**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 5 residents (Residents #1 and Resident #2) reviewed for quality of care. The facility failed to ensure that residents receive treatment and care in accordance with the comprehensive person-centered care plan, and the residents' choices when needing help due to call light malfunction. An Immediate Jeopardy (IJ) was identified on 06/16/23. While the IJ was removed on 06/16/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This failure could place the residents at risk of injury and not being able to obtain assistance or care as needed. Findings include: Record review of Resident #1's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: epilepsy (a disorder of the brain characterized by repeated seizures), transient cerebral ischemic attack (a stroke that lasts only a few minutes), lack of coordination, systemic lupus erythematosus (autoimmune disease in which the immune system attacks its own tissues), muscle weakness, schizophrenia, diabetes mellitus, hemiplegia (a one-sided muscle paralysis or weakness), hypertension (high blood pressure), multiple sclerosis (a potentially disabling disease of the brain and spinal cord), and difficulty walking. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 had seizure disorder or epilepsy and required one person assistance for the following ADLs: transferring, locomotion on/off unit, dressing, toilet use, and personal hygiene. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and frequently incontinent of bowel and needed assistance for toileting hygiene. Record review of Resident #1's care plan, last revised on 04/03/23, revealed Resident #1 was at risk for falling due to weakness, and diagnosis of multiple sclerosis, stroke, and lupus. The interventions included Assist resident with all transfers and encourage resident to call for assistance and not to attempt to transfer self.; Keep call light in reach at all times.; and Provide toileting assistance as needed. The care plan revealed Resident #1 had seizures due to diagnosis of epilepsy. The interventions included Monitor resident for impending seizure symptoms and respond quickly when noted; Changes in consciousness, fixed staring, jerking of arms and legs; Monitor seizure drug level lab boluses as ordered by MD; and Protect resident from injury during a seizure. Use pillows to pad body if in bed, safely lower to the ground to prevent falls if upright, use tongue blade to protect tongue biting. Further review revealed, Resident #1 required ADL assistance with toileting and intervention included one person was to assist. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 05/01/23 at 7:08 PM which reflected This nurse was called to resident restroom thinking she might be having a stroke, assessed resident noted facial and mouth drooping to left. Resident A&O (alert & oriented), V/s (vitals) obtain b/p (blood pressure) 113/74, p (pulse)76, r (respiration)19, t (temperature) 97.0. Assisted resident back to bed, and notified [physician], order received to transfer to ER (emergency room). 911 was called to the facility and resident was send to [hospital] for further [NAME] (evaluation);/TX (treatment). RP (representative) notified [RP] unable to reach as this time. LVM (leave voicemail). Record review of Resident #1's hospital records, dated 05/01/23, revealed Per EMS, they state they were called by nursing home staff for a stroke the pt (patient) began experiencing approximately 40 minutes pta (Patient Transport Ambulance). On EMS arrival, they noted the pt was experiencing a questionable, focal seizure localized to the facial region with L-sided (left) gaze deviation. The record revealed labs were conducted and diagnosis revealed Resident #1 was ruled out for a stroke. The record revealed resident was discharged and diagnosis included recurrent seizure. In an interview on 05/31/23 at 12:14 PM, Resident #1 stated the call light in her room was fixed yesterday (05/30/23) but prior to yesterday, the call light was not working for about 2-3 weeks. She stated the facility had provided a bell, but staff were not responding when she pressed the bell, and they would tell her they could not hear it ringing. Resident #1 stated she had to use her cell phone to call to the nurse's station to get help. She stated sometimes they would not answer the phones. Resident #1 stated on 05/01/23 she was in the bathroom and thought she was having a stroke. Resident #1 stated she had a stroke before and she also had epilepsy, so she was accustomed to reoccurring seizures. Resident #1 stated on 05/01/23 it felt more like a stroke because she could not feel the left side of her face and body, which did not normally happen when she had seizures. Resident #1 stated she was in the bathroom yelling for help and no one came until 30-45 minutes. She stated the call light in the bathroom was not working and the facility had not provided accommodations for emergencies in the bathroom. Resident #1 stated once the nurse arrived, they assessed her, and she was sent to the hospital. She stated at the hospital it was determined she did not have a stroke and it was a seizure. She stated she did not have any injuries from the incident. Resident #1 stated she had spoken to the DON about her concerns with the call light not working, especially in the bathroom. She stated the DON advised her that staff were supposed to be doing rounds every 15 minutes, but she stated that was not being done because she had been in the bathroom for almost 45 minutes. Record review of Resident #2's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included the following: paraplegia (the inability to voluntarily move the lower parts of the body), heart disease, muscle weakness, lack of coordination and muscle wasting atrophy (the decrease in size and wasting of muscle tissue). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #2's cognition was intact. In an interview on 05/31/23 at 12:35 PM, Resident #2 stated she heard Resident #1 in the bathroom screaming. She said it sounded like she was saying help, but her voice did not sound normal. Resident #2 stated she knew something was wrong. She stated the call lights were not working and they gave her a bell, but it was not in reach. Resident #2 stated it did not matter about the bell anyway, because staff never heard them. Resident #2 stated she used her cell phone to call to the nurse's station. She stated when they answered (she does not know who) she told them something was wrong with Resident #1, and she needed help in the bathroom. Resident #2 stated they told her they would come help. She stated about 30 minutes had passed and no one came to help, so she attempted to call the nurse's station again, but no one answered. Resident #2 stated as time was passing Resident #1's speech was becoming clearer, and she heard her screaming she was having a stroke. Resident #2 stated she was a paraplegic, so she could not get out of bed to find help. Resident #2 stated she called the nurse's station a third time. She stated someone answered the phone (does not know who) and she told them she believed Resident #1 was having a stroke. She said a nurse (does not know name) came about 5 minutes after the third call. Resident #2 stated she believed Resident #1 was in the bathroom for about 45 minutes before the nurse came to the room. In an interview on 05/31/23 at 1:27 PM, the facility's Maintenance Director (MD) stated he started at the facility about 2 weeks ago and there was already an issue with the call light system. He stated there was a bad storm, and the lightning struck the building, which caused the call light system to malfunction. He stated from his understanding a tech company came out and had ordered the equipment to fix the system. He stated he was not sure exactly what date because this was done prior to him working at the facility. He stated the equipment took several weeks to come in and the company returned he believed on 05/19/23 and they replaced the malfunctioned equipment. He stated the system went out again and the company came back out and then realized there was an issue with the call light system at the nurse's station, so they had to order more equipment to fix that. He stated the company returned yesterday (05/30/23) with equipment for the nurse's station and everything was working. He stated later yesterday evening, they found out that some of the call lights were still not working. The MD stated the tech company was currently in the building and they were conducting an audit on which rooms were not working. He stated its difficult to account for which rooms are working because one minute they are working and the next they are not. In an interview on 05/31/23 at 2:15 PM, the Administrator stated the call light system first went out on 04/06/23. She stated the MD at that time was trying to fix the system and realized he was unable to, so they called a tech company to come help. She stated the tech company came on 04/11/23 and discovered equipment was burned due to the lightening and