Health inspection·January 10, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for one (Resident #1) of 5 residents reviewed for ADLs. Residents Affected - Few The facility failed to ensure Resident #1 received timely incontinent care. This failure could put residents at risk of impaired skin integrity, and decreased feelings of self-worth and dignity. Findings Include: Record review of Resident #1's electronic Face Sheet, dated 01/09/24, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Review of Resident #1's physician orders dated 01/2024 reflected diagnoses included diabetes mellitus (no type indicated) and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Record review of Resident #1's admission MDS assessment, dated 12/18/23, revealed a BIMS score of 15 indicating intact cognition. Further review of the MDS assessment revealed Resident #1 was always incontinent of urine and bowel, dependent on staff for toileting, and required substantial/maximal assistance for bathing. Record review of Resident #1's care plan, dated 12/21/23, revealed self-care deficit, incontinence and the risk for skin breakdown were addressed. The care plan reflected the resident was confined to bed/wheelchair most of the time, experienced generalized weakness and required total extensive assistance with bed mobility and transfers. Interventions included providing assistance with self-care as needed, keeping skin clean, dry, and free of irritants. Care plan goals included Resident #1 would maintain self-care in the area of hygiene and maintain clean and intact skin. Interview on 01/09/24 at 11:02 p.m. Resident #1 stated during the night shift on 01/05/24 he was incontinent of bowel, activated his call light at approximately 12:00 a.m. and received no response or incontinent care until approximately 6:30 a.m. on the morning of 01/06/24 after the day shift arrived. The resident stated he had been incontinent of bowel and remained in feces that burned his skin until the day shift arrived and provided incontinent care. The resident stated during the night shift at approximately 11:00 p.m. CNA A told him she would not be able to provide incontinent care for Page 1 of 2 676358 676358 01/10/2024 The Villages on MacArthur 3443 N MacArthur Blvd Irving, TX 75062

F 0677 Level of Harm - Minimal harm or potential for actual harm him again because she had no help and a lot of residents to take care of. Resident #1 stated in the past there had been other times during the night shift when he had to wait for hours to receive incontinent care. Attempts to interview the CNA who provided care for Resident #1 on the morning of 01/06/24 was unsuccessful. Residents Affected - Few Record review of a facility grievance form dated 01/08/24 revealed Resident #1 voiced concerns of patient care during the night shift 10:00 p.m. 01/05/24 to 6:00 a.m. 01/06/24. The grievance form did not reflect any specifics about what the care concern was. The grievance report further reflected the facility acknowledged the concern, staff was increased to cover resident needs, staff educated on call light response time and the DON would continue spot-checking on the night shift. Interview on 01/09/24 at 11:50 a.m. CNA A stated she was assigned to provide care for Resident #1 during the night shift on 01/05/24. She stated the night was busy and she was assigned alone to Hall 400 and Hall 300 and all residents required some type of assistance including incontinent care, repositioning and/or assistance to the bathroom. She stated Resident #1 was experiencing diarrhea and she provided incontinent care approximately two times relatively close together sometime around the start of her shift which began at 10:00 p.m. CNA A stated five minutes after providing incontinent care for the resident the second time Resident #1 requested incontinent care again. She stated she explained to the resident she was busy assisting others, and she was the only one working his hall plus another hall and could not provide the care at that time. CNA A stated she only made one round during the night of 01/05/24, beginning her first round after 10:00 p.m. and did not finish until nearly 1:00 a.m. She called the on-call nurse asking for help and was told her request would be addressed in the a.m. She stated she told the on-call nurse she was going to leave if she did not receive help within the hour. CNA A stated she received no help and left the facility after 3:00 a.m. on the morning of 01/06/24 because she was not feeling well. Interview with LVN B on 01/10/24 at 2:09 p.m. revealed she was the night shift charge nurse on 01/05/24. She stated on the night of 01/05/24, CNA A told her she was overwhelmed with the two halls she was assigned. The nurse stated sometime after 2:00 a.m. she was unable to locate CNA A and notified the on-call nurse and the DON. LVN B stated she performed incontinent care for Resident #1 at approximately 4:00 a.m. on the morning of 01/06/24. Interview on 01/10/24 at 2:49 a.m. the DON stated the expectation was for rounds to be performed every two hours and it was important for residents to receive timely incontinent care to prevent negative issues such as skin breakdown and worsening of wounds. Record review of the facility's policy/procedure entitled Perineal Care revised 04/10/23, reflected staff would provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection. The policy/procedure did not address the timeliness of the provision of incontinent care. 676358 Page 2 of 2