Health inspection·July 24, 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 ensure residents were treated with respect and dignity 1 of 6 (Resident #1) sampled residents reviewed for resident rights. The facility failed to ensure that Resident # 1 was dressed appropriately. Resident # 1 was left sitting in his recliner with his pants pulled down to his knees, exposing his adult brief. This failure could affect all residents in the facility not to be treated with respect and dignity and could affect their quality of life and well- being. The findings included: Record reviewed of Resident #1's admission face sheet dated 7/24/2023 revealed Resident # 1 was a [AGE] year-old man with an admission date of 10/16/2020 with unspecified Dementia (a group of thinking and social symptoms that interfere with daily living), Limitation of activity due to disability, Cerebral infraction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), Hemiplegia ( a sever or complete loss of strength or paralysis on one side of the body) and Hemiparesis (partial weakness or loss of strength on one side of the body) following cerebral infraction affecting Left non-dominant side, need for assistance with personal care, and muscle wasting (weakening, shrinking, and loss or muscle) Record reviewed of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 99 which indicated the assessment was unable to be completed. Section G (functional status) of the assessment revealed Resident #1 required extensive assistance with dressing, toileting bed transfers, and personal hygiene. Section also reflected Resident # 1 was total dependent for bathing and he was in a wheelchair. Record reviewed of Resident #1's care plan dated 6/15/2023 reflected, a goal to maintain current level of function in bed mobility, Transfers, eating, and toileting. Interventions included: Resident # 1 required 2 staff assistance with personal hygiene, bathing, bed mobility, dressing, and eating. An interview on 7/24/2023 at 11:30am with Hospice staff, revealed she was contacted by another community provider that provided independent skills for Resident # 1. Hospice staff reported that she was advised that Resident # 1 was found sitting in his recliner asleep with his pants pulled down to his knees with his adult brief exposed. Hospice staff reported that the community provider, provided her with a picture of how she found Resident # 1. Hospice staff stated this was unacceptable of how the staff left Resident # 1 and that she contacted the facility with her concerns. Page 1 of 2 676427 676427 07/24/2023 Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few An interview on 7/24/2023 at 12:30pm with Community provider staff, revealed she arrived at the facility on 5/26/2023 at 10:10am. The Community provider staff stated when she entered Resident # 1's room she observed Resident # 1 sitting in his recliner with his pants pulled down to his knees. She stated she was surprised to find Resident # 1 like that and looked for staff. The Community provider staff stated she found two CNA's who were providing care to another resident and showed them how Resident # 1 was left. The Community provider staff stated CNA B, advised her that CNA A left Resident # 1 in this condition and stated she should not have left the resident that way. The community provider staff reported that Resident # 1 is not able to pull his pants down on his own and stated that she had worked with the Resident # 1 on independent skills. An interview on 7/24/2023 at 3:30pm with CNA B, revealed on 5/26/2023 at approximately 10:30am she and another staff had provided care to another resident when they were made aware by community provider of the condition in which Resident # 1 was left in his room. CNA B stated when she went in the room Resident # 1 was observed sitting his recliner with his pants pulled down and his adult brief was exposed. CNA B stated CNA A had left and went on break before she provided care to Resident # 1. CNA B stated CNA A had to leave Resident #1's pants down because Resident # 1 was not able to pull his pants down himself. CNA B stated she had been in-serviced on resident rights, resident care, and abuse/neglect. CNA B reported the administrator was the abuse/neglect coordinator and stated she had never seen or suspected abuse/neglect at this facility. An interview on 7/24/2023 at 3:45pm with DON, revealed on 5/26/2023 she was advised by LVN A that a complaint was made by a community provider staff regarding Resident # 1. She stated she was advised that Resident # 1 was left with his pants down and the staff went on break. The DON stated when she learned of the incident Resident # 1 had already been changed and had on appropriate clothing when she checked on Resident # 1. The DON stated she brought in the staff CNA A and had discussed with CNA A what was expected of her, she stated she also went over job duties with CNA A. DON stated CNA A was no longer with the facility, she stated she resigned her position. The DON stated all staff had been in-serviced on abuse/neglect and resident care and rights. An interview on 7/24/2023 at 5:00pm with ADM, revealed he had been with this facility since September 2022. The ADM stated he expected all residents are provided the care and services needed and treated with dignity and respect when those services were provided. The ADM stated he learned of the incident regarding Resident # 1 on 5/26/2023 by DON. He stated Resident # 1 was left with his pants down and the staff did not complete the care of the resident before she went on break. The ADM stated he spoke with CNA A regarding Resident # 1 and stated she did not remember leaving that residents pants down but stated she must have. He stated CNA A resigned from the facility. Record review of CNA A personnel file on 7/24/2023, reflected she resigned from the facility on 7/5/2023. Record review of an in-service on Resident care (5/26/2023), Abuse/Neglect/exploitation (5/10/2023), completed with all staff. Record Review of facility policy Resident Rights reflected: The resident has a right to be treated with respect and dignity. 676427 Page 2 of 2