Health inspection·June 30, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 17 of 39 residents reviewed for environmental concerns in that: The facility failed to provide hot running water in the bathrooms for 17 residents assigned to A-Hall for over a month. The facility failed to keep a safe and sanitary environment due to black substance being found in 3 of 39 resident's rooms. This failure placed residents at risk of living in an unsafe, unsanitary, and uncomfortable environment and could potentially cause a decline in their health. Findings included: Observation on 06/30/2024 at 12:44p.m., revealed black substance around the sprinkler head in room [ROOM NUMBER]. Observation on 6/30/2024 at 1:13p.m., revealed black substance around the sprinkler head in room [ROOM NUMBER]. Observation on 6/30/2024 at 1:16p.m., revealed a broken water heater. During an interview on 6/30/2024 at 1:17p.m. with the Floor Tech, he said the water pipe was out of service. He said there is a work order in place. He said there is not hot water on A-hall and C-hall, but C-hall did not have any residents on the hall. He said some residents had been without hot water in their bathrooms for months. He said they only had cold water. Observation on 06/30/2024 at 1:28p.m., revealed a spot of black substance on the ceiling in the restroom in room [ROOM NUMBER]. The smell of mold was present in the restroom. Observation on 6/30/2024 at 1:58p.m., revealed the temperatures of hot water in room [ROOM NUMBER] as 22.8 c, at 1:49p.m., B-hall shower as 42.5c, room [ROOM NUMBER] at 1:54p.m., as 27.2, room [ROOM NUMBER] 1:59p.m. as 44.2c, and room [ROOM NUMBER] at 2:00p.m., as 22.6c. Record Review of the Plumbing Company's invoice for hot water heater dated 6/27/2024, revealed price to complete the following, install a new100-gallon tank water heater, remove the existing water Page 1 of 4 455477 455477 06/30/2024 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0584 heater, hookup material is included, and tax included. Level of Harm - Minimal harm or potential for actual harm Record Review of the Plumbing Company's Purchase of Order Form revealed date required, 6/28/2024. Description, remove old water heater, install new water heater. Residents Affected - Some Observation and interview on 6/30/2024 at 3:00p.m. with an Anonymous resident, revealed them sitting outside of the building in their wheelchair and they said the facility had them in another room where they were becoming sick. They said there was black substance in their room, and it made them cough. They said they were coughing up their food because they were coughing so much. They said black mold could kill people. They said someone came into the room and sprayed bleach on the black substance. They said it took the facility four days to move them to another room. They said they stayed gone from their room throughout the day because breathing in the black substance at night was bad enough. Observation and interview on 6/30/2024 at 3:35p.m. with an Anonymous resident, revealed them sitting in another resident's room, in their wheelchair, next to their bed. They said they experienced no hot water for a month or so. They said it affected them by having to wait longer than normal on staff for a bed bath while they left the room to go all the way to the shower room to get hot water because they were not able to get hot water from the bathroom inside of their room. They said they believed there was black substance inside of the building. They said when they passed by a certain room, while they were going outside to smoke, they said they could smell mold and mildew in the hallways. They said they became sick and had a hard time breathing a few weeks ago. They said they did not inform staff about their sickness. They said mold was not good for anyone's health. Observation and interview on 6/30/2024 with Anonymous resident and they said they did not have hot water and it had been on order for a while. They said it had been a month or so that they had been without hot water. They said it was an inconvenience for them because they cannot shave in their room. They said they would have to go to another room or shave with cold water. They said cold water did not kill germs. During an interview on 6/30/2024 at 1:18p.m. with the Floor tech, he said he strips and waxes floors at the facility. He said they had been understaffed, so he had been doing housekeeping work. He said the water heater had been out for two maybe three months. He said the facility kept sending off quotes to different plumbing companies. He said they sent an order to a company they normally use but the quotes were so high they had to ask for another one. He said on A-hall the resident's had been without hot water in their restrooms for 3 months. He said he is not sure how the residents had been able to get hot water. He said the cold water works fine. He said the showers associated to B-hall, were hot. He said A-hall sinks in the restrooms did not have hot water. He said he believed the water heater is just