Health inspection·May 30, 2024

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 observation, interview, and record review, the facility failed to promote and maintain the residents' right to be treated with respect and dignity for 1 of 8 residents (Residents #20) reviewed for resident rights, in that: On 05/29/24 CNA A failed to knocked or requested permission before entering Resident #20's room. This deficient practice could place residents at risk of psychosocial harm due to diminished self-image and could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth. Findings include: A record review of Resident #20's face sheet reflected a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #20's diagnoses included type 2 diabetes mellitus with ketoacidosis without coma (a severe lack of insulin in the body), muscle wasting and atrophy (decrease in muscle tissue), chronic pain syndrome (a pain that persist over time and typically results from long standing medical conditions or damage to the body), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition), muscle weakness (lack of muscle strength), and chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems). A record review of Resident #20's Quarterly MDS assessment, dated 05/23/2024, reflected Resident #20 had a BIMS score of 12, which indicated moderately impaired cognition. In an interview and observation of Resident #20 on 05/29/24 at 12:40pm, Resident #20 stated that CNAs often walk in her room without knocking or requesting permission. Resident #20 stated she did not like that because she could be getting undressed, and staff could just walk in without has asking. CNA A was observed walking into Resident #20's room on 05/29/24 at 12:15pm and at 12:25pm. In an interview with CNA A on 05/29/24 at 1:00 pm, CNA A stated that she was not aware that she walked into Resident #20s room without knocking or requesting permission. CNA A stated that staff were to knock before entering a resident's room. CNA A stated if staff don't knock before entering the resident could be scared. In an interview with the DON on 05/30/24 at 12:30pm, the DON stated staff were to knock before entering a resident's room. The DON stated all staff should knock and request permission before entering (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 5 Event ID: 676427 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 676427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Skilled Care of Mexia 501 E Sumpter St Mexia, TX 76667 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)