Health inspection·December 23, 2025

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. Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 3 of 3 shower rooms (A-Hall, B-Hall, and C-Hall) reviewed for cleanliness and sanitization.The facility failed to maintain clean and organized shower rooms, maintenance leaking shower head faucet, and properly dispose of dirty briefs and used linen.These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings included: During an observation on 12/19/2025 at 01:12 p.m.in unlocked shower room A-Hall (across from the nurse's station) had leaking water dripping from shower head faucets. Floor and wall tiles were discolored under leaking water. During an observation on 12/19/2025 at 01:14 p.m. in unlocked shower room on B-Hall (resident's hall) were 2-open wall cabinets that were full of unorganized items consisting of loose gloves, unfolded towels, 1 of 2 personal grey bins tipped over on its side, brief wipes slightly opened exposed wipes, 3-shaving cream containers without tops, 1 of 3 leaking cream, 2 of 3 knocked over, and tops sitting to the side. Folded towels hanging halfway off edge of shelf. Atop shower table laid damp and bunched up towels at one end of table. Large clear bag of dirty bedsheets on shower room floor, shower floor was stained and discolored, 3-damp face towels rested on floor in crumpled balls, 1 of 2 trashcans overfilled, blue shaver razor resting on top of an adult brief with blood like substance, discolored shoestring laying on floor near side of can, 2 of 2 trashcans overfilled with used disposable bed protectors, back of shower chair covered with damp bed sheets, clean folded towels sitting on closed seat of toilet, foam hand/bath soap sitting on toilet back, and 1-soiled bagged adult brief on floor near door entry. During an observation on 12/19/2025 at 01:31 p.m. in locked shower room C-Hall (memory care unit) floor tile rubber protector aligning wall loose and laying on floor near floor drain exposing wall adhesive and 1-damp face towel resting on one arm of shower chair. During an observation on 12/19/2025 at 03:12 p.m. shower rooms A, B, and C Halls were in unchanged conditions as last observed on 12/19/2025 between 01:12 p.m. and 01:31 p.m. During an overheard observation on 12/19/2025 at 03:11 p.m. ADON asked a CNA (name unknown) on C-Hall/memory care who last used the showers. The CNA stated that they had not given any showers on 12/19/2025. During an interview on 12/19/2025 at 03:07 p.m. Assistant Director of Nursing (ADON) stated that the certified nursing aides (CNAs) had been responsible for the upkeep of the shower rooms. She stated infection control was the importance of keeping the shower rooms clean. She stated it also kept residents free of various illness exposure. She stated she was not aware of the leaking faucet in A-Hall's shower room. She stated the importance of keeping the faucet leak free was to safeguard buildup of water that could breed bacteria. She stated that she was not aware of shower room B-Hall and C-Hall were dirty or hand damp items within. She stated that it had been the responsibility of the CNA who last used the rooms to disinfect and remove all used items. During an Page 1 of 11 455477 455477 12/23/2025 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interview on 12/19/2025 at 03:27 p.m. Administrator (ADM) stated that leaving the shower rooms dirty, wet and unkept placed residents at risk of dignity and respect issues. He stated the facility was the resident's home and should be upkept as such. During an interview on 12/19/2025 at 03:48 p.m. Housekeeping Supervisor (HS) stated that the dirty briefs, damp and used towels, bedsheets, and shaving razors left in the shower rooms were the responsibility of the CNAs who last used the shower rooms. She started failing to do so, placed residents at risk for infection control issues, and dignity and respect as the facility was the residents home and should be kept up and homelike. During an interview on 12/19/2025 at 03:56 p.m. ADM stated that the leaking shower head faucet in shower room A-Hall had been addressed by the Maintenance Director and would have a list of all staff who used the showers rooms on 12/19/2025. During an interview on 12/19/2025 at 03:59 p.m. ADON stated in-service education would be provided to a hospice staff that last provided a resident a shower on 12/19/2025 in the shower room on the C-Hall. During an interview on 12/19/2025 at 04:05 p.m. HS provided a daily shower room checkoff list (DSRCL) where those who last used the shower room noted they had cleaned the