Health inspection·September 13, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm submitted to the physician and signed on 9/13/2023 and indicated the resident did have a dementia diagnosis. The nursing facility action was PASSR Level 1 Screening remains negative and no new PL1 needs to be completed. The nursing facility files the completed form in the resident's chart. Record review of a new PASSR Level 1 Screening was completed on 8/29/2023 and Residents Affected - Few indicated the resident was negative for mental illness. During an interview on 09/12/23 at 2:30 PM, the Regional Compliance Nurse said Resident #36 had a negative PL1 and was not referred based on the screening that was completed by hospital staff prior to admission to the facility on [DATE]. She said the only time she referred residents for a PASSR evaluation was if the PL1 indicated the resident was positive for mental illness, intellectual disability, or developmental delay and Resident #36 did not have a mental illness diagnosis on admission. She said it was the MDS nurse's responsibility to check the PL1s on admission for accuracy. This failure could place residents at risk for not receiving needed PASSR services. During an interview on 9/12/23 at 4:02 PM, the MDS Coordinator said she had been employed at the facility since 06/13/2022. She said if a resident identified as having a newly evident or possible MI, ID, or related condition after admission, the MDS nurse should have entered the diagnoses in the charting system as an active diagnosis and they would discuss in the care plan meetings with new diagnoses, new medications, or changes. She said the facility did have a psychiatrist that came to the facility and Resident #36 was receiving counseling services and was taking any antipsychotic medications. She said she was responsible for making the referrals to the local authority and entering the PASSR information into the portal. She said she resubmitted a new PL1 for Resident #36 yesterday 09/12/23 after this surveyor questioned if Resident #36 had a mental illness diagnoses without a PASSR evaluation to indicate Resident #36 was positive for MI and sent the form 1012 (Mental Illness/Dementia Resident Review) to the physician for review. During an interview on 09/13/23 at 9:15 AM, the Regional Reimbursement Nurse she said she comes to the facility once or twice every three months. Regional Reimbursement Nurse said she was responsible for overseeing the PASSR process for all the residents in the facility. She said she was aware that Resident #36 had a diagnosis of bipolar and schizophrenia but was not responsible for the PASSR information. She said the MDS nurse was responsible for adding diagnosis and completing a form 1012 as needed. MDS Coordinator was responsible for reviewing diagnoses from hospital records and physician orders and would enter them into the charting system as active diagnoses for the residents. She said the physician would review the diagnoses and sign the orders if applicable. She said if a resident had a new diagnosis, the MDS Coordinator was aware, and the information came from hospital records after a hospital stay or a change in condition. During an interview on 09/13/23 at 9:25 AM, the Administrator said he had been employed at the facility since 12/19/22 and was not aware of the circumstances for Resident #36. He said the MDS Coordinator informed him on yesterday 09/12/23 that she had submitted a form 1012 for Resident #36 related to his diagnoses. He said going forward the facility would ensure all residents would receive correct services and follow the regulations. He said the PASSR information and diagnoses would be reviewed from day one of admission and after a hospitalization. He said a resident was at risk of not being appropriately cared for and or receiving needed services. A policy PASRR Level 1 Screen Policy and Procedure revised 03/06/2019 did not address a Form 1012. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455840 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Arbors Healthcare and Rehabilitation Center 1884 Loop 343 West Rusk, TX 75785 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident # 191) reviewed for accidents and hazards. The facility failed to ensure Resident # 191 had adequate supervision and was wearing appropriate footwear while in wheelchair to prevent a fall in room on 9/11/23. This deficient practice could place the residents at risk for harm, serious injury or death. Findings include: Record review of a facility face sheet dated 9/12/23 for Resident #191 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: cerebral infarction (stroke), type 2 diabetes, hypertension (high blood pressure), and aphasia (trouble speaking). Record review of a comprehensive MDS dated [DATE] for Resident #191 indicated that he had a BIMS score of 00, which indicated that he was unable to complete the interview. He required extensive assistance of 1-2 persons for personal hygiene and dressing. He was dependent for lower body dressing and putting on/taking off footwear. Record review of a care plan dated 8/30/23 for Resident #191 indicated that he was at risk for falls due to hemiparesis (weakness on one side of the body) with an intervention initiated on 9/9/23 of .ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair) . Record review of a fall risk assessment dated [DATE] for Resident #191 indicated that he had suffered 1-2 falls in previous 3 months and was at high risk for falls. Record review of an event nurses note dated 9/4/23 for Resident #191 indicated that he had sustained an unwitnessed fall on 9/4/23. Resident was found on fall mat next to bed. Resident non-verbal and unable to explain how fall occurred. Record review of an event nurses note dated 9/11/23 for Resident #191 indicated that he sustained an un-witnessed fall on 9/11/23 in his room by sliding out of his chair and was found sitting on floor in front of his wheelchair. During an observation on 9/11/23 at 10:03 am Resident #191 was observed sitting up in his room in the wheelchair. He was observed wearing white socks and no shoes. Resident did not speak to surveyor. During an observation on 9/11/23 at 12:00 pm Resident #191 was observed in the floor in front of his wheelchair in his room. Wheelchair was positioned beside bed, against the wall in his room, not visible from hallway. Resident was noted to have on white socks and no shoes. Shoes were observed on his bedside table next to the wheelchair. Residents' socks were not non-skid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455840 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Arbors Healthcare and Rehabilitation Center 1884 Loop 343 West Rusk, TX 75785 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 9/12/23 at 2:15 pm Regional Nurse said that all staff contribute to the care plans, not just one person and she said that it depended on the resident as to what would be considered appropriate footwear. She said that Resident #191 did not have his shoes on because he would always kick them off. During an observation and interview on 9/13/23 at 8:40 am Resident #191 was observed in room, lying in bed with non-skid socks on. Resident had a mattress on the floor beside his bed. CNA B was in room sitting in chair and said that she had been employed here for about 5 years. She said that she was called in today on her day off to sit with the resident. She said that Resident #191 should always be wearing his non-skid socks. She said that she always put them on him when she would get him up and out of bed. She said that when she cares for him she also always put his shoes on him. She said that a lot of times he would kick them off, but she would try to keep them on him. She said that she always tried to bring him out to a common area so staff could keep an eye on him instead of leaving him in his room alone. She said that residents without proper footwear on were at risk for falls. During an interview on 9/13/23 at 9:20 am CNA D said that she had been employed here for about 1 year and said that Resident #191 was already up when she got here Monday morning (9/11/23). She said that night shift had gotten him up prior to her starting her shift that day at 6:00 am. She said that when they get him up, they always put his white socks on him because his family and brought him a new pack and wanted him to wear them. She said that she would always try to bring him out of his room when she was working, but sometimes he would refuse and want to stay in his room. She said that if he remained in his room, then she would check on him every 30 minutes. She said that he had been trying to get up since he was admitted on [DATE] and she had mentioned non-skid socks to them, but his had brought these socks and she wanted him to wear them. She said that a resident could be at risk for falls if they are up in a wheelchair without proper footwear on. During a telephone interview on 9/13/23 at 9:40 am CNA E, who had been employed here about 7 months said that he had gotten Resident #191 up the morning of 9/11/23 and showered him and dressed him. He said that he had put a black shirt and pants on him and his white socks. He said that he normally put his white socks on him, and he had not been told to put non-skid socks on him. He said that residents up in a wheelchair could be at risk for falls without proper footwear on. During an interview with Administrator on 9/13/23 at 10:10 am he said that he did not believe that footwear could have prevented the fall because the resident did not walk. He said that they had a Dycem (a non-slip pad to prevent sliding) in the chair to help prevent him from sliding out and they have now placed a camera in the room to monitor him more closely. He said that he believed that Resident #191 was moving around more because he was doing so much better since his admission on [DATE] and was learning to do new things. During an interview with the DON on 9/13/23 at 11:08 am she said that all residents that are up in wheelchairs should have on some type of non-skid footwear to prevent them from falling. She said that they have non-skid socks in the facility for staff to use for residents. She said that residents up in wheelchairs without proper footwear were at risk for falls and injuries such as fractures and head injuries. She said that going forward, she would in-service all staff on appropriate footwear and she would expect that all residents up in wheelchairs have on non-skid socks or shoes. Record review of facility policy titled Preventive Strategies to Reduce Fall Risk dated 2003 with revision date of October 5, 2016, stated .Footwear, shoes, slippers, etc., worn by residents should fit properly and have slip-resistant soles . and .Shoes and slippers with rubber or crepe soles will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455840 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Arbors Healthcare and Rehabilitation Center 1884 Loop 343 West Rusk, TX 75785 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 be used to provide adequate slip resistance on floors . Level of Harm - Minimal harm or potential for actual harm Record review of a facility policy titled Event Reporting: Completion of, undated, stated .Include and care plan any required interventions or supervision to help prevent further occurrence of the event . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455840 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Arbors Healthcare and Rehabilitation Center 1884 Loop 343 West Rusk, TX 75785 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 staff (ADON) reviewed for infection control. Residents Affected - Few ADON failed to clean the scissors used to cut wound care dressings for Resident #38 and she stored the scissors in her pocket. ADON failed to place wound care supplies on a clean surface while performing wound care to Resident #38. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of an admission Record for Resident #38 undated indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of acute cystitis without hematuria (bladder infection without bleeding), sepsis (extreme infection in the blood), dementia, and hydronephrosis with renal and ureteral calculous obstruction (swelling of the kidneys that blocks urine along with kidney stones in the ureters). Record review of an admission Medicare/5 Day MDS assessment for Resident #38 dated 9/1/2023 indicated she had severe impairment in thinking with a BIMS score of 6. She required extensive assistance with 1-2 person assist with bed mobility, dressing, toilet use and personal hygiene. She had an indwelling catheter and was always incontinent of bowel. Record review of a care plan for Resident #38 dated 8/28/2023 indicated she had a non-pressure ulcer to right hip. During an observation on 9/12/2023 at 2:00 pm, in Resident #38's room the ADON who was present to provide wound care to Resident #38. ADON washed her hands in Resident #38's bathroom. Wound supplies were observed on an over bed table which included: a bottle of wound cleanser, gloves, xeroform dressing (petrolatum gauze-non stick), gauze, and a red biohazard trash bag was taped to one end of the table. ADON applied gloves to both hands. ADON removed a dressing to Resident #38's right hip and placed it in the trash bag along with her gloves. ADON applied gloves without washing or sanitizing her hands and verbalized to the Surveyor that she would wash or sanitize her hands, but she could not use the soap in Resident #38's bathroom because it caused her hands to swell, and she forgot to bring in her hand sanitizer. ADON looked at the surveyor and said she was nervous, and Surveyor told her to do what she normally would while performing wound care. ADON removed the gloves from her hands and placed them in the trash and exited the room to get hand sanitizer from her cart that was in the hallway. ADON reentered the room and went into Resident #38's bathroom and washed her hands. ADON applied gloves to both hands and cleaned the wound on Resident #38's right hip using gauze and wound cleanser. ADON placed the gauze in the trash along with her gloves. ADON sanitized her hands and applied gloves to both hands. ADON removed scissors from a pocket on her pants and cut a petroleum gauze dressing to fit the wound and placed it on Resident #38's right hip and covered it with a bandage. ADON removed her gloves and placed them in the trash. ADON sanitized her hands and placed gloves on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455840 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Arbors Healthcare and Rehabilitation Center 1884 Loop 343 West Rusk, TX 75785 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few both hands and repositioned Resident #38 in the bed. ADON removed the biohazard trash bag and exited Resident #38's room. During an interview on 9/12/2023 at 2:10 pm, the ADON said she had been employed at the facility for over a year. She said she provided wound care to the residents in the facility. She said the wound care provided to Resident #38, she should have washed or sanitized her hands instead to telling the Surveyor that was what she was supposed to do and had to exit the room to get her hand sanitizer. She said she should have cleaned her scissors beforehand and placed them on the over bed table with the wound supplies and not kept them in her pocket. She said residents could be at risk of infection by not cleaning equipment or washing or sanitizing their hands between glove changes. Record review of a Licensed Nurse Proficiency Audit for ADON dated 4/18/2023 indicated she demonstrated competency with infection control with hand washing/hand hygiene. During an interview 9/13/2023 at 10:25 AM, the DON said she had been employed at the facility since March 27, 2023 and oversaw the infection control program at the facility and trained staff on infection control. She said she monitored staff frequently and conducted their proficiency skill check offs around the staff annual hire dates. She said staff were supposed to wash their hands before starting any procedure, any time between care and glove changes. She said any supplies used for treatments should be sanitized before and after. She said the over bed table should be cleaned and supplies placed on wax paper. She said the table should be separated between clean and dirty. She said going forward she would provide education and in-service and continue to monitor staff. She said residents could be at risk of infection to wounds. Record review of a facility policy titled Infection Control Policy and Procedure Manual 2019 indicated, .The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Hand Hygiene: You may use alcohol-based hand cleaner or soap/water for the following. After removing gloves . Record review of a facility policy titled Wound Care Policy and Procedure Manual 2003 indicated, .Treatment Table, 1. Wash hands. Put on gloves. 2. Place wax paper on wound care bedside table or small cart. 3. One end will be considered clean, and the other end of table will be open for dirty. (To replace scissors, etc. to be cleaned). 5. On open end scissors on top of second cover of wax paper . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455840 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Arbors Healthcare and Rehabilitation Center 1884 Loop 343 West Rusk, TX 75785 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. 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 be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 8 residents (Resident # 25) reviewed for call lights. Residents Affected - Few The facility failed to ensure Resident # 25's emergency call light in the bathroom would reach the floor. The call light cord for Resident # 25 was wrapped around the grab bar. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life. Findings: Record review of facility face sheet dated 09/12/2023 indicated Resident # 25 was an [AGE] year-old female admitted to the facility on [DATE] with dementia (impaired memory), encounter for fall, and vertebrae fracture (fractured back). Record review of quarterly MDS dated [DATE] indicated Resident # 25 had a BIMS of 05 indicating poor cognition. Functional status indicated Resident # 25 required limited assist times 1 person for transfers and extensive assist times 1 person for toileting. Bowel and bladder section indicated Resident #25 had frequent incontinence but did have at least 1 continent episode. Record review of comprehensive care plan with revision date of 08/01/2023 indicated Resident # 25 was at risk for falls and to ensure call light was within reach. During an observation on 09/11/2023 at 09:22 am Resident # 25 resided in room [ROOM NUMBER] and the call light was wrapped around grab bar in the bathroom. During an observation on 09/11/2023 at 3:00 pm the call light in the bathroom in room [ROOM NUMBER] was wrapped around the grab bar in the bathroom and unable to be activated when pulled. During an observation on 09/12/2023 at 7:58 am the call light in the bathroom in room [ROOM NUMBER] was wrapped around the grab bar in the bathroom and unable to be activated when pulled. During an interview on 09/12/2023 at 8:41 am Resident #25 stated she had been at the facility for 3-4 years and she was able to toilet herself and used her bathroom in her room. She stated she had not used the call light in her bathroom but if she fell, she might would need to. During an interview on 09/12/2023 at 10:45 am NA A stated she had worked at the facility since February 2023. She stated Resident # 25 was able to transfer by herself, but it was safer to have someone with her, but she did not always ask for help. She stated Resident #25 used her toilet in her bathroom a few times a day. She stated Resident #25 was instructed to use call light if she needed assistance but does not always do that. She stated she was not aware the call light was wrapped around the rail and would not activate if pulled. She stated the staff should make sure the light was accessible. She stated if the resident could not pull the light the staff would not know they needed help. During an interview on 09/12/2023 at 10:52 am CNA B stated she had been a CNA at the facility 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455840 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455840 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Arbors Healthcare and Rehabilitation Center 1884 Loop 343 West Rusk, TX 75785 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Level of Harm - Minimal harm or potential for actual harm year. She stated that call lights should always be in reach and accessible by the residents including the bathrooms. She stated Resident # 25 was able to toilet herself but did not toilet often and was mostly incontinent. She stated Resident #25 would go the bathroom and the staff were not aware she was in there and if she were to fall, she could not use her call light if it was wrapped around the grab bar. She stated this could cause a resident not getting quick response to a fall or injury. Residents Affected - Few During an interview on 09/12/2023 at 10:55 am LVN C stated she had been employed at the facility 5 1/2 months. She stated Resident # 25 was able to transfer self with stand by assist but would often transfer herself without asking for help. She stated Resident # 25 would toilet in her bathroom but not often. She stated she was not aware of any falls but Resident # 25 was a fall risk and if she were to fall in the bathroom a delay in help could occur if her call light was not able to be pulled. During an interview on 09/12/2023 at 11:00 am the DON stated she had been the DON since March 2023. She stated it was the responsibility of all staff to ensure the call lights were accessible to the resident either in their room or bathroom. She stated all call lights should be checked every shift to ensure they can be used. She stated if a call light could not be activated when a resident was to fall serious injury or delay in treatment could occur. She stated she expected all call lights to be checked and never wrapped around the grab bar keeping them from being activated. During an interview on 09/12/2023 at 3:50 pm the regional compliance nurse stated the facility did not have a policy regarding call lights nor a monitoring system to ensure call lights were accessible. She stated all staff were trained on call lights being within reach. She stated she had in-serviced all staff on call lights and ensuring they were freely hanging to activate properly. She stated the importance was so the resident could use the light in event of an incident. During an interview on 09/13/2023 at 10:11 am the administrator stated all staff were responsible for ensuring call lights were accessible by the residents. He stated the risk to residents could be not getting the help they needed and expected all staff going forward to check call lights were accessible and were always in reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455840 If continuation sheet Page 9 of 9