they had to order new equipment. The Administrator stated equipment did not come in until 05/16/23. She stated they provided bells to the residents and staff were doing round every 15 minutes. She stated there were no bells provided for the bathroom and that is why staff were doing rounds every 15 minutes. She stated the tech company replaced the equipment and call lights were working. She stated on 05/24/23 it was discovered the call light were no longer working and they called the tech company back out. The Administrator stated the facility went back to using bells and doing rounds every 15 minutes. She stated the tech company explained the equipment at the nurse's station was burned out and had to be replaced. She stated they ordered more parts, and they returned yesterday (05/30/23) to install the new equipment. The Administrator stated yesterday the call lights were working after the tech left, and then later in the evening they learned they were out again in some rooms. She stated the tech was currently in the building working on the call lights. She stated she was aware of the incident with Resident #1 on 05/01/23. The Administrator stated staff were expected to complete rounds every 15 minutes, so staff were in-serviced on making sure they are doing rounds every 15 minutes, after this incident occurred. In an interview on 06/01/23 at 9:30 AM, LVN B stated on 05/01/23 she was at the nurse's station charting and Resident #2 called and stated Resident #1 was in the bathroom, and she believed she was having a stroke. LVN B stated she immediately went to the room. She stated she assessed the resident for injuries and took her vitals. She stated there were no injuries and her vitals were stable, but Resident #1's face was droopy she believed on the left side. She stated she notified the DON, family, and doctor. LVN B stated she received orders from the doctor to send Resident #1 to hospital, so she called 911. LVN B stated she only spoke to Resident #2 twice and she immediately went to the resident's room. She stated the call lights system were not working and residents were provided bells to notify for help. LVN B stated CNAs were doing rounds every 15 minutes. She stated she did not know how long Resident #1 was in the bathroom nor the last time a CNA had checked on her. An observation and interview on 05/31/23 at 2:43 PM revealed as the Investigator approached Resident #1's room, Resident #1 was screaming from the bathroom I need help. MA A was observed standing behind the medication cart in front of the room next to Resident # 1's room. Resident #2 was observed lying in bed. Resident #2 stated she had been in the bathroom screaming for help for about 30 minutes. Resident #2 stated the call light was working earlier this morning, but she believed it had gone out again. Resident #1 was asked, while she was in the bathroom, if she pressed the call light and she stated yes but she believed it was not working again. The Investigator went into the hall and advised MA A that Resident #1 was in the bathroom screaming for help. MA A stated she would get a CNA to help. MA A was observed to continue to stand at the medication cart. The investigator went on the adjacent halls to look for help but was unable to find anyone to come help. When the Investigator returned to Resident #1's hall, MA A was observed to be standing in the same spot. When the Investigator asked Resident #2 was anyone in the bathroom with Resident #1, she stated no, and staff had still not come to help. In an interview on 05/31/23 at 3:16 PM, Resident #1 stated she made a bowel movement and needed help wiping herself. She stated she was sometimes incontinent with her bowels and had accidents, but she made it to the toilet this time. Resident #1 stated she was unable to reach her bottom to clean herself after a bowel movement due to some of her medical conditions. She stated she pressed the call light for help, but she believed it stopped working. She stated the facility had fixed it yesterday (05/30/23) and it worked earlier in the morning but must have stopped. She stated she was screaming for help for about 30-40 minutes. In a record review and interview on 06/01/23 at 12:24, the DON, she stated was aware of the incident on 05/01/23 with Resident #1. She stated since the call lights were out, the residents were given bells to call for help and the staff were doing rounds every 15 minutes. She stated Resident #1 and Resident #2 did tell her that Resident #1 was in the bathroom for about 30 minutes and staff had not come in to help. The DON stated she did speak to the nurse, who answered the first phone call made by Resident #2, but she couldn't recall which nurse it was, but the nurse told her she was in the middle of working with another resident and was checking their chart, when Resident #2 called. The DON stated the nurse advised her that when Resident #2 called she said Resident #1 needed help in the bathroom. She stated the nurse said she did not tell her it was emergency and she assumed she needed help with toileting. The DON stated nurse told her there was no one in the halls to ask them to check on Resident #1, so she went to finish up with her current situation and then was going to check on Resident #1. She stated when Resident #2 called the second time and spoke to LVN B and said Resident #1 was having a stroke in the bathroom, LVN B went to the room right away. The DON stated if staff would have been completing rounds every 15 minutes on 05/01/23 this would not have happened. She stated she in-serviced all direct care staff that had to do 15-minute rounds the following day. The DON stated she was made aware of the incident with Resident #1 not receiving help with toileting. She stated her expectations was for all CMAs, CNAs, and nurses to help with toileting and incontinence care. The DON stated she also in-serviced staff to continue with doing rounds every 15 minutes due to issues with call lights. She stated incontinence care was not a job only for CNAs. She stated she answered call lights to provide incontinence care and had wiped resident's bottoms, so her expectation was for all other staff to do the same. The DON provided an in-service titled Incontinence Care dated 05/31/23 and stated she started in-servicing yesterday (05/31/23) by going to each direct care staff personally and explaining her expectations regarding incontinence care. She stated she was still meeting individually with staff who did not work yesterday. In an interview on 06/16/23 at 12:28 PM, CNA C stated she was covering Resident #1's hall the day she was sent out to the hospital. She stated did not know exactly what happened to Resident #1, but what she recalled was her coming out of another resident's room and saw the paramedics taking Resident #1 out on a stretcher. CNA C stated she was giving showers to the residents during the time of the incident. She stated the call light system was not working so residents were given bells and they were doing 15-minute rounds. CNA C stated showers took longer than 15 minutes, so she let the nurse know when she was giving showers, so they could do the rounds. She stated even though showers take longer than 15 minutes, she would still complete rounds. CNA C stated once she is done with a resident's shower, she would do a round and then get started on the next shower. In an interview on 06/16/23 at 11:18 PM, the DON stated Resident #1 was alert and oriented, so she advised her to take her phone with her to the bathroom and provided her personal cell phone number to call if she needed help and was unable to get anyone. She stated the 15-minute rounds meant the CNAs were going up and down the hall listening for bells or anyone calling for help. She stated it did not mean they were going to each resident rooms because they were not able to complete that. She stated staff who were assigned to the hall could have been helping a resident, which could take over 15 minutes. The DON stated the expectation was once staff were finished with the resident if it took over 15 minutes, they should do rounds before moving on to the next task. The DON stated their corporate approved 1 additional staff per shift to help with the rounds. She stated the corporate would not approve any additional people, due to budget constraints. The DON stated staff were documenting the rounds and she was responsible for monitoring. She stated she checked the sheets three times per week. A record review of the facility document titled Q 15- Minute Checks- 600 (hall) PM Shift, dated 05/01/23, revealed from the timeframes of 6:00 PM to 4:45 AM, 15-minute checks were completed and checked off. The document did not have a staff signature on it, just a check mark. A record review of the facility's policy titled Statement of Resident Rights, undated, revealed You, the resident, do not give up any rights when you enter a nursing facility. The Facility must encourage and assist you to fully exercise your rights . You have a right to: 1. All care necessary for you to have the highest possible level