room. She stated a charge nurse would then check off verifying that the cleaning tasks were performed. She stated on 12/19/2025 no shower rooms were checked off as they were being cleaned. She stated the importance of keeping the shower rooms clean was to maintain infection control and residents' dignity and respect. During an interview on 12/19/2025 at 04:40 p.m. CNA A stated that she had worked at the facility for over 2 years on a rotating 6 a.m. to 6 p.m. She stated that she had provided a shower to a resident at the beginning of her shift on 12/19/2025 in the B-Hall shower room, but had cleaned and sanitized the shower floor, shower chair, and shower bed when she was done. She stated that CNA C also provided a resident with a shower on the B-Hall on 12/19/2025 but had not cleaned up after the shower. During an interview on 12/19/2025 at 05:01 p.m. CNA B stated that CNA A used the B-hall shower room on that day at the beginning of their shift on 12/19/2025 and had cleaned the room once finished. She stated CNA C had last used B-Hall's shower room but had not cleaned up the room once finished. During an interview on 12/19/2025 at 05:24 p.m. CNA C stated she had used B-Halls shower room but had not had time to clean it before lunch trays had come out. She stated when trays come to the floor it had been her responsibility to assist with getting them to the residents immediately. She stated she had forgotten to go back to clean the shower room after passing trays. She stated the bags on the floor in the shower room all had bins for proper disposal within the shower room. She apologized and stated it had been her fault and noted that the importance of keeping the shower areas cleaned and kept up was to ensure residents-maintained dignity and respect as the facility was their home, infection control, and keeping residents free of infections. During an interview on 12/23/2025 at 03:09 p.m. CNA D stated the importance of maintaining clean shower rooms related to and maintaining residents' dignity and respect. During an interview on 12/23/2025 at 03:20 p.m. CNA E stated that water had been leaking in shower room A-Hall since she began working for the facility in April 2025. She stated that the facility was aware but would not tell how she knew or who had known. She stated that the faucets should remain leak free to maintain residents' dignity and respect, infection control, and infection free. During an interview on 12/23/2025 at 03:30 p.m. Maintenance Director stated he had not been made aware of the leaking faucet in shower room on A-Hall. He stated there were no maintenance requests for the leak noted in the maintenance logbook kept at the nurse's station. He stated on 12/22/2025 a plumber replaced a part in the faucet, and it was no longer leaking water. He stated the importance of ensuring that there was no leaking/dripping water was to avoid legionella (a serious lung infection (pneumonia) caused by a bacteria, caught by inhaling mist from contaminated warm water sources like cooling towel and showers), harmful molds and mildew. During 455477 Page 2 of 11 455477 12/23/2025 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some an interview on 12/23/2025 at 6:04 p.m. ADM and ADON stated that staff received in-service training on the new shower room policy (but had not provided the in-service for review). Record review of an email dated 12/19/2025 at 04:13 p.m. ADM indicated that there were 3-CNA A, CNA B, and CNA C who performed showers for residents on 12/19/2025. Record review of the DSRCL date beginning 11/25/2025 - 12/19/2025 reflected that on 12/19/2025 A-Hall's shower room was checked off as being cleaned by housekeeping staff A and verified by licensed vocational nurse (LVN) A, but there had been no time listed. Record Review Policy titled: Shower Room Cleaning Policy Purpose To ensure shower rooms are cleaned and disinfected consistently to prevent the spread of infection and maintain a safe, sanitary environment for residents, staff, and visitors. Policy: All resident shower rooms at the facility will be cleaned and disinfected after each resident use and daily at minimum, using facility-approved disinfectants and following infection prevention standards.Procedure: After Each Resident UseThe following surfaces must be cleaned and disinfected either by EVS or Nursing staff immediately after use: Shower chair / shower stretcher Grab bars Shower controls and handles Walls within splash zone Floors and drains Any reusable equipment used during bathing Steps:1. [NAME] appropriate PPE (gloves; gown and face protection if splashing is