Health inspection·December 1, 2023

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 promote care for resident in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 1 (Resident #1) of 3 residents reviewed for dignity in that: The facility failed to provide dignity and respect for Resident #1 by leaving the resident on the floor face down with his buttocks exposed. This failure could place residents at risk for embarrassment. Findings include: Record review of Resident #1's face sheet dated 11/30/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included: hypoglycemia (low blood sugar), Parkinson Disease, Depression, Heart Failure, Dysarthria and Anarthria, Secondary Malignant Neoplasm, Anemia, Morbid Obesity, Chronic Atrial Fibrillation, Cognitive Communication Deficit, Type 2 Diabetes, Unspecified Dementia, Peripheral Vascular disease, Muscle Weakness, Dysphagia Edema, Hypertension, Vitamin Deficiency, Presence of Coronary angioplasty implant and Graft, and Muscle Weakness, Muscle weakness and atrophy. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed Resident #1 had a BIMS of 10 which indicated moderately impaired cognition. Section H noted the resident had bowel continence and urine continence. Record Review of Resident #1's care plan dated 07/13/23 revealed Resident #1 had a plan for assistants with ADL due to declining physical status. Resident needs help with bathing, dressing, incontinence care, and transfer. Resident was also care planned for falls. Precautions to prevent falls were bed in lowest position fall matt and during transfer two person assist and Hoyer lift. Observation of a photo on 11/30/23 at 10:45 am. that was obtained from CNA-A revealed Resident #1 was lying on the floor in his room face down with his buttocks exposed. Resident #1 brief was position in a manner to where his buttocks was completely exposed for anyone to see. In an interview on 11/30/23 at 6:36 p.m. with CNA-A revealed that she went into Resident #1 room at the beginning of her shift to check on the residents on her assigned hall when she discovered him lying on the floor face down and his buttocks exposed. CNA-A said she took a photo of the resident to show administration what condition the resident was in because the facility's Nursing staff refused Page 1 of 4 676050 676050 12/01/2023 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0550 to come assess the resident. Level of Harm - Minimal harm or potential for actual harm In interview on 12/01/23 at 2:00pm with ADON-A revealed that she was aware of the photo, and she stated that she instructed CNA-A that her action of taking the photo was disrespectful to the resident and it was a HIPPA violation. ADON-A also stated that it was also against facility policy to take any photos of residents without their consent and that it was against facility policy to share residents' information. Residents Affected - Few In interview on 12/01/23 at 2:30pm with the Administrator revealed that he was aware of the photo and that CNA-A should not have taken the photo and that she should have tried to cover the resident to protect the resident's dignity. Also, during this interview, it was revealed by the Administrator that upon the hire of CNA-A she signed a facility policy that taking photos of residents were a violation of HIPPA. 676050 Page 2 of 4 676050 12/01/2023 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident was free from abuse, neglect, and exploitation for 1 (Resident #1) of 3 residents reviewed for abuse in that: The facility photographed Resident #1 exposed buttock. This failure could place residents at risk for embarrassment. Findings include: Record review of Resident #1's face sheet dated 11/30/23 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included: hypoglycemia (low blood sugar), Parkinson Disease, Depression, Heart Failure, Dysarthria and Anarthria, Secondary Malignant Neoplasm, Anemia, Morbid Obesity, Chronic Atrial Fibrillation, Cognitive Communication Deficit, Type 2 Diabetes, Unspecified Dementia, Peripheral Vascular disease, Muscle Weakness, Dysphagia Edema, Hypertension, Vitamin Deficiency, Presence of Coronary angioplasty implant and Graft, and Muscle Weakness, Muscle weakness and atrophy. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed Resident #1 had a BIMS of 10 which indicated moderately impaired cognition. Section H noted the resident had bowel continence and urine continence. Record Review of Resident #1's care plan dated 07/13/23 revealed Resident #1 had a plan for assistants with ADL due to declining physical status. Resident needs help with bathing, dressing, incontinence care, and transfer. Resident was also care planned for falls. Precautions to prevent falls were bed in lowest position fall matt and during transfer two person assist and Hoyer lift. Observation of a photo on 11/30/23 at 10:45 am. that was obtained from CNA-A revealed Resident #1 was lying on the floor in his room face down with his buttocks exposed. Resident #1 brief was position in a manner to where his buttocks was completely exposed for anyone to see. In an interview on 11/30/23 at 6:36 p.m. with CNA-A revealed that she went into Resident #1 room at the beginning of her shift to check on the residents on her assigned hall when she discovered him lying on the floor face down and his buttocks exposed. CNA-A said she took a photo of the resident to show administration what condition the resident was in because the facility's Nursing staff refused to come assess the resident. In interview on 12/01/23 at 2:00pm with ADON-A revealed that she was aware of the photo, and she stated that she instructed CNA-A that her action of taking the photo was disrespectful to the resident and it was a HIPPA violation. ADON-A also stated that it was also against facility policy to take any photos of residents without their consent and that it was against facility policy to share residents' information. In interview on 12/01/23 at 2:30pm with the Administrator revealed that he was aware of the photo and that CNA-A should not have taken the photo and that she should have tried to cover the resident to protect the resident's dignity. Also, during this interview, it was revealed by the Administrator 676050 Page 3 of 4 676050 12/01/2023 Focused Care at Pasadena 3434 Watters Rd Pasadena, TX 77504

F 0600 that upon the hire of CNA-A she signed a facility policy that taking photos of residents were a violation of HIPPA. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676050 Page 4 of 4