Health inspection·February 27, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 5 residents reviewed for care in that: Resident #1 was left exposed in his room in an undignified manner. This failure could cause residents to feel uncomfortable and disrespected leading to feeling of isolation and deterioration in general health conditions. Findings include: Record review of Resident #1's face sheet dated 2-27-2024 revealed he was a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), hypertension(a condition in which the foresee of the blood against the artery walls is too high), malignant neoplasm of the bladder, (a fast-growing cancer of the bladder that spreads to other areas of the body), malnutrition(lack of proper nutrition), myocardial infarction (heart attack), and aftercare following survey of the genitourinary system. Record review of Resident #1's last MDS revealed a Medicare 5-day assessment completed on 2-23-2024 with a BIMS of 13 indicating he was cognitively intact, and he had a functional status of requiring partial to moderate assistance with most of his activities of daily living. Section H-Bladder and Bowel: HO100 Appliances-C. Ostomy (including urostomy, ileostomy, and colostomy)-Resident #1 was listed as having an ileostomy. HO300 Urinary Continence-Resident #1 is marked as 1. Occasionally incontinent (less than 7 episodes of incontinence). HO400 Bowel Continence-Resident #1 is marked as 2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement). Record review of the Physician Order Report for Resident #1 with active orders as of 2-27-2024 revealed the following physician's order: Page 1 of 3 675851 675851 02/27/2024 Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

F 0550 Level of Harm - Minimal harm or potential for actual harm - For RLQ surgical site, Cleanse with wound cleanser, pat dry with 4x4. Apply skin prep to peri-wound. Apply Wound vac, to be ran at -125mmHg continues. TIW (M-W-F). one time a day every Mon, Wed, Fri for Wound to Lower abdominal area. Start Date: 02/26/2024 - Nurse to empty Ileum conduit bag to right lateral back. Residents Affected - Few four times a day. Start Date: 02/19/2024 Record review of the care plan with admission date of 02-19-2024 for Resident #1 revealed the following: - The resident has bowel incontinence Date Initiated: 02/20/2024. - Resident has a surgical site to: Hypogastric region, res has a wound vac. Date Initiated: 02/19/2024. - The resident has Ileal conduit urinary diversion cath. Due to bladder being taken out related to Bladder cancer. Date Initiated: 02/23/2024. During an observation and interview on 2-27-2024 at 07:34 AM revealed Resident #1 was overheard from the hallway asking if someone would please close his door. This surveyor observed Resident #1 from the hallway due to his door was completely open and he was in a single occupancy room with no privacy curtain pulled. Resident #1 was noted to be lying in his bed with his cover pushed down below his feet. Resident #1 was wearing only a brief. Resident #1 was observed to have a right-side ileostomy to his abdomen attached to a catheter container hanging from the foot of his bed with a small amount of amber liquid in the container. No privacy bag was provided for the urine container. Also noted was an abdominal wound that had a dressing in the wound that was connected to a VAC wound container. The surrounding abdominal skin tissue was observed. Upon entry Resident #1 stated, I'm looking to get cleaned up, my bed is always wet. Resident #1 was noted to be laying on a draw sheet that was stained amber in color and was wet. There was no noted feces. Resident #1 stated, I always have to ask to have the door closed. Resident #1's call light was noted on the floor. Resident #1 reported that he had kicked of his sheets because everything was wet and soiled with feces. Resident #1 stated, That is why I want the door closed so people walking by won't see me in this condition. Resident #1 was noted to have 50cc's of clear amber urine in his catheter container. Resident #1 did not appear to have any skin breakdown, redness, and his ileostomy bag appeared intact, and his VAC wound appeared in good condition. During an observation on 2-27-2024 at 08:05 AM ADON A and RN B were observed entering Resident #1's room for care and shutting the door. During an observation on 2-27-2024 at 09:05 AM Resident #1 was observed in his room in a hospital gown under his covers. His catheter container could be observed from the hallway with amber liquid due to the door being open. The catheter container was not in a privacy bag. A housekeeper was noted in the room. Resident #1 requested again that his door be closed. 675851 Page 2 of 3 675851 02/27/2024 Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 2-27-2024 at 11:57 AM RN B (the RN that provided care for Resident #1 this AM) reported that Resident #1 was a two person transfer and that she left him in the condition he was in this morning to get a second persons assistance. RN B reported that Resident #1 had a brief covering his private area, and she considered Resident #1 was covered. RN B reported that she felt that Resident #1 knew she was coming back so it was not a dignity issue, that Resident #1 was wet, and that was why they removed all his clothing and covers. RN B verified that Resident #1 always requests that his door be closed, and that staff will often forget and leave it cracked or completely open. RN B verified that Resident #1 was oriented and can and will tell staff when the door was open. RN B reported that the way Resident #1 was left could be a dignity issue. During an interview on 2-27-2024 at 12:04 PM ADON A reported that she rounded at 06:45 AM when she noted that Resident #1 was wet. ADON A removed his robe and Resident #1 asked that it not be replaced due to the ileostomy was leaking and the new robe would just get wet again. ADON A reported that she covered him to the waist with a blanket and left (with his door cracked) to let RN B know that Resident #1 needed care after RN B completed passing her meds. ADON A did not know when Resident #1's door was completely opened but did verify that Resident #1 did not receive his total care that cleaned him up until she and RN B entered the room at 8AM. When asked what the consequences of leaving a Resident exposed, ADON A stated, I know I would not want to be exposed like that. During an interview on 2-27-2024 at 12:25 PM the CN (who verified the facility does not currently have a DON) reported that a resident who was left exposed in their room with the door open was an issue due to direct care staff such as the nurse or aides should have been providing for that resident's privacy. The CN reported that it would be a dignity issue for any resident involved if they were left exposed like that. The CN reported that if the family were to discover a resident like that they would be upset, and it could affect the resident emotionally and physically. Record review of facility provided policy titled, Resident Rights revised 11-28-2016 revealed the following: The resident has a right to a dignified existence . A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and enhancement of his or her quality of life, recognizing each resident individuality. 675851 Page 3 of 3