anticipated).2. Remove visible soil using approved cleaner.3. Apply facility-approved disinfectants to all required surfaces.4. Allow disinfectants to remain wet for required contact time per manufacturer instructions.5. Rinse surfaces if required and allow area to air dry.6. Remove PPE and perform hand hygiene. Daily Cleaning (Even If Not Used)EVS staff will clean and disinfect: Floors Walls Grab bars Door handles Light switches Trash receptacles (No razors should be discarded in the trash; please use sharps receptacles) Terminal CleaningShower rooms will receive enhanced cleaning: After use by a resident on isolation precautions Following a known or suspected infectious outbreak As directed by Infection Prevention or Nursing Leadership 455477 Page 3 of 11 455477 12/23/2025 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0692 Provide enough food/fluids to maintain a resident's health. 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 maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or resident preferences indicated otherwise for 1 (Resident #1) of 6 residents reviewed for weight loss: The facility failed to provide weekly weights for Resident #1 on 10/27/2025, 11/10/2025, 11/17/2025, 11/24/2025, 12/08/2025, and 12/15/2025. Resident #1 was noted to have weight loss on 12/01/2025 and 12/17/2025 who had gastrostomy status (refers to a patient having a surgically placed tube (G-tube) into their stomach for feeding or draining, requiring ongoing care) diagnosis. These failures had the potential to affect other residents requiring weight management, especially those who have weight loss and weight gain and who could be at risk of serious harm due to poor nutrition and weight loss. Findings Included: Record review of Resident #1's Facesheet dated on 12/19/2025 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnosis included but were not limited to gastroparesis (chronic condition where the stomach muscles work poorly, slowing or stopping the movement of food to the small intestine), muscle wasting and atrophy (the loss or thinning of muscle tissue, leading to decreased mass and strength), Rett's syndrome (a rare genetic neurological disorder, primarily affecting females, that causes a progressive loss of motor skills, speech, and purposeful hand use), seizures (sudden, uncontrolled electrical disturbances in the brain, causing temporary changes in movement), epilepsy (chronic neurological disorder defined by recurrent, unprovoked seizures, which are sudden bursts of abnormal electrical activity in the brain), disturbances of salivary secretion (too little (xerostomia) or too much (sialorrhea) saliva, causing dry mouth, difficulty eating/swallowing, bad taste, or drooling), functional dyspepsia (chronic indigestion, causing upper belly pain, burning, fullness, or bloating without a clear cause), other dysphagia (difficulty swallowing food or liquids, caused by problems with the nerves or muscles involved in moving items from the mouth to the stomach), gastrostomy status (refers to a patient having a surgically placed tube (G-tube) into their stomach for feeding or draining, requiring ongoing care), mixed receptive-expressive language disorder (communication challenge affecting both understanding (receptive) and using (expressive) language), protein-calorie malnutrition (muscle/fat loss), and irritable bowel syndrome (chronic gut disorder causing abdominal pain, cramping, bloating, gas, and changes in bowel habits (diarrhea). Record review of Resident #1's Care Plan undated reflected Focus: Resident had potential nutritional problem related to (r/t) feeding tube, low body, mass, index (BMI), malnutrition, nothing by mouth (NPO) Feeding: Jevity (nutritional supplement and tube-feeding formula using a syringe, rather than continuously) 1.5, 237 milliliter (ml) bolus (single, large syringe dose of a substance administered over a short period) every (q) 6 hours (hrs.) water flush 60 ml before and after each bolus medications: levOCARNitine (naturally occurring amino acid derivative (creating important compounds like hormones) and a prescription medication used to prevent and treat carnitine (a naturally occurring compound, derived from an amino acid, that is crucial for energy production by transporting fatty acids into the cells) deficiency in the body), multi-vitamin infusion (MVI) Date Initiated/Created: 08/05/2023. Goal: Resident will maintain adequate nutritional status as evidenced by maintaining weight daily through review date. Date initiated: 08/05/2023 and created on 08/05/2023. Intervention/Tasks Monitor/record/report to medical