of health; 2. Safe, decent, and clean conditions; 4. Be treated with courtesy, consideration, and respect . A record review of the facility policy titled Emergency Disaster and Life Safety Policies and Procedures, dated 02/01/20, revealed 4. Nursing personnel: D. Will establish and maintain a medical communication system to all areas not equipped with patent/resident call lights. This may include but is not limited to: 1. Use of bells or other devices 2. Runners to convey information 3. Periodic or routine rounds . This failure resulted in an identification of an Immediate Jeopardy on 06/16/2023 at 4:45 PM. The Administrator was informed and provided the IJ template on 06/16/2023 at 4:49 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: F558 - Reasonable accommodations of needs/preferences Resident identified with no negative outcomes Call light system failure identified on 4/6/23. Diversify notified immediately for request a quote for repair of the call light system Repair quote for call light system repair from Diversify received on 4/11/23 Diversify returned on 5/24/23 after receiving the needed part for repair of the call light system. Once there, Diversify identified a more complex issue and were required to involve additional technicians and additional electrical repair 6/2/23 Diversify returned to continue repairs 6/9/23 Diversify returned and were able to partially repair the call light system 6/12/23 Diversify returned and completely repaired the call light system Residents who reside in the facility have the potential to be affected by this alleged deficient practice. In the event of call light system failure 15-minute checks will be initiated to monitor residents for needs and will continue until the call light system has been repaired. A monitoring tool will be used to document the 15-minute checks and will be used until call light system is repaired In the event the call light system fails affected residents will be provided bells. In the event of call light system failure, a resident council meeting will be held to inform residents of plan for alerting staff for assistance and the plan for the repair of the call light system In the event of call light system failure, the administrator will contact companies to obtain quotes for repairs of the call light system Facility employees will be educated on the plan that was initiated: Immediate notification to administrator of call light failure residents will have handheld call bells to alert the nursing staff for assistance in the event of call light failure An assignment will be made by the administrator and/or Director of Nursing for 15-minute checks on residents to monitor for residents needs in the event of call light failure Any employee not receiving this education by 6/16/23 will receive before their next scheduled shift. This will include any agency personnel and new hire orientation. Maintenance Director will perform weekly preventive maintenance to validate the call light system is functioning properly for 4 weeks, then monthly. Regional Maintenance Director will validate monthly preventive maintenance completed. Director of Nursing and Administrator will make rounds throughout the day to validate that the call light system is functioning properly, and resident needs are being met. In the event of call light system failure, Clinical Consultant will validate 15-minute checks completed weekly. Any concerns will be addressed at time of discovery. The medical director was informed of the Immediate Jeopardy and the contents of this plan on 6/16/23. An ad hoc Quality Assurance Performance Improvement meeting will be held on 6/16/23. The Plan of Removal was accepted on 06/16/23 at 6:12 PM. Monitoring of the plan of removal included: Observations and interviews were conducted on 06/16/23 from 1:45 PM to 3:05 PM on various rooms and revealed Rooms 401, 405, 406, 408, 413, 418, 419, 503, 506, 510, 511, 517, 518, 521, 522, 603, 604, and 608 call lights were working. Interviews with the residents of these rooms revealed the call lights had been working for approximately one week and staff were responding. Interviews with the 2 RNs, 1 LVN, 2 CMAs, 5 CNAs, who worked multiple shifts, revealed the call lights had been working for approximately one week and they knew the protocols should the call lights go out, which included residents would be provided bells and they were required to complete 15-minutes rounds. A record review on 06/16/23 of a memo from the tech company who fixed the call light system, dated 06/16/23, reflected the following To Whom It May Concern: As of June 12, 2023, our technicians have completed work to make sure that all devices on 400, 500, and 600 halls are operating for nurse call emergency calls for the rooms. By Friday, June 9 we were able to have most of the rooms up with the exceptions of a few devices needed to be ordered. In an observation and interview on 06/16/23 at 6:17 PM, the DON was observed providing in-services on expectations (report to DON/Administrator, bells, 15-minute checks) should call light system go out to 3 nurses and 4 CNAs. The DON stated she would continue to in-service the night and weekend staff. She stated all staff would be required to complete in-service, prior to starting their shift. The DON stated she would be responsible for doing rounds to ensure the call light system was working and were being answered. The Administrator were informed the Immediate Jeopardy was removed on 06/16/23 at 6:20 PM. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to be adequately equipped to allow resident to call for assistance for 2 of 5 residents (Residents #1 and Resident #2) reviewed for accommodation of needs. The facility failed to be adequately equipped to allow residents to call for staff assistance when needing help due to call light malfunction. An Immediate Jeopardy (IJ) was identified on 06/16/23. While the IJ was removed on 06/16/23, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This failure could place the residents at risk of injury and not being able to obtain assistance or care as needed. Findings include: Record review of Resident #1's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: epilepsy (a disorder of the brain characterized by repeated seizures), transient cerebral ischemic attack (a stroke that lasts only a few minutes), lack of coordination, systemic lupus erythematosus (autoimmune disease in which the immune system attacks its own tissues), muscle weakness, schizophrenia, diabetes mellitus, hemiplegia (a one-sided muscle paralysis or weakness), hypertension (high blood pressure), multiple sclerosis (a potentially disabling disease of the brain and spinal cord), and difficulty walking. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 had seizure disorder or epilepsy and required one person assistance for the following ADLs: transferring, locomotion on/off unit, dressing, toilet use, and personal hygiene. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and frequently incontinent of bowel and needed assistance for toileting hygiene. Record review of Resident #1's care plan, last revised on 04/03/23, revealed Resident #1 was at risk for falling due to weakness, and diagnosis of multiple sclerosis, stroke, and lupus. The interventions included Assist resident with all transfers and encourage resident to call for assistance and not to attempt to transfer self.; Keep call light in reach at all times.; and Provide toileting assistance as needed. The care plan revealed Resident #1 had seizures due to diagnosis of epilepsy. The interventions included Monitor resident for impending seizure symptoms and respond quickly when noted; Changes in consciousness, fixed staring, jerking of arms and legs; Monitor seizure drug level lab boluses as ordered by MD; and Protect resident from injury during a seizure. Use pillows to pad body if in bed, safely lower to the ground to prevent falls if upright, use tongue blade to protect tongue biting. Further review revealed, Resident #1 required ADL assistance with toileting and intervention included one person was to assist. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 05/01/23 at 7:08 PM which reflected This nurse was called to resident restroom thinking she might be having a stroke, assessed resident noted facial and mouth drooping to left. Resident A&O (alert & oriented), V/s (vitals) obtain b/p (blood pressure) 113/74, p (pulse)76, r (respiration)19, t (temperature) 97.0. Assisted resident back to bed, and notified [physician], order received to transfer to ER (emergency room). 