Inspection·September 17, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, Resident #2) of 6 residents reviewed for ADLs. Residents Affected - Some The facility failed to ensure: 1Resident #1 had his fingernails trimmed and cleaned. 2Resident #2 had his fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, injuries to self or other residents, and a decreased quality of life. Findings include: 1Review of Resident #1's Comprehensive MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included elevated blood pressure and schizoaffective disorder. Resident #1 had a BIMS of 5 which indicated Resident #1's cognition was severely impaired. He required extensive assistance of two-persons physical assistance with bed mobility and toilet use. He required extensive assistance of one-person physical assistance with personal hygiene. Review of Resident #1's Comprehensive Care Plan, revised 07/12/23, reflected the following: Problem: Resident may require staff assistance for ADL's related to decreased mobility at times. Goal: Resident will increase independence with ADLS. Interventions: Staff to assist with ADLs as needed. An observation on 09/17/23 at 2:22 PM revealed Resident #1 was walking in the hallway using the walker. The nails on both hands were approximately 0.4 cm in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #1 unable to answer questions. (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: 676217 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 676217 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Royse City Medical Lodge 901 W Interstate 30 Royse City, TX 75189 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)