doctor (MD) as needed (PRN) signs and symptoms (s/sx) of malnutrition: Emaciation (Cachexia), Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] reflected that the resident was unable to answer the questions of the Brief Interview of Mental Status (BIMS). Record review of Resident #1's Physician Residents Affected - Some 455477 Page 4 of 11 455477 12/23/2025 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Orders dated 03/28/2023 at 06:00 p.m. reflected medical doctor (MD) A ordered Resident #1 was to received enteral feeding (method of delivering nutrition directly into the gastrointestinal tract, typically through a tube, for individuals who cannot consume food orally) q shift and to be flushed with 10 cubic centimeter (cc) water between medications. Record review of Resident #1's Physician Orders dated 03/28/2023 at 06:00 p.m. reflected MD A ordered enteral feed q shift and monitor g-tube for swelling and drainage and notify MD of s/sx. Record review of Resident #1's Physician Orders dated 04/04/2023 at 06:00 p.m. MD A ordered enteral feed 4x a day and verify g-tube placement and to be checked for residual. Record review of Resident #1's Physician Orders dated 04/04/2023 at 03:00 p.m. Nurse practitioner (NP) A 4 ordered enteral feed q 6 hrs. with water flush 60 ml before and after each bolus. Record review of Resident #1's Physician Orders dated 06/05/2025 at 06:00 p.m. order enteral feed q night shift and cleanse g-tube stoma (surgically created opening that allows waste to exit the body) with soap and water. Record review of Resident #1's Physician Orders dated 12/19/2025 08:00 p.m. NP A order enteral feed q 6 hrs. Jevity 1.5, 285 ml bolus every 6 hrs. Record review of Resident #1's Weights reflected:10/1/2025 at 02:36 p.m. 88.0 pounds (lbs.) with standing scale10/13/2025 at 03:55 p.m. 88.3 lbs. with wheelchair scale11/3/2025 at 04:30 p.m. 89.0 lbs. with wheelchair scale 11/5/2025 at 11:05 a.m. 89.0 lbs. with wheelchair scale12/1/2025 at 03:48 p.m. 87.0 lbs. with mechanical lift scale12/17/2025 at 12:52 p.m. 82.2 lbs. with mechanical lift scale(No scheduled weights were taken on 10/27/2025, 11/10/2025, 11/17/2025, 11/24/2025, 12/08/2025, and 12/15/2025.) Record review of Resident #1's Progress Notes dated 06/05/2025 at 02:36 p.m. reflected registered dietitian (RD) performed resident's nutritional quarterly review noting that in June 2025, resident's weight was 89.4 lbs., with a body mass index (BMI measurement of body fat based on height and weight) of 18.1 resulting in an insidious loss of 4.8 percentage (%) times (x) 30 days. Resident was receiving 237 ml. Jevity 1.5 bolus q 6 hr with water flush 60 ml. before and after each bolus. No pressure injuries, no current labs, with weekly weights in place. Nursing staff reported resident tolerating Jevity very well, with no reports of nausea/vomit/diarrhea (N/V/D). Staff also report resident's responsible party (RP) preferred resident's weight to be at 90 lbs. Record review of Resident #1's Progress Notes dated 07/14/2025 at 09:56 p.m. reflected ordered enteral feed q 6 hrs. of Jevity 1.5, 237 ml bolus. Record review of Resident #1's Progress Notes dated 09/18/2025 at 11:04 a.m. reflected Registered Dietitian (RD) noted during her quarterly review that in September resident's weight was 86 lbs., with a BMI of 17.6. and noted a loss of 7.1% of weight within a 30-day period. RD noted no changes would be made to resident's multi-vitamin mineral (MVM) and Jevity formula at 1.5, 237 ml. bolus q 6-hr, with 60 ml. water flush before and after each bolus and 1380 ml free water feeding formula with a goal weight of 90 lbs. Noted that a various in resident's weight loss could be contributed to weight being taken by wheelchair scale vs mechanical lift scale. Record review of Resident #1's Progress Notes dated 09/24/2025 at 08:02 a.m. reflected resident started getting irritated during feeding and unable to tolerate/complete feeding. Completing only 3/4 of feeding. Resident able to tolerate medication. Record review of Resident #1's Progress Note dated 09/29/2025 at 05:21 p.m. NP A ordered weekly weight every day shift every Mon for tube feeding inaccurate reading on scale. Record review of Resident #1's Progress Notes dated 10/20/2025 at 07:19 p.m. reflected NP A placed an order for resident to receive weekly weights every Monday on day shift related to tube feeding. Record review of Resident #1's Progress Notes dated 11/5/2025 03:44 p.m. reflected NP A placed order for enteral feed 4 x a day, and verify G-tube placement, and check for residual. Record review of Resident #1's Progress Notes