Health inspection·December 2, 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 observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #01) of four residents reviewed for reasonable accommodations. Residents Affected - Some The facility failed to provide a different mattress to help alleviate Resident#1 pain due to his diagnoses and physical condition. Resident #01 was admitted to the facility on [DATE] and was provided with a low air loss mattress. Resident transferred to Long-term care on 11/13/24 and transferred rooms on 11/22/24 and he was provided with a pressure relieving mattress instead. This failure could place residents at risk of not being able to have their needs met. Findings included: Record review of Resident#1 admission MDS assessment, dated 09/17/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included: malignant neoplasm of unspecified part of unspecified bronchus or lung (a type of lung cancer); adjustment disorder (a mental health conditions that occurs when someone has an extreme reaction to a stressful event or change in their life), other Malaise (general feeling of discomfort, weakness, illness, or lack of well-being), antineoplastic chemotherapy induced pancytopenia (A condition that occurs when blood- forming stem cells in the bone marrow are affected by chemotherapy), Neoplasm related pain (acute chronic)(pain caused by cancer), unspecified chord compression, Hypo-osmolality and Hyponatremia (low levels of electrolytes in the blood), depression unspecified, paraplegia (a chronic condition that involves the loss of movement and sensation in the lower body) unspecified other chronic pain and other long term (current) drug therapy. Record review of Resident#1 quarterly MDS assessment dated [DATE] reflected Resident# 01 determination of pressure ulcer/injury risk by clinical assessment. Resident#1 was at risk of developing pressure ulcers/injuries. For ulcer/injury treatment a pressure reducing device for bed to be used. his BIMS was 15 out of 15, which revealed he was cognitively intact. Record review of hospital records dated, 08/03/24 reflected Resident#1 was admitted to the hospital on [DATE] for thoracic spinal cord injury and lung cancer. Past medical history reflected: small cell carcinoma (port inn place), spinal cord compression with paraparesis (status T4-T5 and T10-T11 laminectomy on 06/04/24), mediastinal mass, stage 3 coccyx pressure injury. Record review of hospital Assessment and plan dated, 09/04/24: Diagnoses: Stage 3 pressure injury coccyx section reflected on 08/05/24: Patient seen and examined. Undetermined onset. Given the depth, Page 1 of 3 676315 676315 12/02/2024 The Hillcrest of North Dallas 18648 Hillcrest Rd Dallas, TX 75252

F 0558 we will begin to pack with hydrophore blue. Patient advised to reposition often if in bed to reduce the pressure at the wound. Will also benefit from a low air loss mattress. Level of Harm - Minimal harm or potential for actual harm 1. Residents Affected - Some Stage 3 pressure injury coccyx, - offloading: LAL mattress ordered, nursing staff to turn q2h Record review of Resident#1 care plan dated 11/05/24 reflected, focus: ulcer or potential for pressure ulcer. development r/t Disease process, paraplegia and lung cancer. Goal: skin, free of redness, blisters, or discoloration by/through review date. Interventions: Notify nurse immediately of any new areas of skin break down . Record review of weekly wound assessment dated [DATE] reflected, Resident#1 Stage 2 pressure wound sacrum Record review of weekly wound assessment dated [DATE] reflected, Resident#1 Stage 2 pressure wound sacrum (Resolved on 09/17/24) Record review of bed census from 09/05/24 to 11/22/24 reflected, Resident#1 transferred to long term care on 11/13/24 and transferred rooms again on 11/22/24. Record review of progress notes from 11/02/24 to 12/02/24 reflected, no documentation of Resident# 1's mattress change from LAL to a pressure relieving mattress. Record review of orders on 12/02/24 reflected, no orders for a LAL mattress. Interview on 12/02/24 at 3:30 PM Resident#1 stated he has not been able to sleep because his back hurts and he was not comfortable on the mattress he had now. Resident#1 stated he was moved to Long Term Care and was not able to stay in the room with his roommate and asked to be transferred to a different room. Resident#1 stated when he was moved, he was given a different mattress. Resident#1 stated he had multiple surgery on his back and had cancer. Resident#1 stated he used to have a wound on his bottom, but it was healed. Resident#1 stated he told the DON, ADON B and previous Administrator and new Administrator that he needed his old mattress back. Interview and observation on 12/02/14 at 4:00 PM the ADON A stated she was not familiar with Resident#1. ADON A stated ADON B worked the upstairs halls and was out on vacation. Observation of the mattress revealed Resident#1 mattress was a pressure relieving mattress and firm to the touch. Interview on 12/02/24 at 4:25 PM the DON stated all the residents were at risk for getting pressure sores and that interventions were on the resident's care plans. DON stated the mattress changed should have been documented on Resident#1 progress notes. DON stated the resident had a pressure relieving mattress and did not met criteria for the LAL mattress. Interview on 12/02/24 at 5:00 PM the Administrator stated he has been in the facility for two weeks. The Administrator stated Resident#1 was admitted with a pressure wound on the bottom and it had healed by the beginning to mid-September. Administrator stated Resident#1 had a LAL mattress since he was admitted to the facility. Administrator stated in mid-November, he was transferred to a pressure relieving mattress because another resident needed the mattress. Administrator stated Resident#1 did not meet the facility criteria for a LAL mattress. The Administrator stated he talked with 676315 Page 2 of 3 676315 12/02/2024 The Hillcrest of North Dallas 18648 Hillcrest Rd Dallas, TX 75252

F 0558 Resident#1 and a spare LAL mattress was switched out with the resident's pressure relieving mattress. Level of Harm - Minimal harm or potential for actual harm On 12/02/24 at 6:oo PM, attempted to call ADON B and phone went straight to voicemail. Residents Affected - Some Record review of policy undated, titled: Support Surface Guidelines reflected, The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown . II. The Facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development . (b) Low?air?loss mattresses are giant air?permeable pillows that are continuously inflated with air; the air flow has a drying effect on tissues. (i) Indicated for residents with stage I pressure ulcers who develop hyperemia on static surfaces and for residents with stage III or IV pressure ulcers. Record review of policy revised 08/2020, titled: Resident Rights .B. Gather information about the resident's personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record; . 676315 Page 3 of 3