Health inspection·August 15, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 3 (Resident #27, #60, and #64) of 4 residents reviewed for accident prevention. The facility failed to obtain physician orders or a physician assessment as of 08/13/2024 for Residents #27, #60, and #64 for the usage of a Bolster mattress prior to installing the mattress to assist in fall prevention. This failure could prevent residents from having an environment that was free and clear of accidents and hazards. Findings included: Record review of Resident #27's Face Sheet, dated 08/15/2024, reflected she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified dementia (memory decline), lack of coordination, and repeated falls. Record review of Resident #27's Quarterly Minimum Data Set (MDS) dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 06 (severe cognitive impairment) and for ADL care it reflected assistance for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #27's physician orders dated 08/14/24 reflected no orders for a bolster mattress and no physician assessment was observed in the facility system records. An observation on 08/14/24 at 11:03 AM of Resident #27's bed revealed she was sleeping on a bolster mattress, which had the upper and lower sides of the mattress had raised sides of at least 6 inches. Record review of Resident #60's Face Sheet, dated 08/14/2024, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified Alzheimer Disease (memory loss), muscle weakness, and repeated falls. Record review of Resident #60's Quarterly Minimum Data Set (MDS) dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 04 (severe cognitive impairment) and for ADL care it reflected assistance for transfers, toileting, and bathing and the resident was totally dependent (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 4 Event ID: 745039 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 745039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Midtowne Meadows Health & Rehab 110 Dylan Way 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)