old. He said he was not sure how it went out. He said there were a couple of spots in the facility that had mold. He said across the hall in room [ROOM NUMBER], and room [ROOM NUMBER] there was black substance in the restroom. He said the Maintenance Director bought mold killer and sprayed the black substance. He said if residents did not have hot water, they could not wash their hands and germs could not be killed and it could spread throughout the facility. He said not having hot water running in the sinks could prevent residents from shaving their beards. He said hot water would open pores while shaving. During an interview on 6/30/2024 at 2:32p.m. with the Assistant Administrator, she said the Maintenance Director told her on Thursday, 6/27/2024 that there was no hot water in some of the resident's rooms. She said she informed corporate, and she was waiting on them to give her a quote regarding 455477 Page 2 of 4 455477 06/30/2024 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0584 how much it will cost to fix the water heater. Level of Harm - Minimal harm or potential for actual harm During an interview on 6/30/2024 at 2:36p.m. with the Administrator, she said she had been the administrator off and on for three years. She said she recently came back on 2/9/2024. She said the hot water heater was working before she left to go home a few weeks ago. She said she was not aware that the water had not been working for over a month. She said she first found out that the hot water was not working in the resident's bathrooms on Thursday, 6/27/2024. She said she immediately contacted the plumbing company, and they gave her a quote. She said the plumbing company should be at the facility on Tuesday, 7/2/2024. Residents Affected - Some During an interview on 6/30/2024 at 2:43p.m. with the Maintenance Director, he said he had been the maintenance director for five years. He said he found out three weeks ago that the residents on A-hall did not have hot water. He said it could have been a month ago. He said he was not sure about the amount of time the residents were without hot water. He said he had a company to come to the facility, but their quote was too high. He said he informed the Administrator of the issues with the water heater and another company came out last Monday or last Wednesday. He said the regional maintenance director knew about the hot water not working in the resident's restroom before last week. He said the first quote given for the water heater was $19,000.00 and it was too high, and the second quote was approved. He said it is his understanding that the Administrator and the Assistant Administrator were aware that the hot water was not working on A-hall. He said he informed someone when he realized the hot water heater was not working. He said he would not keep something like that to himself. He said if the residents did not have hot water, it would prevent them from washing their hands properly and it could cause them to spread germs. During an interview on 6/30/2024 at 2:14p.m. with CNA A, she said she gave residents their showers three times a week. She said she used B-hall shower. She said there are two shower rooms, B-hall, and C-hall. She said the water was hot. She said there had not been a resident complain to her about the water not being hot. She said when she gave bed side baths, she used water from the showers. She said she was not sure if the hot water on A-hall was working. During an interview on 6/30/2024 at 2:19p.m. with CNA B, she said she has worked all the halls, but today she worked A-hall and B-hall. She said she used B-hall shower because there were no residents on C-hall. She said the shower was never really used. She said she also used the shower water on B-hall because it had hot water. She said she could and use the water from the sinks because there was no hot water. She said she asked different staff members how they could wash their hands if there was no hot water. She said she washed her hands with cold water and would find a bathroom where there was hot water to wash hands. She said it had not been a hindrance for her to perform her job properly, but she said if there was no hot water that means they are not killing germs. Record Review of the facility's policy titled Water Temperatures, Safety of revised on 12/2009 read in part . Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110° F (43 ° C), or the maximum allowable temperature per state regulation. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log . Record Review of the facility's policy titled Homelike Environment revised on 02/2021 read in part . Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximize, to the extent possible, the 455477 Page 3 of 4 455477 06/30/2024 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0584 Level of Harm - Minimal harm or potential for actual harm characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment; The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include institutional odors . Residents Affected - Some 455477 Page 4 of 4