Health inspection·December 3, 2025

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 interviews, observations, and record reviews, the facility failed to protect and promote the right to a dignified existence for 1 (Resident#1) out of 3 residents reviewed, The facility failed to provide Resident#1 with a dignified lunch meal service, when the Medical Record Staff stood beside Resident#1 bed and leaned over Resident#1 to feed him on 10/24/25. This failure could result in resident not feeling respected and a decline in Quality of life.Findings included: Record review of Resident#1's face sheet, dated 10/24/25 reflected, he was a [AGE] year-old male who was originally admitted on [DATE] and readmitted on [DATE]. He was diagnosed with but not limited to: Legal blindness as defined in USA (central visual acuity of 20/200 or less in the better eye with the use of a correcting lens, or visual field of 20 degrees or less), Cognitive communication deficit (difficulty in communication caused by problems with underlying cognitive functions like memory, attention, and executive function), Acute Kidney failure (a sudden and significant decline in kidney function that leads to an inability to remove waste products and excess fluid from the body), Unspecified severe protein-calorie malnutrition (a condition characterized by a significant deficiency in both protein and calories, without a specific underlying cause), major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest), recurrent unspecified, altered mental status unspecified (a change in a person's level of consciousness, orientation, or cognitive function without a specific underlying cause), Type 2 Diabetes Mellitus with ketoacidosis without coma (an acute medical emergency characterized by high blood sugar, ketones in the urine, and an acidic blood state, but the patient remains conscious) and unspecified abnormalities of gait and mobility (any changes or irregularities in the way a person walks or moves that cannot be attributed to a specific underlying medical condition. ). Record review of Resident#1's quarterly MDS assessment, dated 10/20/2025 reflected his BIMS score was 15 which indicated [Resident #1's] cognition was intact. [Resident#1] was independent (Resident completes the activity by themselves with no assistance from a helper) with Eating (The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). Record review of Resident#1's care plan, dated 10/20/2025 reflected: [Resident#1] had renal insufficient r/t AKI. [Resident#1] goal included no s/sx of complications r/t fluid deficit. Resident#1 interventions included assist resident with ADL's and ambulation as needed. Watch for SOB and match level of assistance to residents' current energy level. Resident #1's review reflected, ADL self-care performance deficit r/t blindness. [Resident#1] would maintain level of function.eating [Resident #1] interventions included staff will provide the appropriate level of physical assistance with ADL's as needed due to his self-ability may fluctuate throughout the day. Page 1 of 2 676188 676188 12/03/2025 Millbrook Healthcare and Rehabilitation Center 1850 W Pleasant Run Rd Lancaster, TX 75146

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 10/24/25 at 12:45 pm, the Medical Records Staff stood next to Resident #1's bed and asked him to take a couple bites of Jello. The Medical Records Staff fed Resident#1 two spoonsful of Jello. Resident #1 took more than three sips of water and took two sips of his shake supplement. Resident #1 refused to eat any more food from his plate. The Medical Records Staff asked Resident#1 if he would like chicken noodle soup. Resident #1 agreed, and the Medical Records Staff fed Resident#1 two spoonsful of chicken noodle soup while she stood over him. During an interview on 10/24/25 at 1:10 pm, the Medical Records Staff stated that she did rounds during meals to see if the residents needed help with their meals. The Medical Records Staff stated Resident #1 had to have the meals set-up and cued to eat. Medical Records Staff stated she had not realized she was standing and was trying to help assist residents during meals. During an interview on 10/24/25 at 2:20 pm, LVN A stated when assisting a resident with meals staff should sit down with the residents and not stand over the residents. During an interview on 10/24/25 at 2:30 pm, CNA B stated for Resident #1, staff should set-up his tray and tell him where everything was located. CNA B stated that when feeding residents staff should sit at eye level and not stand over residents. During an interview on 10/24/25 that started at 2:40 pm, CNA C stated when feeding residents staff should sit down to feed residents because it is a dignity concern when standing over residents. CMA E stated Resident#1 was supposed to have his tray set-up and cued. During an interview on 10/24/25 at 2:55pm, the DON stated staff were supposed to sit down and be able to be at eye level with the residents. The DON stated staff could have conversations with the residents. The DON stated Resident #1 was supposed to be cued and encouraged to eat his meals. Record review of the facility's policy, undated, titled: Section: Quality of care. Subject: ADL., services to carry out reflected,. It is the policy of the facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care Record review of facility admission packet, revised 02/2022 reflected: .you have the right to be treated with respect and dignity. 676188 Page 2 of 2