Health inspection·May 12, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were treated with dignity and respect for 3 (Resident #1, #5, and #7) of 10 residents reviewed for residents' rights in that: -Resident #1 was found to have soiled (feces) wipes left in her brief until her scheduled shower time. -Residents #5 and #7 did not have their briefs changed in a timely manner according to the facility's policy and procedures. These deficient practices could place residents at risk for impaired dignity, loss of self-worth, and a decline in psychosocial well-being. Findings included: Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Lymphedema (define), Rheumatoid Arthritis (define), Primary Hypertension (high blood pressure), and Generalized Muscle Weakness. Observation and Interview on 5/11/2024 at 1:57 PM revealed Resident #1 alert and oriented to person, place, time, and event. Her daughter was at her bedside. Staff transferred Resident #1 from the bed to her wheelchair. She was waiting to be discharged from the facility. The resident said the facility was short staffed, so the level of care was inadequate and unacceptable . She said she was incontinent to bowel and bladder. She said the CNA left soiled (feces) wipes in her brief before bringing her to take her scheduled shower. She said knowing a soiled wipe had been left in her brief made her feel uncomfortable and upset. She said she told her daughter, spoke with the administrator, and filed a grievance. She said the treatment and conditions were unacceptable, and she could not wait to leave the facility. She said she felt dehumanized when they left the soiled wipe in her brief. She said she was embarrassed and worried about potential infection from the fecal contact with her private parts. Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year-old female admitted on [DATE] with diagnoses of schizoaffective disorder (combination of symptoms of schizophrenia and mood disorder, Page 1 of 2 675991 675991 05/12/2024 Park Manor of Humble 19424 McKay Dr Humble, TX 77338

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some such as depression or Bipolar Disease), Bipolar Disorder (mental illness that causes unusual shifts in mood from extreme highs to lows), Dysphagia (difficulty swallowing), Generalized Muscle Weakness, and Morbid Obesity. Record review of Resident #5's MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating she was cognitively intact. Interview on 05/11/24 at 3:53 PM, Resident #5, said she had been at the facility for five years. She said she has to call the CNA several times before they change her brief. She said it would take so long she had to use her cell phone to contact the front desk staff because the call light was not answered. She said the problem was not enough staff. She said there had been a slow decline in care, and she would get very upset when it took so long to change her brief because she had sensitive skin, and she worried her urine would cause skin breakdown and turn into some worse. She said she felt like less of a person while she waited hours to change her soiled briefs. She said it made her feel like no one cared. Resident #7 Record review of Resident #7's face sheet revealed a [AGE] year-old male admitted on [DATE] with diagnoses of Dementia (memory loss), Primary Hypertension (high blood pressure), Peripheral Vascular Disease (poor circulation), and Muscle Wasting. Record review of resident #7's MDS dated [DATE] revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. Interview on 5/12/24 at 10:25 AM with Resident #7, he said his shower days were Tuesdays, Thursdays, and Saturdays. He said sometimes he had gone without his brief being changed during an entire shift. He said the facility was shorthanded and needed help. He said, I feel small and not like a human being when they do not change me when I need to be changed. In a telephone interview on 05/12/24 at 11:24 AM with CNA A, she said she had worked at the facility for 7 years. She said she worked as the shower tech from 6:00 AM to 2:00 PM Monday through Friday. She said she remembered a resident who had a wipe with stool left in her brief. She said it was removed when she took her brief off for her scheduled (Mondays, Wednesdays, and Fridays) shower . She said she thought it was an accident and wasn't purposely left in the brief by CNA B. CNA A said this was the first time she witnessed a wipe left in a resident's brief. Interview on 05/12/24 at 1:05 PM with the Administrator, he said the reason why CNA B was no longer on the schedule was due to the incontinent care concern with Resident #1. Record review of facility policy titled Resident Rights and Guidelines for all Nursing Procedures, undated, read in part, . Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including Resident dignity and respect . Record review of facility policy titled Perineal Care, revised December 2011, read in part, .The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . . 675991 Page 2 of 2