911 was called to the facility and resident was send to [hospital] for further [NAME] (evaluation);/TX (treatment). RP (representative) notified [RP] unable to reach as this time. LVM (leave voicemail). Record review of Resident #1's hospital records, dated 05/01/23, revealed Per EMS, they state they were called by nursing home staff for a stroke the pt (patient) began experiencing approximately 40 minutes pta (Patient Transport Ambulance). On EMS arrival, they noted the pt was experiencing a questionable, focal seizure localized to the facial region with L-sided (left) gaze deviation. The record revealed labs were conducted and diagnosis revealed Resident #1 was ruled out for a stroke. The record revealed resident was discharged and diagnosis included recurrent seizure. In an interview on 05/31/23 at 12:14 PM, Resident #1 stated the call light in her room was fixed yesterday (05/30/23) but prior to yesterday, the call light was not working for about 2-3 weeks. She stated the facility had provided a bell, but staff were not responding when she pressed the bell, and they would tell her they could not hear it ringing. Resident #1 stated she had to use her cell phone to call to the nurse's station to get help. She stated sometimes they would not answer the phones. Resident #1 stated on 05/01/23 she was in the bathroom and thought she was having a stroke. Resident #1 stated she had a stroke before and she also had epilepsy, so she was accustomed to reoccurring seizures. Resident #1 stated on 05/01/23 it felt more like a stroke because she could not feel the left side of her face and body, which did not normally happen when she had seizures. Resident #1 stated she was in the bathroom yelling for help and no one came until 30-45 minutes. She stated the call light in the bathroom was not working and the facility had not provided accommodations for emergencies in the bathroom. Resident #1 stated once the nurse arrived, they assessed her, and she was sent to the hospital. She stated at the hospital it was determined she did not have a stroke and it was a seizure. She stated she did not have any injuries from the incident. Resident #1 stated she had spoken to the DON about her concerns with the call light not working, especially in the bathroom. She stated the DON advised her that staff were supposed to be doing rounds every 15 minutes, but she stated that was not being done because she had been in the bathroom for almost 45 minutes. Record review of Resident #2's electronic Face Sheet, dated 05/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses which included the following: paraplegia (the inability to voluntarily move the lower parts of the body), heart disease, muscle weakness, lack of coordination and muscle wasting atrophy (the decrease in size and wasting of muscle tissue). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #2's cognition was intact. In an interview on 05/31/23 at 12:35 PM, Resident #2 stated she heard Resident #1 in the bathroom screaming. She said it sounded like she was saying help, but her voice did not sound normal. Resident #2 stated she knew something was wrong. She stated the call lights were not working and they gave her a bell, but it was not in reach. Resident #2 stated it did not matter about the bell anyway, because staff never heard them. Resident #2 stated she used her cell phone to call to the nurse's station. She stated when they answered (she does not know who) she told them something was wrong with Resident #1, and she needed help in the bathroom. Resident #2 stated they told her they would come help. She stated about 30 minutes had passed and no one came to help, so she attempted to call the nurse's station again, but no one answered. Resident #2 stated as time was passing Resident #1's speech was becoming clearer, and she heard her screaming she was having a stroke. Resident #2 stated she was a paraplegic, so she could not get out of bed to find help. Resident #2 stated she called the nurse's station a third time. She stated someone answered the phone (does not know who) and she told them she believed Resident #1 was having a stroke. She said a nurse (does not know name) came about 5 minutes after the third call. Resident #2 stated she believed Resident #1 was in the bathroom for about 45 minutes before the nurse came to the room. In an interview on 05/31/23 at 1:27 PM, the facility's Maintenance Director (MD) stated he started at the facility about 2 weeks ago and there was already an issue with the call light system. He stated there was a bad storm, and the lightning struck the building, which caused the call light system to malfunction. He stated from his understanding a tech company came out and had ordered the equipment to fix the system. He stated he was not sure exactly what date because this was done prior to him working at the facility. He stated the equipment took several weeks to come in and the company returned he believed on 05/19/23 and they replaced the malfunctioned equipment. He stated the system went out again and the company came back out and then realized there was an issue with the call light system at the nurse's station, so they had to order more equipment to fix that. He stated the company returned yesterday (05/30/23) with equipment for the nurse's station and everything was working. He stated later yesterday evening, they found out that some of the call lights were still not working. The MD stated the tech company was currently in the building and they were conducting an audit on which rooms were not working. He stated its difficult to account for which rooms are working because one minute they are working and the next they are not. In an interview on 05/31/23 at 2:15 PM, the Administrator stated the call light system first went out on 04/06/23. She stated the MD at that time was trying to fix the system and realized he was unable to, so they called a tech company to come help. She stated the tech company came on 04/11/23 and discovered equipment was burned due to the lightening and they had to order new equipment. The Administrator stated equipment did not come in until 05/16/23. She stated they provided bells to the residents and staff were doing round every 15 minutes. She stated there were no bells provided for the bathroom and that is why staff were doing rounds every 15 minutes. She stated the tech company replaced the equipment and call lights were working. She stated on 05/24/23 it was discovered the call light were no longer working and they called the tech company back out. The Administrator stated the facility went back to using bells and doing rounds every 15 minutes. She stated the tech company explained the equipment at the nurse's station was burned out and had to be replaced. She stated they ordered more parts, and they returned yesterday (05/30/23) to install the new equipment. The Administrator stated yesterday the call lights were working after the tech left, and then later in the evening they learned they were out again in some rooms. She stated the tech was currently in the building working on the call lights. She stated she was aware of the incident with Resident #1 on 05/01/23. The Administrator stated staff were expected to complete rounds every 15 minutes, so staff were in-serviced on making sure they are doing rounds every 15 minutes, after this incident occurred. In an interview on 06/01/23 at 9:30 AM, LVN B stated on 05/01/23 she was at the nurse's station charting and Resident #2 called and stated Resident #1 was in the bathroom, and she believed she was having a stroke. LVN B stated she immediately went to the room. She stated she assessed the resident for injuries and took her vitals. She stated there were no injuries and her vitals were stable, but Resident #1's face was droopy she believed on the left side. She stated she notified the DON, family, and doctor. LVN B stated she received orders from the doctor to send Resident #1 to hospital, so she called 911. LVN B stated she only spoke to Resident #2 twice and she immediately went to the resident's room. She stated the call lights system were not working and residents were provided bells to notify for help. LVN B stated CNAs were doing rounds every 15 minutes. She stated she did not know how long Resident #1 was in the bathroom nor the last time a CNA had checked on her. An observation and interview on 05/31/23 at 2:43 PM revealed as the Investigator approached Resident #1's room, Resident #1 was screaming from the bathroom I need help. MA A was observed standing behind the medication cart in front of the room next to Resident # 1's room. Resident #2 was observed lying in bed. Resident #2 stated she had been in the bathroom screaming for help for about 30 minutes. Resident #2 stated the call light was working earlier this morning, but she believed it had gone out again. Resident #1 was asked, while she was in the bathroom, if she pressed the call light and she stated yes but she believed it was not working again. The Investigator went into the hall and advised MA A that Resident #1 was in the bathroom screaming for help. MA A stated she would get a CNA to help. MA A was observed to continue to stand at the medication cart. The investigator went on the adjacent halls to look for help but was unable to find anyone to come help. When the Investigator returned to Resident #1's hall, MA A was observed to be standing in the same spot. When the Investigator asked Resident #2 was anyone in the bathroom with Resident #1, she stated no, and staff had still not come to help. In an interview