dated 12/19/2025 at 04:55 p.m. reflected a Nutrition/Dietary Note: RD noted that resident's December 2025 weight had been 87 lbs. with a BMI of 17.5. Noting that the residents' weight had 455477 Page 5 of 11 455477 12/23/2025 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some been stable between 86 lbs. and 89 lbs. in the last 180 days. RD was notified of 12/17/2025 weekly weight of 82.2 lbs. and 12/19/2025 weight of 78 lbs. with a BMI of 15.7 noted to be a weight loss of 10%. Resident #1 had no pressure injury reported and labs performed on 10/30/2025 were within range. Resident received Jevity 1.5, 237 ml bolus q 6 hrs, water flush of 60 ml before and after each bolus and 30 ml before and after med pass with 10 ml between each medication to provide 1422 kcal, 60 gm pro and 1380 ml free water. Recommend increase bolus feeding; Jevity 1.5, 285 ml q 6 hrs. with same water flush to provide 1710 kcal, 72.7 gm pro and 1526 ml free water. Resident #1 will be monitored for feeding tolerance and weighed weekly. Record review of Resident #1's Progress Notes dated 12/19/2025 at 05:28 p.m. reflected RD notified of weight loss and recommendations received to increase Jevity 1.5 to 285 ml q 6 hrs. to reduce risk of additional weight loss. NP A in agreement, and RP aware. During an observation on 12/19/2025 at 03:32 p.m., certified nursing aide (CNA) A pointed out a weight written on the back bottom area of resident's wheelchair of 81.2 lbs. reflected the weight of the resident's wheelchair. CNA A, CNA B, and CNA C weighed Resident #1's wheelchair on the wheelchair scale resulting in a weight of 81.2 lbs., then placed Resident #1 in her wheelchair and weighed both the resident and her wheelchair reflected a weight of 159.2. Hence subtracting resident's wheelchair weight from the total weight resulted in resident's weight of 78 lbs. During an interview attempt on 12/19/2025 at 3:01 p.m. Resident #1's RP was contacted and not reached. During an interview on 12/19/2025 at 3:07 p.m., assistant director of nursing (ADON) stated that RD was scheduled to visit the facility every 2-weeks, where the RD made rounds with residents, in the kitchen, and reads weights. She stated if any weight issues arose RD would share with ADON any change recommendations to be implemented. During an interview on 12/19/2025 at 3:27 p.m. the administrator (ADM) stated that he was not aware of any residents with weight loss off hand but was informed by the ADON that Resident #1's weight was off by a few pounds. During an interview on 12/19/2025 at 03:57 p.m. CNA A and CNA B both stated there was a discrepancy with Resident #1's weight. CNA A stated that the resident was not normally weighed with the wheelchair scale. She stated that she and CNA B normally weighed Resident #1 by using a mechanical lift scale. CNA A stated after Resident #1 was weighed on the wheelchair scale, her and CNA B weighed the resident using the mechanical lift scale and resident's weight was 80.2 lbs. and both CNA A and CNA B stated that 80.2 lbs. most represented the resident's weight since last being weighed on 12/17/2025. CNA A stated that the wheelchair scale weight of 78 lbs. was incorrect. During an interview on 12/19/2025 at 5:22 p.m. ADON stated that the RD increased Resident #1's Jevity 1.5 ml to 285 ml x6. from 237 x6. To avoid weight loss. She stated that the nursing staff were to monitor the resident to ensure she had been tolerating the increase well. During an interview on 12/19/2025 at 5:55 p.m. ADON stated that she had been responsible for ensuring that weekly weights were performed by her staff. She stated every month she pulled weights and reviewed them and admitted she had been slacking on the responsibility. Since there had been no director of nursing (DON) it had been her responsibility. She stated on this date she would do a weight audit to ensure all weights had been performed and were within reasonable ranges and follow-up to ensure they were performed and accurate. She stated she had contacted the RD to review charts as well. She stated the importance of ensuring weights were performed were to avoid the risk of loss of weight, risk the failure to thrive, suspectable to illness, if a resident got sick, they wound not have enough weight to fend off the infections. She stated that the CNAs were to weigh residents, the charge nurses were to obtain the weights and entered them into the resident's chart. She stated the charge nurses were to inform her any weights were more or less of 5 lbs. and then she would report to the resident's physician and the RD for further possible order