Health inspection·September 14, 2023

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. Based on observation, interview, and record review, the facility failed to ensure an environment free of potential hazards. The facility failed to provide assistive devices that prevent avoidable accidents for 1 of 2 residents sampled for safety. (Resident #117) The findings include: On 9/11/23 at approximately 11:00 AM, an interview was conducted with Resident # 117. She explained that she needed a new commode chair. She stated that asked the nurses for a bariatric chair about 2 weeks ago but had not received one yet. About 2 weeks ago, the regular sized commode chair she used rusted through and broke while she was seated on it. She received a minor scratch to her thigh as a result. She told the surveyor that the replacement regular sized chair that she is currently using might break because it also has rust on it. She verbalized concerns about injuring herself. The resident explained that she really needs a bariatric commode chair because she takes a blood thinner medication and bruises easily. The resident showed pictures of the regular sized commode chair that broke while she was on it two weeks ago. The surveyor noted that Resident #117 had a wide shower chair, a wide wheelchair, and a wide rollator in the room at the time of the interview. The surveyor went to look at the commode chair that was currently placed over the toilet. The commode was a standard size. The chair had a large amount of rust intrusion under the toilet seat. The rusted areas were located at bolts that hold the chair supports in the front of the chair. There was also significant rust on the back of the chair under the toilet seat. (Photographic evidence obtained) On 9/14/23 at approximately 9:00 AM, a second interview was conducted with Resident #117. She said that, on 9/13/23, she asked Nurse A, a Licensed Practical Nurse (LPN), when she would get the bariatric bed side commode. Despite making staff aware of this issue, she still had not received one at the time of this interview. The surveyor looked and the same rusted commode chair was in the bathroom. On 9/14/23 at approximately 9:20 AM, an interview was conducted with Nurse A. She explained that a bariatric chair had been ordered for Resident #117 . Nurse A was asked about the injury Resident #117 received from the commode 2 weeks ago. She explained that the resident received a superficial scratch after the chair broke. The surveyor showed Nurse A the photographs of the chair that is currently in use. She was asked if that chair looked safe for use by Resident #117. She explained that it might be better to get a different chair. She explained that a bariatric chair had been ordered. A bariatric chair had just become available and she would get it for the Resident to use. Page 1 of 2 105364 105364 09/14/2023 Seven Hills Health & Rehabilitation Center 3333 Capital Medical Blvd Tallahassee, FL 32308

F 0689 Level of Harm - Minimal harm or potential for actual harm On 9/14/23 at approximately 9:30 AM, a record review of the care plan for Resident #117 revealed that she was at risk for falls related to gait/balance problems, with a history of falls, osteoarthritis, morbid obesity, cellulitis in both lower extremities, and left lower extremity edema. Her weight as of 9/13/23 was 349. Resident #112 took Eliquis Oral Tablet 5 MG (Apixaban) twice a day for deep vein thrombosis (DVT) prophylaxis. Residents Affected - Few On 9/14/23 at approximately 11:29 AM, an interview was conducted with the Director of Nursing (DON). She was shown a picture of the commode chair in use by Resident #117 and asked if she felt the chair was safe for use by Resident #117. The DON agreed that the chair needed to be replaced. She was asked to explain the process for checking equipment such as commode chairs to ensure safety for use. She explained that housekeeping and maintenance usually check them. She explained that several new commode chairs were ordered yesterday. The facility started doing an audit of all commode chairs starting 9/13/23. On 9/14/23 at approximately 2:00 PM, the surveyor noted that the commode chair in the room of Resident #117 had been replaced and maintenance had two old commode chairs from unknown resident rooms on a cart removing them from the area. (Photographic evidence obtained) 105364 Page 2 of 2