on 05/31/23 at 3:16 PM, Resident #1 stated she made a bowel movement and needed help wiping herself. She stated she was sometimes incontinent with her bowels and had accidents, but she made it to the toilet this time. Resident #1 stated she was unable to reach her bottom to clean herself after a bowel movement due to some of her medical conditions. She stated she pressed the call light for help, but she believed it stopped working. She stated the facility had fixed it yesterday (05/30/23) and it worked earlier in the morning but must have stopped. She stated she was screaming for help for about 30-40 minutes. In a record review and interview on 06/01/23 at 12:24, the DON, she stated was aware of the incident on 05/01/23 with Resident #1. She stated since the call lights were out, the residents were given bells to call for help and the staff were doing rounds every 15 minutes. She stated Resident #1 and Resident #2 did tell her that Resident #1 was in the bathroom for about 30 minutes and staff had not come in to help. The DON stated she did speak to the nurse, who answered the first phone call made by Resident #2, but she couldn't recall which nurse it was, but the nurse told her she was in the middle of working with another resident and was checking their chart, when Resident #2 called. The DON stated the nurse advised her that when Resident #2 called she said Resident #1 needed help in the bathroom. She stated the nurse said she did not tell her it was emergency and she assumed she needed help with toileting. The DON stated nurse told her there was no one in the halls to ask them to check on Resident #1, so she went to finish up with her current situation and then was going to check on Resident #1. She stated when Resident #2 called the second time and spoke to LVN B and said Resident #1 was having a stroke in the bathroom, LVN B went to the room right away. The DON stated if staff would have been completing rounds every 15 minutes on 05/01/23 this would not have happened. She stated she in-serviced all direct care staff that had to do 15-minute rounds the following day. The DON stated she was made aware of the incident with Resident #1 not receiving help with toileting. She stated her expectations was for all CMAs, CNAs, and nurses to help with toileting and incontinence care. The DON stated she also in-serviced staff to continue with doing rounds every 15 minutes due to issues with call lights. She stated incontinence care was not a job only for CNAs. She stated she answered call lights to provide incontinence care and had wiped resident's bottoms, so her expectation was for all other staff to do the same. The DON provided an in-service titled Incontinence Care dated 05/31/23 and stated she started in-servicing yesterday (05/31/23) by going to each direct care staff personally and explaining her expectations regarding incontinence care. She stated she was still meeting individually with staff who did not work yesterday. In an interview on 06/16/23 at 12:28 PM, CNA C stated she was covering Resident #1's hall the day she was sent out to the hospital. She stated did not know exactly what happened to Resident #1, but what she recalled was her coming out of another resident's room and saw the paramedics taking Resident #1 out on a stretcher. CNA C stated she was giving showers to the residents during the time of the incident. She stated the call light system was not working so residents were given bells and they were doing 15-minute rounds. CNA C stated showers took longer than 15 minutes, so she let the nurse know when she was giving showers, so they could do the rounds. She stated even though showers take longer than 15 minutes, she would still complete rounds. CNA C stated once she is done with a resident's shower, she would do a round and then get started on the next shower. In an interview on 06/16/23 at 11:18 PM, the DON stated Resident #1 was alert and oriented, so she advised her to take her phone with her to the bathroom and provided her personal cell phone number to call if she needed help and was unable to get anyone. She stated the 15-minute rounds meant the CNAs were going up and down the hall listening for bells or anyone calling for help. She stated it did not mean they were going to each resident rooms because they were not able to complete that. She stated staff who were assigned to the hall could have been helping a resident, which could take over 15 minutes. The DON stated the expectation was once staff were finished with the resident if it took over 15 minutes, they should do rounds before moving on to the next task. The DON stated their corporate approved 1 additional staff per shift to help with the rounds. She stated the corporate would not approve any additional people, due to budget constraints. The DON stated staff were documenting the rounds and she was responsible for monitoring. She stated she checked the sheets three times per week. A record review of the facility document titled Q 15- Minute Checks- 600 (hall) PM Shift, dated 05/01/23, revealed from the timeframes of 6:00 PM to 4:45 AM, 15-minute checks were completed and checked off. The document did not have a staff signature on it, just a check mark. A record review of the facility's policy titled Statement of Resident Rights, undated, revealed You, the resident, do not give up any rights when you enter a nursing facility. The Facility must encourage and assist you to fully exercise your rights . You have a right to: 1. All care necessary for you to have the highest possible level of health; 2. Safe, decent, and clean conditions; 4. Be treated with courtesy, consideration, and respect . A record review of the facility policy titled Emergency Disaster and Life Safety Policies and Procedures, dated 02/01/20, revealed 4. Nursing personnel: D. Will establish and maintain a medical communication system to all areas not equipped with patent/resident call lights. This may include but is not limited to: 1. Use of bells or other devices 2. Runners to convey information 3. Periodic or routine rounds . This failure resulted in an identification of an Immediate Jeopardy on 06/16/2023 at 4:45 PM. The Administrator was informed and provided the IJ template on 06/16/2023 at 4:49 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: F558 - Reasonable accommodations of needs/preferences Resident identified with no negative outcomes Call light system failure identified on 4/6/23. Diversify notified immediately for request a quote for repair of the call light system Repair quote for call light system repair from Diversify received on 4/11/23 Diversify returned on 5/24/23 after receiving the needed part for repair of the call light system. Once there, Diversify identified a more complex issue and were required to involve additional technicians and additional electrical repair 6/2/23 Diversify returned to continue repairs 6/9/23 Diversify returned and were able to partially repair the call light system 6/12/23 Diversify returned and completely repaired the call light system Residents who reside in the facility have the potential to be affected by this alleged deficient practice. In the event of call light system failure 15-minute checks will be initiated to monitor residents for needs and will continue until the call light system has been repaired. A monitoring tool will be used to document the 15-minute checks and will be used until call light system is repaired In the event the call light system fails affected residents will be provided bells. In the event of call light system failure, a resident council meeting will be held to inform residents of plan for alerting staff for assistance and the plan for the repair of the call light system In the event of call light system failure, the administrator will contact companies to obtain quotes for repairs of the call light system Facility employees will be educated on the plan that was initiated: Immediate notification to administrator of call light failure residents will have handheld call bells to alert the nursing staff for assistance in the event of call light failure An assignment will be made by the administrator and/or Director of Nursing for 15-minute checks on residents to monitor for residents needs in the event of call light failure Any employee not receiving this education by 6/16/23 will receive before their next scheduled shift. This will include any agency personnel and new hire orientation. Maintenance Director will perform weekly preventive maintenance to validate the call light system is functioning properly for 4 weeks, then monthly. Regional Maintenance Director will validate monthly preventive maintenance completed. Director of Nursing and Administrator will make rounds throughout the day to validate that the call light system is functioning properly, and resident needs are being met. In the event of call light system failure, Clinical Consultant will validate 15-minute checks completed weekly. Any concerns will be addressed at time of discovery. The medical director was informed of the Immediate Jeopardy and