Health inspection·November 8, 2025

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that resident who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #1) of five residents.The facility failed to change Resident #1 colostomy bag upon request.These failures placed residents at risk of embarrassment, at risk of loss of dignity and a decrease in quality of life.The findings include:During a review of the Face Sheet for Resident #1 reflected a [AGE] year old male admitted to the facility on [DATE] with the following diagnoses: unspecified intestinal obstruction (food or stool cannot pass through the small or large intestine, but the specific cause is not yet known or categorized), unspecified as to partial versus complete obstruction; dysphagia (difficulty swallowing, where food or liquids cannot move easily from the mouth to the stomach), cognitive communication deficit (difficulty in communication that arises from an underlying cognitive impairment, affecting mental processes like attention, memory, problem-solving, and executive function), , gastrostomy status (presence of a gastrostomy (G-tube), which is a surgically created opening in the stomach to allow for feeding or to relieve air and fluid pressure). During a review of Resident #1's Minimum Data Set (MDS) assessment, dated 10/31/25, did not reflect a Brief Interview for Mental Status (BIMS) score for Resident #1 and did not reflect colostomy bag.During a review of Resident #1's Care Plan undated, reflected Resident #1 is on antibiotic therapy Ciprofloxacin 500 milligrams twice a day times five related to urinary tract infection initiated 10/30/25.During an observation and interview on 11/08/17 at 10:30 a.m., Resident #1 was in bed covered up, no odor noted, no distress noted. Resident #1 reported to the state surveyor he wanted his colostomy bag changed. Resident #1 pressed his call light; a facility aide came and checked Resident #1 request and informed Resident #1 they would get the nurse. The state surveyor observed the staff member inform the nurse that Resident #1 wanted his bag changed. Resident #1 stated the bag had not been emptied since last night and that the bag had started to lift and that is why he wanted it changed because he did not want it to leak on him again. Resident #1 stated the bag had leaked on his clothes before but could not recall when or how long it took. Resident #1 stated that he had only been here a few weeks so not that long ago.During an interview on 11/08/25 at 10:50 a.m., the complainant she stated that on 10/26/25 she was in the facility and had observed Resident #1's in bed and his colostomy bag required changing as it had leaked onto his clothing. The complainant stated she witnessed the aide inform the nurse that Resident #1 bag needed to be changed and it took over two hours for the nurse to come change the colotomy bag and then the aide cleaned him up. She stated she was not sure how long he had been like that prior to her arrival but took a picture and stated she would provide the picture. During a record review of complainant photo received on 11/08/25 of Resident # 1. Resident #1 was lying in bed in a blue crewneck sweater and blue pants with noted brown and yellowish stains on Page 1 of 2 676178 676178 11/08/2025 Duncanville Healthcare and Rehabilitation Center 419 S Cockrell Hill Rd Duncanville, TX 75116

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few outside or sweater and pants near Resident #1 right side of the mid-section.During an interview on 11/08/25 at 11:06 a.m., CNA A revealed that only nurses can burp (to expel air through the drainable end or filter opening. Done to manage any odor or splashing), [empty or change colostomy bags. CNA A stated that Resident #1 is the only resident that had a hard time getting his colostomy bag changed. She stated she could tell the nurse, and it could take an entire shift for the nurse to change Resident #1 colostomy bag. CNA A stated if the bag is not changed it could cause resident distress, there was the potential for it to leak on to the skin and cause breakdown and the dignity of the resident, and if not emptied or changed the colostomy bag can have a blowout.During an interview on 11/08/25 at 11:42 a.m., CNA B revealed that aides could not change colostomy bags they were to inform their nurse on duty if resident requested or required their colostomy bag changed. CNA B stated that there had been occasions where a resident requested for their bag to be changed and had to ask the nurse to change the bag multiple times during a shift an entire shift and had witnessed the nurse take all shift before they would change the bag out. CNA B stated when the nurses did not change the bag that the bag would lift and leak onto the resident, which was a dignity issue and could have led to possible skin irritation or breakdown.During an interview on 11/08/25 at 12:25 p.m., LVN C revealed that nurses were the only staff members who could burp/empty/change colostomy bags. LVN C stated that she had one resident on her hall who had a colostomy bag. LNV C stated that Resident #1 had requested it to be changed today on/or before 11 a.m. The LVN stated she had not changed the bag but had burped the bag and would change it after Resident #1 ate lunch. LVN C stated that she asked Resident #1 if he wanted to wait until after lunch for his colostomy bag to be changed and Resident #1 agreed. LVN C stated that residents have the right to have their bag changed upon request. LVN C stated Resident #1 bag was not full so no risk to Resident #1 if bag was not changed.During an interview on 11/08/25 at 1:14 p.m., the DON stated she expects nurses to burp/empty/change colostomy bags as soon as they are able once a resident request. The DON stated the harm of not changing the colostomy bag would be dignity issues at the least and to prevent bag from leaking on the skin which could be causative to the resident's skin and there is potential for infection.During an interview on 11/08/25 at 1:24 p.m., the ADM stated that the resident has the right to have his or her colotomy bag emptied changed at any time it was their right. The ADM stated that the harm of not emptying the colostomy bag when requested would cause resident dignity issues and prevent leaking on the skin. The ADM stated that his expectation of his staff was for staff to change upon request as soon as possible.During a record Review of facility document titled, Rights of the Elderly dated 7/21/18 reflected An elderly individual has all the rights, benefits, responsibilities and privileges granted by the constitution and laws of this stat and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.(1) Has the right to make the individual's own choices regarding the individual's personal affairs, care, benefits and servicesRequested a policy on colostomy care from the DON on 11/08/25 it was not provided prior to exit. 676178 Page 2 of 2