changes/recommendations. During an interview on 455477 Page 6 of 11 455477 12/23/2025 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 12/23/2025 at 12:01 p.m. RD stated that she was not aware that Resident #1 was to have weekly weights as of September 2025. She stated that she had last been to the facility on [DATE] and no one had mentioned that the resident had weight issues. She stated she received a call 12/19/2025 from the ADON that the resident's weight had gone from 87.0 lbs. on 12/01/2025 (mechanical lift) to 82.2 lbs. on 12/17/2025 (mechanical lift). She stated she had not been made aware that the resident had not been getting her weekly weights and stated that maybe the staff had forgotten to report those weights. She stated normally the staff were really good at keeping her informed of weight fluctuations. She stated at the beginning of each month any residents with weight changes were reported to her by the ADON. She stated she visited the facility every 2 weeks and had the resident had issues with weight stabilization she would have expected ADON to inform her. She stated that the resident had a history of a 3-5 lbs. weight fluctuation and the RP wanted for the resident's weight between 85 to 90 lbs. She stated she had the resident's weight up to 95 lbs. and the RP indicated that was too much. She stated that if the resident was able to tolerate the formula increase, Jevity 1.5 ml change would remain at 285 ml x6. from 237 x6. She stated that the facility was good for calibrating the scales regularly. During an interview on 12/23/2025 at 12:23 p.m. ADON stated that NP A had come on board for oversight of Resident #1's care. She stated that all residents with g-tubes required as good measure and nursing practices. She stated that the resident was weighed again on 12/22/2025 and had a weight of 77.8 lbs. (mechanical lift). She stated the resident's order for weekly weights had been placed in August of 2025 and again in September 2025. During an interview on 12/23/2025 at 12:29 p.m. NP A stated that he had begun taking over Resident 1's care late October/early November 2025. He stated that he learned on 11/19/2025 from ADON that the resident's weights were dropping and he ordered for RD to consult, and for weekly weights to be kept. He stated he would closely monitor the resident's weights for any weight loss. He stated the importance of monitoring resident weight, especially residents with g-tubes was to keep their calorie intake up. He stated that Resident #1 does not eat anything by mouth and the nursing staff need to keep the resident's calorie intake up. He stated the loss of protein places the resident at risk of health issues, skin breakdown, and at risk of fighting bacteria off. Record review Policy titled Food and Nutrition Services Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization.2. A resident-centered diet and nutrition plan will be based on this assessment.3. Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled mealtime, and in accordance with the resident's medication requirements.4. Reasonable efforts will be made to accommodate residents' choices and preferences.5. The food and nutrition staff will be available and adequately staffed to assist residents with eating as needed. Nurse aides and feeding assistants will provide support to enhance the resident experience, but not as a critical component to the functioning of the department.6. Nursing staff will ensure that assistive devices are available to residents as needed.7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. The food appears palatable and attractive, and it is served at a safe and appetizing temperature.a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the Food Service Manager so that a new food tray can be issued.b. Foods that are left without a source of 455477 Page 7 of 11 455477 12/23/2025 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded.8. Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems.a. Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse.b. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian.9. Meals are scheduled at regular times to ensure that each resident receives at least three (3) meals per day. Mealtimes are posted in common areas.10. Nourishing snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. 