Health inspection·September 9, 2022

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Kidney Disease, Type 2 Diabetes Mellitus, Hyperlipidemia (too many lipids (fats) in the blood), Muscle Weakness and Respiratory Failure. Review of Resident # 41's MAR for September 2022 reflected an order for Carvedilol Tablet 6.25 mg. Give 1 tablet by mouth two times a day for AFIB hold for SBP less than 100 or DBP less than 60 or pulse less than 60. An observation and interview of taking blood pressure using a wrist blood pressure monitor on 09/08/2022 beginning at 10:00 am, revealed MA-A did not sanitize the wrist blood pressure cuff after using it on Resident #19 and before using it on Resident #41 until the surveyor intervened. MA-A stated that all the healthcare providers should sanitize their hands as well as reusable medical equipment after the use. She stated that it was a mistake from her side and will remember not to repeat the same mistake in the future. She also said she did not sanitize the blood pressure cuff in between residents during her entire medication administration task in the morning on 09/08/2022. Review of Resident # 7's medical record reflected an [AGE] year-old woman admitted on [DATE]. Her diagnoses included Type 2 Diabetes Mellitus, Transient Cerebral Ischemic Attack (a temporary period of symptoms similar to those of a stroke), Hypertension and Dementia. Review of Resident # 7's MAR for September 2022 reflected an order for Hydrochlorothiazide Tablet 12.5 MG. Give 1 tablet by mouth one time a day for HTN. Hold for SBP less than 100 and/or DBP less than 60. Review of Resident # 144's medical record reflected a [AGE] year-old woman initially admitted on [DATE] and readmitted on [DATE]. Her diagnoses included Chronic Atrial Fibrillation (an irregular and often very rapid heart rhythm), Major depressive Disorder, Primary Osteoarthritis (a degenerative disease of bones that worsens over time), Absolute Glaucoma (a condition of the eyes causing gradual loss of eyesight), Hypertension and Unspecified Dementia. Review of Resident #144's MAR for September 2022, reflected an order for Labetalol HCL tablet 200 mg. Give 1 tablet by mouth two times a day related to essential (primary) Hypertension. An observation and interview of taking blood pressure using a wrist blood pressure monitor on 09/08/2022 beginning at 10:50 am, revealed MA-B took over the medication administration task from MA-A at 10.30 am on 09/08/2022 in Hall 500. MA B did not sanitize the wrist blood pressure cuff after using it on Resident #86 and before using it on Resident #144 until the surveyor intervened. MA-B stated that she was aware that sanitization should be done on blood pressure cuffs and other medical equipment after it was used on residents. She stated that she work in the facility almost a year. She said forgot about it and will remember sanitizing every time after the use of it on residents. An interview on 09/09/2022 at 11:00 am with the DON revealed that her expectation was that the nursing staff follow facility policy/procedure for handwashing/sanitization and when using reusable medical equipment. The DON added that they had infection control training annually and in services on regular intervals related to infection control (e.g., Hand washing). The facility identifies deficiencies in infection control practices through direct observations by the ADON and DON on a regular basis. The DON said in services were provided to the relevant staff members by her when any deficiencies were identified. Facility's policy Cleaning and disinfection of resident-care items and equipment dated July 2014 it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676374 If continuation sheet Page 2 of 5 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 676374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Midlothian Healthcare Center 900 George Hopper Rd Midlothian, TX 76065 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)

F 0880 was stated that Level of Harm - Minimal harm or potential for actual harm . 3. Durable medical equipment (DME)must be cleaned and disinfected before reuse by another resident Residents Affected - Some 4. Reusable resident care equipment will be decontaminated and /or sterilized between residents according to manufacturer's instructions 5. Only equipment that is designated reusable shall be use by more than one resident. Review of the MDS assessment for Resident #19 dated 7/05/22 reflected a BIMS score of 00 indicating she was unable to complete the questions. She was assessed with Inattention, disorganized thinking, and altered level of consciousness. Her functional assessment reflected she required extensive assistance for all ADLs except eating. She was assessed as having a catheter and always incontinent of bowel. Review of the Care Plan for Resident #19 reflected interventions were in place for: Urinary Tract Infection, Anxiety, Dementia, Psychotropic Drug use, Unplanned weight loss, Antibiotic therapy (9/02/22), DNR status, Depression, Potential complications related to use of Foley catheter due to urinary retention. Review of the Physician's orders for Resident #19 dated 3/07/22 reflected her Foley Catheter leg bag should be removed at bedtime and replace with a Foley catheter bag. Review of progress Notes from 8/23/22 to 9/08/22 reflected no mention of changing catheter bag from leg bag to catheter drainage bag. Review of Infection Control Logs reflected Resident #19 had Urinary Tract Infection or UTI from 9/01/22 to 9/07/22 and laboratory results reflected the infection was from E Coli bacteria (commonly found in stool and urine). Observation on 9/08/22 at 11:07 am of Resident #19's room revealed a catheter drainage bag was stored in a clear plastic bag in the bathroom, with plastic toilet measuring hat. The tubing was observed to have urine in the collecting tube and a urine smell was noted in the bathroom. The plastic bag was open at the top, not closed or tied. Resident #19 was up in her wheelchair in the room. In an interview on 9/08/22 at 1:37 pm Resident #19 was observed sitting up in her wheelchair. She stated her leg bag was usually replaced weekly, but they did not always replace it on time. In an interview on 9/08/22 at 1:45 pm, LVN S stated catheter care was regularly done each shift and as needed. LVN S stated she understood catheter bags were to be changed weekly. She stated catheter replacement and switching bags was performed by a nurse. Observation on 9/08/22 at 2:32 revealed