the contents of this plan on 6/16/23. An ad hoc Quality Assurance Performance Improvement meeting will be held on 6/16/23. The Plan of Removal was accepted on 06/16/23 at 6:12 PM. Monitoring of the plan of removal included: Observations and interviews were conducted on 06/16/23 from 1:45 PM to 3:05 PM on various rooms and revealed Rooms 401, 405, 406, 408, 413, 418, 419, 503, 506, 510, 511, 517, 518, 521, 522, 603, 604, and 608 call lights were working. Interviews with the residents of these rooms revealed the call lights had been working for approximately one week and staff were responding. Interviews with the 2 RNs, 1 LVN, 2 CMAs, 5 CNAs, who worked multiple shifts, revealed the call lights had been working for approximately one week and they knew the protocols should the call lights go out, which included residents would be provided bells and they were required to complete 15-minutes rounds. A record review on 06/16/23 of a memo from the tech company who fixed the call light system, dated 06/16/23, reflected the following To Whom It May Concern: As of June 12, 2023, our technicians have completed work to make sure that all devices on 400, 500, and 600 halls are operating for nurse call emergency calls for the rooms. By Friday, June 9 we were able to have most of the rooms up with the exceptions of a few devices needed to be ordered. In an observation and interview on 06/16/23 at 6:17 PM, the DON was observed providing in-services on expectations (report to DON/Administrator, bells, 15-minute checks) should call light system go out to 3 nurses and 4 CNAs. The DON stated she would continue to in-service the night and weekend staff. She stated all staff would be required to complete in-service, prior to starting their shift. The DON stated she would be responsible for doing rounds to ensure the call light system was working and were being answered. The Administrator were informed the Immediate Jeopardy was removed on 06/16/23 at 6:20 PM. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents were free of accident hazards as was possible for one of 8 (Resident #1) residents reviewed for Incidents and accidents. On 10/31/22, CNA A and CNA B failed to follow Resident #1's care plan for extensive 2 person assistance for bed mobility, transfers, dressing and total dependence with 2 person support for bathing, which resulted in Resident #1 rolling off the bed and transferred back onto her bed, prior to being assessed by LVN C, which resulted in Resident #1 being diagnosed with comminuted angulated intertrochanteric left femoral neck fracture (Thigh bone fracture) on 11/02/22. It was determined a Past Non-Compliance Immediate Jeopardy existed and Administrator F was notified on 12/01/22 at 12:06 PM. The Immediate Jeopardy was determined to have been removed on 11/02/22 due to the facility's implemented actions that corrected the non-compliance of suspending CNA A and CNA B on 11/02/22 and terminating them on 11/04/22, re-educating staff about following the resident's plan of care, fall prevention and what to do after a resident fell, and a Quality Assurance meeting to discuss fall interventions was completed The Staff were interviewed and it was determined the facility staff were adequately trained about fall prevention, following plan of care, and what to do after a resident fell. There were actions put into place which included continued monitoring of the facility's preventive measures and Inservice trainings prior to the beginning of the HHSC investigation on 11/28/22 These failures could place all residents at risk for accidents, falls and serious injury resulting in a decreased psycho-social well-being, physical decline or death. Findings included: Record review of Resident #1's Physician Order Report dated 10/26/22 -11/28/22 revealed a [AGE] year old female who admitted [DATE] with diagnoses COPD, fracture of unspecified part of neck of left femur, Acquired absence of right leg, above knee, Acquired absence of left leg, below knee, morbid obesity, hypertension, diabetes mellitus Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 (cognitively intact), extensive assistance with 2 person assistance for Bed Mobility, transfers, dressing .total dependence with 2 person support for bathing, unable to walk with no impairment of upper extremity and impairment on one side of lower extremity, use of a wheelchair and frequently incontinent to bowel and bladder functioning . Record review of Resident #1's Incident/Accident Report by LVN C dated 10/31/22 revealed, At 11:45 am in patient's room resident had a witness fall and slid to the floor from low air low mattress and sustained an abrasion of the Left distal amputated site. Resident was alert/oriented, no change in condition .paraplegia, COPD, DM, HTN and incontinent to bowel and bladder .CNA stated patient slid off bed holding on to bed holding on to siderail during care provided; patient made contact with floor however did not fall or hit head; explained to have been in standing like position on amputated sites bilateral lower extremities .Findings and analysis: Section was blank Follow up step to prevent reoccurrence : 2 person assist at all times with ADL's .Describe patient's health condition dated 11/04/22: Hospital Record review of Resident#1's Care Plan dated 10/31/22 by MDS revealed, Created 11/04/22 Falls - Abrasion to left above the knee amputation - will remain free from injury, monitor and treat abrasion, transfer and care of resident with 2 staff members .Edited 11/14/22 Pain - resident has acute and chronic pain - Resident will receive adequate fast and effective pain relief and maintain pain at 3/10 or less- give pain medication as ordered and reassess for effectiveness in 30 minutes .Edited 11/14/22 ADL function/Rehabilitation potential - resident require assistance with ADL's - resident will be assisted with all activities of daily living and be allowed to be as independent as possible - resident needs assist with bed mobility, personal hygiene, toilet use, with transfers with Hoyer lift Record review of Resident #1's Falls Investigations Worksheet dated 11/01/22 by DON revealed, 10/31/22 at 11:45 am, In resident's room getting a bed bath, yes the resident called for help .witnessed fall individual(s) witnessing fall: CNA A and CNA B, no injury, Doctor notified 10/31/22 at 12:15 pm Recommendations/Interventions: Resident remain 2 person assist with bed mobility and transfers. Record review of Resident #1's Nurses note Recorded as late entry 11/02/22 (6:07 PM) by LVN C revealed, On 10/31/22 at 3:00 PM, nurse called to patient room by CNA for report of patient sliding off of bed; upon entering room patient was lying in bed and had been assisted back by CNA via Hoyer lift; Assessment of patient completed by nurse at this time, vital signs normal .Pain 0/10, when questioned about what occurred patient stated: she was receiving care by CNA, when being turned lost balance at edge of bed grabbed a hold of the side rail to prevent falling, stated she held onto rail with upper torso and bottom torso slid off of the bed; this further explain by CNA present that patient did not hit her head nor lay flat on floor instead was in a standing like position holding onto to [sic] rail due to being paraplegic; skin assessment performed and small redness noted to (Left) distal amputation site; Appears as abrasion without w/o any bleeding noted; no other injury noted; patient denies pain; ROM assessed w/o issue; patient stated her upper half appeared to be weak as she noticed while holding rail during incident; X-ray suggested to patient to r/o any possible unseen injury r/t the incident despite stating she did not fall, patient claimed she did not want to have an X-ray completed; nurse informed patient it could be done within the facility and she would not have to go out for procedure; patient still refused; will continue to monitor for any s/s of significant change. Report to be given to oncoming nurse. Resident #1's Provider Investigative Report dated 11/02/22 by Former Administrator E revealed on 10/31/22 Resident #1 was getting a bed bath from CNA A and fell out of the bed and then CNA B helped CNA A get Resident #1 back into her bed with the use of a Hoyer lift before LVN C assessed Resident #1. LVN C assessed resident with a abrasion to the left stump. On 11/02/22, CNA A and CNA B listed as alleged perpetrators were interviewed and suspended and LVN C was put on the do not return list. And Inservice trainings with all staff regarding fall prevention and management, abuse and neglect and following the resident's plan of care were conducted and on 11/04/22 CNA A and CNA B were terminated. Findings: Confirmed. Record review of Resident #1's Hospital Record dated 11/02/22 revealed she was admitted for Chief Complaint: Fall with leg pain .diagnosed with comminuted angulated intertrochanteric left femoral neck fracture (thigh bone fracture), no dislocation Assessment and Plan: Fracture of femoral neck, left .CT Pelvis wo Contrast: Patient presents to the hospital after a fall at her nursing facility