Health inspection·March 21, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. - There was 1 bag of frozen of pizza sausages located in the walk-in freezer that was removed from the original package and not dated or labeled with contents. -There was 1 sealed storage bag of approximately 10-12 pork chops removed from the original package without a label of its contents -There was 1 sealed storage bag of chopped carrots removed from the original package without a label of its contents. -There was 1 sealed storage bag of cooked bacon removed from the original package without a label of its contents. -Dietary Aide L not wearing a beard net while in the kitchen. Dietary Aide L's hair was not restrained and sticking out under the cap. These failures could place residents at risk of food-borne illness. Findings included: Observation on 03/21/2024 at 11:15 a.m., of the walk-in freezer revealed a gallon sized zipper storage bag of frozen pizza sausages removed from the original package without a label of contents or date food item was removed from the original package. Observation on 03/21/2024 at 11:17 a.m., of walk-in refrigerator revealed a gallon sized zipper storage bag of 10-12 pork chops dated 03/20, that were removed from the original package without a label of contents. Observation on 03/21/2024 at 11:17 a.m., of walk-in refrigerator revealed a gallon sized zipper storage bag of approximately 1-2 cups of chopped carrots dated 03/20 that was removed from the original package without label of contents. Observation on 03/21/2024 at 11:17 a.m., of walk-in refrigerator revealed a gallon sized zipper storage bag of approximately 20-25 pieces of cooked bacon dated 03/20 that was removed from the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676179 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676179 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Midland Medical Lodge 3000 Mockingbird LN Midland, TX 79705 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)