Health inspection·December 4, 2024

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 ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of six residents (Resident #6) reviewed for activities of daily living . Residents Affected - Few The facility failed to ensure Resident #6 was fed her lunch in a timely manner. This failure could place residents at risk for not receiving adequate care and services to prevent infection, injury, and diminished quality of life. Findings include: Record review of Resident #6's, undated, admission record revealed a [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included senile degeneration of brain (progressive deterioration of brain tissue), dementia (symptoms affecting memory, thinking, and social abilities), and discitis (infection of the intervertebral disc space causing severe back pain, leading to a lack in mobility). Record review of Resident #6's quarterly MDS, dated [DATE], revealed Resident #6 had a BIMS score of 03, which indicated the resident had severe cognitive impact. Resident #6 required supervision or touching assistance for eating. Record review of Resident #6's care plan, dated last revised on 06/24/2024, revealed Resident #6 had an ADL self-care performance deficit related to disease process, she was unable to handle hot liquids and required assistance with meals. Observation of the dining room lunch tray pass on 12/02/2024 at 11:34 AM revealed the ADON oversaw tray pass to the residents seated in the dining area. A lunch tray was placed in front of Resident #6 at 11:49 AM, she was the only resident seated at her table and she was in a Geri chair (specialized recliner). She did not begin eating and continued to watch as the staff passed trays to the rest of the residents. Four other residents at different tables were given their trays and had CNA's sit beside them and began feeding assistance before Resident #6 was assisted with her lunch. The ADON sat next to Resident #6 at 11:59 AM after all residents received their trays to assist Resident #6 with her lunch . An interview with Resident #6 was attempted on 12/02/2024 at 12:05 PM. Resident #6 was asked if she enjoyed her lunch and she responded with a yes, it is good. Resident was unable to follow along for a more in-depth conversation . 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 7 Event ID: 676374 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 12/04/2024 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)