complaints of fall earlier this morning when and [sic] caretaker at rehab facility with assisting patient she fell from bed and landed on her bottom, has bilateral leg pain now Interview on 11/28/22 at 10:15 am, Resident #1 stated she had left leg pain because it was broken because a young lady, CNA A gave her a bed bath about three weeks ago and turned her to the side. Resident #1 told the aide she was sliding but she did not listen and next thing she knew she fell off to the right side of bed (closest to the bathroom). She said her left leg stump was what hit the floor then she started screaming to staff to get her off of the floor with her pain level at a 9 out of 10 [severe pain]. She stated her left leg stump hit the floor and bed side table, then CNA A got another aide CNA B to get the sling Hoyer lift to put her back into bed. She stated she did not really remember much after that then she was at the hospital and was told by the hospital Doctor she had a left femur that was broken. Resident #1 said she hated the fact of having to go through this and it made her feel like the aide really did not care about having a second person helping her with her bed bath. She stated after she fell, the second aide CNA B helped CNA A get her back into bed. Interview on 11/28/22 at 3:53 pm, Administrator F stated she started working at this facility on 11/15/22 and heard about Resident #1's incident was reported to HHSC. Interview on 11/28/22 at 11:21 am, the DON stated Resident #1 was a total care (required extensive staff assistance) resident who received bed baths and Hoyer lift transfers because of her weight and recently had an incident. The DON stated she fell based on an incident report on 10/31/22, and she said she asked CNA A what happened and was told Resident #1 was moved from the bed to the floor. Then CNA A said she went to get CNA B to help get Resident #1 back into the bed with the use of the Hoyer lift and Resident #1 was assessed She stated she found out from the hospital the resident had a left femur fracture on 11/01/22 then she informed the Former Administrator E about it. She stated Resident #1 was a 2-person staff assistance resident and if CNA A had someone with her she would not have encountered the resident falling. She stated CNA A did Resident #1's bed bath by herself and did not say why and stated CNA A and CNA B should have waited for the nurse to do the assessment before they transferred Resident #1 to bed. She stated LVN C said the resident was already in the bed when he went to assess her and asked CNA A and CNA B what happened. She stated CNA A and CNA B did not follow the facility's fall protocol and plan of care and they were suspended on 11/02/22 and a few days later terminated. She stated Resident #1 had no history of falls, was alert/oriented, was getting therapy and after she fell they updated her care plan and added falls to it and her plan of care remained 2 person staff assistance. She stated a day after Resident #1's fall incident on 11/01/22, she had LVN C return to the facility to do the Incident Report and complete the nurses documenting in the EMR about the incident. She said LVN C told her he did the nurses documentation on 10/31/22 but forgot to press the save button. Interview on 11/29/22 at 9:09 am, CNA B stated the afternoon of 10/31/22 she was not in the room when Resident #1 fell but walked into her room and saw the resident on the floor about 2 feet from her bed and she was crying in pain and wanted to get up. She stated she reported Resident #1's fall to LVN C who was sitting at the nurse's station, but he did not get up to assess Resident #1, so she went with CNA A to get the Hoyer lift and assisted with putting Resident #1 back to her bed. She stated she was told she should not have moved the resident because the nurse had not assessed her and said she lost her job behind it. She stated she came to work the next day 11/02/22 and was told Resident #1 was transferred to the hospital. She stated she worked Wednesday 11/02/22 then later in the day, Former Administrator E suspended her and then on Friday 11/04/22 she was terminated. She said she was a new CNA for 4 months and was trained on falls, assessments and she had a training for falls and assessment after this fall incident. She stated she knew Resident #1 was a 2 person assist but CNA A asked for her help, and she got fired for helping someone else and in hindsight she said she never would have walked into Resident #1's room to help CNA A and should have reported CNA A to the DON immediately. She stated she broke one rule, helping to pick Resident #1 up before the resident was assessed by the nurse. Interview on 11/29/22 at 10:10 am, CNA A stated she worked as a Medication Aide and at times filled in as a CNA and said Former Administrator E suspended her on 11/02/22 then Friday 11/04/22 they terminated her because of Resident #1's fall. She stated on Monday 10/31/22 around 10:00 AM she was giving Resident #1 a bed bath by herself, and the resident slid down the bed. She stated Resident #1 fell with her upper body up against the bed and her lower body of her leg stump was on the floor and the resident appeared to be in pain saying that her leg hurt. She stated she went to get someone to help her get Resident #1 off the floor and CNA B helped her get Resident #1 back into her bed. She stated that the DON told her she should have waited for the nurse to assess the resident then she and CNA B were fired. She said after Resident #1 was put to bed LVN C went to assess Resident #1 and gave her a pain pill but Resident #1 did not go to the hospital. She stated a day later, Tuesday 11/01/22, Resident #1 went to the hospital because she had a change in condition. She stated she worked at the facility on 11/01/22 and 11/02/22 and on 11/02/22 around 4:00 pm she was suspended because she did not call the nurse before getting the resident into bed. She stated she was sorry for Resident #1 falling onto the floor and that she had almost completed Resident #1's bed bath and was putting on her adult brief and the resident turned to her right side, and she fell with her leg stump hitting the floor. She stated she knew from trainings she was to let the charge nurse know when a resident fell and said she did not get a second staff to help her with Resident #1's bed bath because the other aide was by herself on another hall. She stated she thought she could do Resident #'1s bed bath by herself, because she had done it four other times and the resident was able to move and roll over. She stated she was new working at this facility and did not know Resident #1 was a 2- person assist and did not check the EMR to see if Resident #1 was a 2 person assist. She stated the last training she had on fall prevention was when she first started working at this facility but stated no one had told her where to look to determine if a resident was a 1 or 2 person assist. She stated in CNA school she was taught not to move a resident if they fell but that day, she asked CNA B to help her get Resident #1 into bed. She stated in hindsight she should have called the nurse first and learned her lesson from this definitely to wait for the nurse to come to assess the resident and stated she felt sorry for Resident #1 and needed to make sure she asked who was a 2 person assist and to look into the EMR for the resident's plan of care. She stated the DON told her she was wrong for moving Resident #1 before the nurse assessed her because it could have caused more of an injury. Interview on 11/29/22 at 1:40 pm, the DON stated the ADON assisted her with monitoring how the staff completed their ADL tasks with random observations of resident care and with how they navigated in the EMR system to get to the resident's care plan and with nursing documentation and communicating with the resident's doctors. She stated the facility also ensured the agency staff reviewed and understood all of what was on the Orientation Checklist for caring for the residents. She stated she reviewed all of what the facility had done with the Corporate Nurse Consultant, and she did not have any further suggestions but to continue in service trainings and monitoring the staff. She stated she and the ADON would continue to do random observations of the staff twice weekly and continue to discuss the effectiveness of their trainings and monitoring in their Quality Assurance Meetings. Interview on 11/30/22 at 8:13 am, the Former Administrator E stated she was the interim Administrator from 11/02/22 to 11/18/22. She stated Resident #1's incident occurred on 10/31/22 and the DON notified her on 11/02/22 about Resident #1 falling and was at the hospital with a left femur fracture. She stated she started asking did Resident #1 fall at this facility and asked the DON what happened and was told Resident #1 fell during the 2:00 pm 10:00 pm shift on 10/31/22. She stated she was not able to determine when LVN C assessed Resident #1, but it was at some point with the resident already back in bed and the resident had no signs or symptoms