Health inspection·June 12, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 resident (Resident #1) reviewed for accidents and supervision. The facility failed to ensure the resident was assessed upon admission to the facility to determine if he was safe to smoke independently. The resident started a fire in his room. The facility failed to follow interventions to keep resident staff by supervising resident while he was smoking. An Immediate Jeopardy (IJ) situation was identified on 06/07/2023. While the IJ was removed on 06/12/2023 at 11:30 AM, the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk of smoke inhalation, burns, loss of property and could affect residents by placing them at risk of serious injury when residents were not supervised when smoking. The findings were: Record review of Resident #1's face sheet, dated 06/07/2023, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included acute on chronic systolic (congestive) heart failure, chronic obstructive pulmonary disease with (acute) exacerbation, mood disorder due to known physiological condition with depressive features, and persistent mood [affective] disorder, unspecified. Record review of the admission MDS for Resident #1, dated 04/26/2023, reflected a BIMS score of 8 which indicated moderate cognitive impairment. Record review of the care plan for Resident #1, dated 03/01/2023, reflected the following: The resident was a smoker. Resident #1 started a fire in his room r/t violating the smoking policy. Resident #1's care plan goal was resident would not suffer injury from unsafe smoking practices. Resident was informed that supervised smoking was now mandatory and to notify the charge nurse if unsafe smoking techniques were present. Observation on 06/07/2023 at 11:00 AM of Resident #1 outside of the facility alone, with no residents or staff member, smoking and in possession of a lighter. Page 1 of 6 676026 676026 06/12/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Observation on 06/07/2023 at 11:00 AM revealed HA approached Resident #1 in the company of the State Surveyor and HA took the lighter from Resident #1 and returned it to the building leaving the State Surveyor with the resident who was smoking alone with no facility staff supervision. In an interview on 6/12/2023 at 9:59 AM with CNA A revealed on 03/01/2023 she was alerted by a housekeeper, who looked anxious and said fuego (fire) and pointed to Resident #1's room. When CNA A got to Resident #1's room, Resident #1 was holding a pillow that was ignited. CNA A revealed she grabbed the pillow and threw it to the floor, grabbed a cup that contained water from the bedside table and threw the water on the pillow, ran to get the fire extinguisher from the wall in the hallway and when she returned, the fire had smoldered out. A lighter was found on Resident #1's bed. CNA A stated she was absolutely sure Resident #1 lit the pillow on fire and he was the only one in the room. CNA A revealed Resident #1 did not have a roommate. In an interview on 06/12/2023 at 11:00 AM with Resident #1, he revealed he did not light a pillow on fire and the incident did not happen. When asked if he was alone outside smoking, he said there was a staff member with him, but the staff member went inside and had not come out yet and did not know if she was going to come back out. Resident #1 said it was not unusual for him to be outside smoking without a staff member. Resident #1 stated he lit his cigarette with his lighter. An interview on 06/12/2023 at 2:25 PM with the ADM revealed the facility had not had any fire drills for the year 2023 and on 06/07/2023 LSC issued the facility a citation for not having fire drills. Record review of Resident#1's care plan reflected no smoking safety assessment completed for Resident #1 upon admission. Record review of Resident #1's Smoking - Safety Screen, dated 03/01/2023, revealed Resident #1 started a fire in his room on 03/01/2023 due to cognition issues. Resident #1 was noted to have had cigarettes and ashes in his room on two different occasions. Record review of Resident #1's Smoking - Safety Screen, dated 06/01/2023, revealed Resident #1 was not safe to smoke independently at this time. Record review of the facility's, undated, policy Record of Drills revealed the facility shall maintain a record of all drills that it conducts. Record review of the facility Smoking Policy, dated 08/2022, revealed any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. This was determined to be an Immediate Jeopardy (IJ) on 06/07/2023 at 11:46 AM and the ADM and DON were provided notified and provided the IJ Template. The following Plan of Removal submitted by the facility was accepted on 06/09/2023 at 11:46 AM: Statement F689 The facility failed to have adequate supervision to prevent potential accidents. 