in the United States of America. Resident #3 In an interview on 5/17/24 at 10:27AM Resident #3 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He stated he would like to have a cell phone of his own but cannot afford one. Record Review of Resident #3's admission Record on 5/17/24 at 10:30AM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS of 12, indicating moderate impairment and a diagnosis of, but not limited to Otitis Externa (inflammation, either infectious or non-infectious, of the external auditory canal); Limitation of Activities due to Disability; Other Specified 676010 Page 2 of 5 676010 05/17/2024 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0576 Level of Harm - Minimal harm or potential for actual harm Anxiety Disorders; Cognitive Communication Deficit (trouble participating in conversations); Unspecified Sequelae of Cerebral Infarction (psychological distress and neuropsychiatric disturbance after a Stroke) and Unspecified Symbolic Dysfunctions (social impairment). Resident #5 Residents Affected - Some In an interview on 5/17/24 at 1:08PM Resident #5 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He would like to have a cell phone of his own but cannot afford one. Record review of Resident #5's admission Record 0n 5/17/24 at 1:12PM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS of 15, indicating he was cognitively intact and a diagnosis of, but not limited to Other Voice and Resonance Disorders (hoarseness, strained, breathy or raspy voice quality); Hypovolemia (a state of low extracellular fluid volume, combined with sodium and water loss); Schizoaffective Disorder, Bipolar Type (episodes of mania and sometimes depression), and Cognitive Communication Deficit (trouble participating in conversations). Resident #6 In an interview on 5/17/24 at 1:13PM Resident #6 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record review of Resident #6's admission Record on 5/17/24 at 1:17PM revealed an [AGE] year-old female with a BIMS of 04, indicating severe impairment who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Major Depressive Disorder, Recurrent, Severe Without Psychotic Features (Persistently low or depressed mood); Cognitive Communication Deficit (trouble participating in conversations); Other Reduced Mobility (limitation of independent, personal movement); Other Abnormalities of Gait and Mobility (difficulty walking), and Anxiety Disorder, Unspecified (significant anxiety or phobias without the exact criteria for any other anxiety disorders). Resident #8 In an interview on 5/17/24 at 1:34PM Resident #8 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record review of Resident #8's admission Record on 5/17/24 at 1:39PM revealed an [AGE] year-old female with a BIMS of 15, indicating she was cognitively intact and a diagnosis of, but not limited to, Dysphagia (difficulty swallowing); Cognitive Communication Deficit (trouble participating in conversations); Anxiety Disorder, Unspecified (significant anxiety or phobias without the exact criteria for any other anxiety disorders); Other Reduced Mobility (may require the use of a cane, walker, or wheelchair to ambulate), and Major Depressive Disorder, recurrent, severe with Psychotic Symptoms 676010 Page 3 of 5 676010 05/17/2024 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0576 (persistently low or depressed mood with delusions, hallucinations, or both). Level of Harm - Minimal harm or potential for actual harm Resident #9 Residents Affected - Some In an interview on 5/17/24 at 2:47PM Resident #9 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record review of Resident #9's admission Record on 5/17/24 at 2:51PM revealed a [AGE] year-old female with a BIMS of 12, indicating moderate impairment who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Drug-Induced, Subacute Dyskinesia (sudden, uncontrollable movements of the face and body, caused by long-term use of anti-psychosis drugs); Acquired Stenosis of the External Ear Canal (stenosis caused by infections, inflammation, trauma and radiation therapy); Major Depressive Disorder (persistently low or depressed mood); Anxiety Disorder (response of fear and dread in certain situations), Localized Swelling, Mass and Lump (signs, symptoms and abnormal laboratory findings) and Acquired Absence of Right Breast and Nipple (the absence of one or more breasts, the cause of which is not present at birth). Resident #4 In an interview on 5/17/24 at 3:31PM Resident #4 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He would like to have a cell phone of his own but cannot afford one. Record review of Resident #4's admission Record on 5/17/24 at 3:36PM revealed a [AGE] year-old male with a BIMS of 15 (indicating cognitively intact) who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Acquired Absence of Left Leg (the absence of the left leg, the cause of which is not present at birth); Acquired Absence of Left Upper Limb Above Elbow (the absence of the left arm, above the elbow, which was not present at birth); Cognitive Communication Deficit (trouble participating in conversations), and Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy Without Gangrene (narrowing of the arteries which results in the undersupply of blood and oxygen to different organs). An interview on 5/17/24 at 9:08AM with the Social Worker revealed residents could use her office phone between the hours of 8AM and 5PM, to call outside of the facility, if they do not have a cell phone of their own. She stated if her office was closed, residents had to use the phone at the Nurse's Station. She stated she knew that the Nurse's Station was usually always occupied, so a phone call would not be completely private. An interview with LVN D on 5/17/24 at 1:19PM revealed residents came to the nurse's station to use the phone, but it was not a private place to have a conversation. An observation of Maintenance Supervisor E on 5/17/24 at 1:24PM revealed he received a cell phone call from Administrator C, asking him to purchase cordless phones for the facility, for resident use. When asked if a cordless phone was being bought for resident use, he stated he will be installing 2 676010 Page 4 of 5 676010 05/17/2024 Legacy Rehabilitation and Living 4033 W 51st Ave Amarillo, TX 79109

F 0576 Level of Harm - Minimal harm or potential for actual harm cordless phones in the facility, for resident use. Residents will be able to take the phone to their room or to the parlor for more privacy when making a personal phone call. An interview with Medication Aide F on 5/17/24 at 1:29PM revealed residents came to the nurse's station to use the phone, but it was not a private place to have a conversation. Residents Affected - Some An interview with the Administrator on 5/17/24 at 10:07AM revealed residents could use the receptionist's phone or the phone in a staff member's office if they wanted to make a personal call outside of the facility. He stated that after 5PM, residents would have to use the phone at the Nurse's Station, since there was no portable phone, which could be taken to a resident's room. He stated he was not aware of any problems with residents without personal cell phones, wanting to make a personal call. Record Review of the undated facility policy, Federal Residents Rights stated: Privacy and Confidentiality: You have the right to personal privacy and confidentiality, including accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Information and Communication: You have the right to: have reasonable access to the use of a telephone, including TTY (Tele-typewriters) and TDD (Tele-communication devices for the deaf) services, and a place in the facility where calls can be made without being overheard. 676010 Page 5 of 5