Incontinence Care by CNA O was performed for Resident #19. After washing his hands, the Aide gathered supplies and came to bedside. After undoing the brief, CNA O wiped from front to back with disposable wipes. He did not change his gloves at this time. The Aide then wiped down the catheter tubing, away from the Resident. After completing this portion of care, the aide did not change his gloves or sanitize his hands. Resident #19 turned onto her left side and when the brief was removed, she was incontinent of a small amount of BM. The Aide did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676374 If continuation sheet Page 3 of 5 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 676374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Midlothian Healthcare Center 900 George Hopper Rd Midlothian, TX 76065 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some change his gloves or wash his hands after cleaning the BM. The Aide did not change his gloves or wash his hands on at least three opportunities; after performing the catheter care and cleaning to the front portion of Resident periarea. The aide then cleaned the posterior area and removed the dirty brief. The Aide did not wash his hands or change his gloves after cleaning BM and placed the clean brief on the Resident. In an interview on 9/08/22 at 2:40 pm, CNA O stated he should have changed his gloves after cleaning Resident #19' front peri area and catheter. He stated he should have also changed gloves and washed his hands after cleaning the BM from Resident. In an interview on 9/08/22 at 2:45 pm, LVN S stated Aides who had been trained and completed check-off were allowed to change catheter bags for Residents. She stated trained aides were allowed to change Resident #19's catheter drainage bag from leg to a bedside drainage bag. She stated the bags should be cleaned or rinsed before stored in the bathrooms. She stated the aides should be cleaning the bags after emptying and recording the volume of urinary output for the Resident. LVN S stated if she saw a collecting bag sitting in a Resident's bathroom with urine in it or urine in the collecting tube, she would throw it away and get a new one. She stated the bag would not be suitable for reuse after urine and bacteria sat in it all day. In an interview and observation on 9/08/22 at 2:55 pm, CNA N stated she had been asked by her charge nurse to put a new bedside urinary collection bag in Resident #20's room. Observation revealed the old bag with urine in it had been removed from the bathroom. CNA N stated urinary leg bags were emptied every 2 to 3 hours. She stated Resident #20 was able to get up and go to the bathroom for bowel movements. She stated he received catheter care once per shift and as needed. CNA N stated she did not know why the nurse had replaced the bag. In an interview on 9/09/22 at 9:20 am the DON stated Aides were changing catheter bags, but she was not sure who had done training and when. The DON stated she would supply a copy of the training given to aides changing catheter bags from leg bags to bedside drainage bags. The DON stated the bags should not be stored in the bathroom in open bags. She stated the bags should be sealed, not gapped, or left open to air. She stated the drainage bags should be emptied and clean. She was asked if drainage bags should be rinsed out, she stated she did not know if bags were being rinsed. The DON stated catheter bags should be emptied into a measuring container, which could be a urinal or a hat (sample collection hat for toilet). She stated the drainage bags should not contain fluids and anyone entering the bathroom should not be exposed to bodily fluids. She stated urinals should also be stored in bags. She stated catheter bags should have privacy covers at all times. Observation and interview of catheter care on 9/09/22 at 10:07 am for Resident #8 revealed care provided by CNA K. Resident #8 was positioned in bed, CNA K removed the Resident's brief and then wiped the catheter away from the Resident's body three times. She utilized a clean disposable wipe each time and used each wipe once. She was observed changing gloves and did not sanitize her hands. She was observed cleaning the Resident's skin, down the shaft of the penis and moving it away from the catheter. She changed her gloves again and did not sanitize her hands. She completed a third round of cleaning on Resident #8's skin. She changed her gloves again and did not wash her hands or sanitize. In an interview at 10:11 am, CNA K stated she had not sanitized her hands during glove changes, and she should have. In an interview on 9/09/22 at 2:05 pm, the DON stated she had done training and checkoffs on incontinence care with aides/CNAs. She stated the Aide for Resident #19 should have washed his hands when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676374 If continuation sheet Page 4 of 5 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 676374 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Midlothian Healthcare Center 900 George Hopper Rd Midlothian, TX 76065 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some providing care and should have changed gloves after touching the Resident's skin before moving to another area (should change gloves and wash hands before moving from front to back). The DON stated she was aware the Aide providing care to Resident did not sanitize between glove changes and had been provided in-service education. Review of In-Service/Education for staff reflected on 2/7/22 and on 1/17/22 all staff received education on Perineal/Pericare for Female and Male Residents from the DON. Other in-services for the above dates included Infection control r/t C-Diff (Clostridium Diffocile Bacteria), Handwashing/Hand Hygiene, Isolation Categories and PPE (Personal Protective Equipment). Review of the Infection Control Policy for the facility dated 10/2018 reflected standard precautions (use of gloves, handwashing and PPE as needed) must be used when caring for residents at all times regardless of suspected or confirmed infection status. Washing hands must be performed under runnin water with soap for 20 seconds prior to care and with each change of gloves. Using alcohol based hand rubs, staff are to follow manufactures' directions. Hand hygiene is to be performed after contact with Resident's skin, bodily fluids, surgical dressings and respiratory equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676374 If continuation sheet Page 5 of 5