676026 Page 2 of 6 676026 06/12/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0689 The notification of the immediate jeopardy states as follows: Level of Harm - Immediate jeopardy to resident health or safety On June 7, 2023, around 8am, an abbreviated survey was initiated at (facility). On June 7, 2023, at 7:45pm the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Residents Affected - Few The notification of Immediate Jeopardy states as follows: The facility failed to have adequate supervision to prevent potential accidents. Action: Root Cause Analysis: Elder does not remember, Family and Friends bring in cigarettes and lighters, Elder is from this town and has extended family and friends that might not be informed of rules. The investigation revealed that the Elder reported that his nephew brought the cigarettes, and his sister left the lighter the last time she visited. At a careplan meeting on June 8, 2023, the Responsible Party who is the Elder's son, stated he has informed the nephew and the sisters, and known visitors to NOT bring any smoking materials at all to the Elder. The facility policy of no smoking materials in the Elders' room is part of the admission Packet and a notice of this policy is placed on the front door and front nurses' station for Elder, Visitors and Carepartners to view. Start Date: 06/07/2023 Responsible: Administrator Action: To prevent the Elder from smoking alone or having smoking material on his person, we notified the Elder and family and friends and Inserviced carepartners of the smoking policy. Informing all that Elder is now a scheduled supervised smoker. Elder should not be outside smoking without supervision of staff. Elder is not allowed to have smoking materials in his room per policy. To prevent Elder from smoking alone or in his room, all smoking materials are kept in the locked medication room. Start Date: 06/07/2023 Responsible: Director of Nursing Action: When we first learned that Elder was smoking outside unsupervised, we checked with the Nurses and Medaides who had access to his cigarettes to identify who gave him smoking materials and allowed him to go out and smoke unsupervised. No staff provided any smoking materials. So, then the Social Worker Assistant called the Ombudsman to get them involved to protect the Elder's rights and left two messages on 6/7/2023 and another on 6/8/2023. Since the Ombudsman did not return our call, we sent a copy of the Discharge Notice to the Ombudsman via fax on 6/8/2023. Next, we called the son and informed him that the Elder was currently outside smoking with smoking materials that were not checked out at the nurse's station and that we needed to search the Elder's side of the room to see if there 676026 Page 3 of 6 676026 06/12/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0689 Level of Harm - Immediate jeopardy to resident health or safety were any smoking materials. The son who is the responsible party gave permission. When the Elder returned from smoking, we asked if we could search his room and he gave verbal approval. The roommate and the Elder then went to lunch while the room was cleaned. The smoking material found in the room was confiscated and will be returned to the responsible party per the smoking policy. The social worker visited with the Elder and the roommate to inform both that the room will be checked on a daily basis to look for smoking materials and obtained written permission from both. Residents Affected - Few Start Date: 06/07/2023. Responsible: Activity Assistant and Housekeeping Supervisor Action: Fire Drills were performed on all shifts, 2p-10p, 6a-2p, and 10p-6a starting on 6/7/23 thru 6/8/23. Fire Drills will be repeated again next week on all 3 shifts, then monthly on all 3 shifts until the QA committee reviews in September of 2023. The Fire Drills are recorded on HHSC Form #4719. Start Date: 06/07/2023 Responsible: Administrator and Maintenance Supervisor Action: Visual safety checks of the Elder will be performed by nursing staff and documented every 15 minutes to ensure the Elder is safe and not violating the smoking policy. The Charge Nurse is responsible for checking the room daily until resolved. This plan will be reviewed weekly to determine if anything needs to be adjusted. All carepartners have been inserviced on the visual safety checks and the daily room checks. Start Date: 06/07/2023 Responsible: Nursing Action: Careplan with Family and Elder to discuss concerns and safety and discharge: Note Text: Care plan meeting held at this time, elder attended and son, via phone conference), DON, Administrator, SW, SWA, and this nurse attended, concerns addressed r/t elder smoking against policy guidelines, elder is supervised smoker- now is scheduled supervised smoking from 9am to 9pm, approximately every 2 hours to be supervised by the Charge Nurse or the person he/she designates. Elder states that he chooses not to follow a smoking schedule- Elder asked to discharge to another facility. And the social worker will assist Elder in finding safe placement, son is in agreement on elder discharging due to elder not agreeing to follow a safe smoking schedule, elder is to be on supervised smoking schedule which is posted in his room and