of pain. Then on 11/01/22 Resident #1 was sent to the hospital and the hospital diagnosed her with a left femur fracture and on 11/02/22 around 2:00 pm, the DON notified her about the resident's femur fracture. She asked CNA A why she was giving Resident #1 assistance alone and she did not give her a clear explanation because Resident #1 was a 2 person assist and the second problem was Resident #1 should not have been moved until the nurse assessed her. She stated CNA A said Resident #1 pleaded to please get her up and so CNA A said she did. She stated CNA B helped CNA A move Resident #1 to her bed and both CNA A and CNA B were suspended on 11/02/22. She stated CNA B kept saying Resident #1 was not her patient but told CNA B she had a role and responsibility not to move the resident because it could have potentially caused the resident more injury. She stated after Resident #1 fell, they did Inservice trainings on plan of care, , fall prevention protocol, and what happens after a resident fell. She stated the staff were trained on how to review a point of care document and what a 2 person assist meant, She stated Resident #1 returned to this facility 11/10/22 and added her expectation for resident care was for the resident's plan of care to be reviewed prior to caring for the resident to know how to take care of the patient before providing any ADL assistance, with everything they should do for feeding bathing, positioning. She stated they in serviced the staff to follow the plan of care and if they had any questions to ask the nurse, they did check offs with return demonstration of transfers with therapy and MDS Coordinator and she spoke to the Medical Director and had a Quality Assurance meeting to further discuss Resident #1's incident and other fall incidents to determine if this incident was systemic or isolated. She stated after review, Resident #1's incident appeared to be isolated but stated CNA A was a Medication Aide and still no excuse, she should have known better. Interview on 11/30/22 at 10:31 am, the DON stated the ADON, and staffing coordinator assisted her with in servicing all staff including the Medication Aides and one Restorative Aide. She stated Resident #1 had an order for Hydrocodone PRN since 02/05/22 and had taken it once or twice since her fall 10/31/22 because she did not have regular pain issues. She stated after Resident #1's fall on 10/31/22, she was assessed without injury and there was not a need to notify Former Executive Director D of on 10/31/22 because it was a normal fall and was no cause for alarm. She said initially she was not aware Resident #1 had a bed bath by only one CNA before she fell. Interview on 11/30/22 at 3:05 pm, the facility's Medical Director stated the DON and Administrator F talked to him about Resident #1 having a guided fall but because she was so heavy and unable to move her lower extremity, she fell to the floor. She was hospitalized for another reason, but the hospital found she had a fractured femur, he said he was aware there was one person assisting Resident #1 with bed bath when there should have been two staff. He stated 2 staff were needed especially because Resident #1 was overweight and unable to stand. He stated telling the administrator and DON to ensure that the appropriate help was provided and said it was common sense for a two person assist resident to get proper care. He stated it was about education and would think the CNA's received training on plan or care and with not moving a resident who had fallen. Interview on 11/30/22 at 3:55 pm, the Former Executive Director D stated she was the interim ED from 10/31/22-11/01/22 and Resident #1 was getting a bed bath on 10/31/22 and the two aides lowered her to the floor. She stated it was reported Resident #1 was assessed by the nurse without any pain or injury noted then 11/01/22 the DON told her the hospital reported Resident #1 sustained a leg fracture. She stated when there was a normal fall with no injury or pain the common practice was to have a discussion about it in their standup meeting for interventions. Interview on 11/30/22 at 5:02 pm, the Administrator F stated they terminated CNA A and CNA B and placed LVN C on the do not return status based on the information gathered and they felt like there was too many things that were wrong once it was discovered why Resident #1 fell. She stated when this incident was brought to the DON all the facts were not present because the DON thought it was 2 aides providing Resident #1 care. She stated when Resident #1 had a change in condition with her cognition she was sent to the hospital but anytime there was a fall they have to X-ray and had that been done they would have known about the leg fracture sooner. She stated her expectations with following the care plan was to ensure the staff rounded with each other and between shift changes and to pay attention and review the EMR kiosk to give the residents individualized care. She stated the whole point of the plan of care was for the resident not to get the same care and was the staff's responsibility to report any changes of the resident to the nurse immediately. She stated the DON and ADON were responsible for ensuring the resident's plan of care was followed. Interview on 12/01/22 at 11:28 am, the DON stated after Resident #1 fell on [DATE], she was coming down the hallway and LVN C asked was Resident #1's incident considered a fall and that two CNA's moved resident to the bed then asked LVN C how she got into bed he said she was given a bed bath and the resident fell out of bed. She stated she spoke to Resident #1 and CNA A and CNA B about how they got the resident up and said she did not know LVN C was not in the room when Resident #1 was put to bed. She stated CNA A and CNA B said they used the Hoyer lift to get Resident #1 to her bed. She stated the only policy not followed was with two CNA's and one LVN not following proper protocol. Record review of the facility's Inservice trainings from 11/02/22 to 11/09/22 revealed the staff were trained on Fall Prevention management and steps to take after a resident falls, and with following the resident's plan of care. Interview on 11/30/22 at 8:13 am revealed the Former Administrator E stated they had a Quality Assurance meeting with the Medical Director and other department heads to address Resident #1's fall. Interviews from 11/29/22 at 9:09 am to 12/01/22 at 12:51 pm with the staff revealed they were adequately educated about fall prevention and management, knowing where to find the resident's plan of care and what to do and not do after a resident fell. Record review of the facility's Accident/Incident Reporting - Patient/Resident policy dated 11/01/2017 revealed, Policy: The facility's leadership will follow the established guidelines for the reporting of accidents and incidents.6. The Director of Nursing designates the responsible party to complete the follow-up. The designee conducts a complete investigation of all accidents and incidents and documents the findings on the second page of the worksheet (Fall investigation worksheet) . Accidents or incidents involving a patient/resident that result in an injury are immediately reported to his/her physician promptly reported .8. For 3 days following an incident/accident the nurse documents the condition of the patient/resident in the medical record every shift Record review of the facility's Fall Management Policy dated 09/18/2017 revealed, Policy: Facility staff will identify each patient/resident who is at risk for falls and develop a resident-centered and individualized plan of care to reduce fall risk. Definitions: Fall refers to the unintentional coming to rest on the ground, floor or other lower level . a fall without injury is still defined as a fall 5. If a fall occurs, qualified staff completes a root cause analysis of the patient/resident for injury from the fall and determines what may have caused or contributed to the fall .addresses the risk factors for the fall such as the resident's medical condition, facility environment issues, or staffing issues, and determines appropriate interventions to prevent future falls It was determined a Past Non-Compliance Immediate Jeopardy existed and Administrator F was notified on 12/01/22 at 12:06 PM. The Immediate Jeopardy was determined to have been removed on 11/02/22 due to the facility's implemented actions that corrected the non-compliance of suspending CNA A and CNA B on 11/02/22 and terminating them on 11/04/22, re-educating staff about following the resident's plan of care, fall prevention and what to do after a resident fell, and a Quality Assurance meeting to discuss fall interventions was completed The Staff were interviewed and it was determined the facility staff were adequately trained about fall prevention, following plan of care, and what to do after a resident fell. There were actions put into place which included continued monitoring of the facility's preventive measures and Inservice trainings prior to the beginning of the HHSC investigation on 11/28/22