at the nurse's station from 9am to 9pm, approximately every 2 676026 Page 4 of 6 676026 06/12/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few hours, to be supervised by the charge nurse or his/her designee until discharge to another facility and all smoking apparatuses to be kept at nurses station and son is informed not to bring elder any smoking supplies and son states that he will inform friends and family to do the same, continues with Q 15 min visual safety checks, SW to refer elder to another facility. The Supervised Smoking schedule is posted in the Elders room. The smoking schedule is approximately every 2 hours between 9am and 9pm. The Carepartners, Elder, family, and friends have been educated on the policy. Staff were inserviced on paper by the Director of Nursing and electronically by the Administrator of the supervised smoking schedule. The charge nurse or his/her designee is responsible for making sure it gets done. Resident #1 discharged on 06/09/2023 at his request. Start Date: 06/07/2023 Responsible: MDS Nurse, DON, Administrator, SW and Assistant, Elder and Responsible Party Action: Because the Elder refused to comply with the safety plan, the QAPI Team agreed to issue a 30-day discharge notice to the Elder, with copies to the medical director, Texas Department of Aging Ombudsman, and Regional Director of Operations. A 30-Day Discharge Notice has been provided to the Elder, Responsible Party, and Ombudsman. The Social Worker is working with the Elder to discharge to the place of his choice or to the home of the responsible party within 30 days. His Right to Appeal is included in the Discharge Notice. Elder is planning to move on 6/9/2023. Start Date: 06/08/2023 Responsible: Administrator Monitoring of the Plan of Removal from 06/07/2023 - 06/12/2023 included the following: Interview on 06/08/2023 at 12:50 PM with Resident #1 who revealed he wanted to leave the facility because they would not allow him to smoke as much as he would like to. Interview on 06/09/2023 11:38 am with Resident #1's son and responsible party who revealed his father wanted to go another facility. In interviews from 06/09/2023 through 06/12/2023 with one HA, one medication nurse, one CMA, one LVN, one housekeeper, and two CNAs stated they participated in in-service fire drills, felt comfortable that they understood the fire drill procedures and the different responsibilities assigned to staff in different areas and were able to describe what action should be taken during the event of a fire to protect the residents. Record review of discharge notice, dated 06/08/2023, to Resident #1 notified him of his right to appeal, included ombudsman contact information, and a carbon copy sent to resident's physician, 676026 Page 5 of 6 676026 06/12/2023 Will-O-Bell 412 N Dalton Bartlett, TX 76511

F 0689 resident's responsible party, and the ombudsman. Level of Harm - Immediate jeopardy to resident health or safety Record review of the in-service dated 06/07/2023, for all personnel revealed Resident #1 was a supervised smoker and should not be outside smoking without supervision and to report to the charge nurse if staff saw Resident #1 outside smoking or found Resident #1 with cigarettes or lighter. Residents Affected - Few Record review of the in-service dated 06/08/2023, for all personnel revealed Resident #1's lighter was to be kept locked in the medication room at the nurse's station and cigarettes and lighters were to be returned to charge nurse at front nurses' station. Record review of 15-minute lighter check for Resident #1, dated 07/07/2023, beginning at 7:45 PM and ending at 11:45 PM. Record review of 15-minute lighter check for Resident #1, dated 06/08/2023, beginning at 6:15 AM and ending at 11:45 PM. Record review of 15-minute lighter check for Resident #1, dated 06/09/2023, beginning at 12:00 AM and ending at 1:15 PM. Record review of the Fire Drill Report dated 06/07/2023 at 8:15 PM, for shift 2:00 PM - 10:00 PM. Record review of the Fire Drill Report dated 06/08/2023 at 9:08 AM, for shift 6:00 AM - 2:00 PM. Record review of the Fire Drill Report dated 06/08/2023 at 10:45 PM, for shift 10:00 PM - 6:00 AM. Record review of the Fire Drill Report dated 06/10/2023 at 10:37 AM, for shift 6:00 AM - 2:00 PM. Record review of the Fire Drill Report dated 06/10/2023 at 2:33 PM, for shift 2:00 PM - 10:00 PM. Record review of the in-service training dated 06/09/2023 for all personnel revealed if time did not allow for a Hoyer lift transfer, all beds in facility fit through the residents' doors and resident should be moved out of room in bed. Record review of the in-service training, dated 06/09/2023 for all personnel, written in Spanish and English, revealed if time did not allow for a Hoyer lift transfer, all beds in facility fit through the residents' doors and resident should be moved out of room in bed. The ADM and DON were informed the Immediate Jeopardy was removed on 06/12/2023 at 11:30 AM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 676026 Page 6 of 6