455477 Page 8 of 11 455477 12/23/2025 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 shower rooms (A-Hall, B-Hall, and C-Hall) observed for infection control practices.The facility failed to maintain clean and organized shower rooms and avoid the development of legionella (a serious lung infection (pneumonia) caused by a bacteria, caught by inhaling mist from contaminated warm water sources like cooling towels and showers), repairing a leaking shower faucet, and not properly disposing of dirty briefs and linen. This failure could place residents at risk of cross-contamination from exposure to another's used personal items.Findings included: During an observation on 12/19/2025 at 01:12 p.m. of A-Hall's unlocked shower room (across from the nurse's station) faucet water dripping from 1 of 1 shower heads. Water accumulating on discolored floor and wall tiles near drip water. During an observation on 12/19/2025 at 1:14 p.m. of B-Hall's unlocked shower room (on resident's hall) were 2-attached wall cabinets with full of cluttered items consisting of but not limited to unfolded towels, loose gloves, 1 of 2 grey plastic bins laying sideways, unsecured brief wipes, 3-open shaving creams with no tops and cream oozing out of 1 of 3, and 2 of 3 laying sideways on shelf, all 3 shaving cream were uncovered and tops sitting on the shelf. Damp shower table was located diagonally in the room with bunched up damp towels laying at one end of the table, dirty bedsheets inside a large clear bag sat inside entry area of shower room, 3-bunched up and damp face towels sitting on floor of shower room, 2 of 2 trashcans overfull with disposable bed protectors, 1 of 1 had exposed shaving razor atop an adult brief with what appeared to be a blood like substance on brief, dirty shoestring sat on floor near backside of trashcan, damp bed sheets hung on back of shower chair, what appeared to be clean folded towel sat on closed lid of toilet seat, and on back of toilet sat foam hand/bath soap, and on the floor near entry door sat an bagged adult brief. During an observation on 12/19/2025 at 01:31 p.m. C-Hall ‘s (memory care unit) locked shower room revealed an unsecured rubber tile wall protector loose and laying on floor drain exposing wall and adhesive and a shower chair with a damp face towel hanging on arm. During an observation on 12/19/2025 at 3:11 p.m. Assistant Director of Nursing (ADON) asked an unknown certified nursing aides (CNA) on the C-Hall whom performed showers in that hall's shower room. That unknown CNA stated that no showers had been performed by facility staff on that day. During an observation on 12/19/2025 at 03:12 p.m. unlocked shower rooms A, B, and came were observed in the same condition as observed on 12/19/2025 at 01:12 p.m. and 01:31 p.m. During an interview on 12/19/2025 at 03:07 p.m. ADON stated that the CNAs had been responsible for shower room upkeep and cleaning, and each was to be immediately cleaned after providing a resident with a shower. She stated additionally the facility's housekeeping staff were to assure that the shower rooms were clean and were to check every 1-2 hours. She stated the importance of keeping the shower room's clean was for infection control and to keep the residents free of contact of different illnesses. She stated she had not been made aware that shower room on A-Hall's faucet had been leaking water and she would then report the leak to the maintenance director. She stated that the faucet should be properly functioning to avoid water buildup that could breed bacteria. She stated that the shower room B-Hall was to have been kept clean and it had been the responsibility of the CNAs who provided showers to do so. She stated it was unknown if the items on the cabinet shelves were used or unused, but would not want the staff to use for or on the residents. She stated that she would find out who had been responsible for the unkept shower rooms. She stated the shower chair in shower room C-Hall should not have a damp towel hanging of the arm. During an interview on 12/19/2025 at 03:27 p.m. Administrator (ADM) Residents Affected - Some 455477 Page 9 of 11 455477 12/23/2025 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated shower rooms left unkept and unclean could place residents at risk for cross-contamination. During an interview on 12/19/2025 at 03:48 p.m. Housekeeping Supervisor (HS) stated that the housekeeping staff were responsible for pulling trash from the shower rooms, but not dirty briefs. She stated that CNAs were responsible for brief disposal and if the housekeeping staff found briefs in the trash, they were to set aside for the CNAs to dispose. She stated that the risk of not properly disposing of dirty and damp towels, sheets, pulling up trash, and properly disposing of sharps posed a risk of infection control and residents could become sick. During an interview on 12/19/2025 at 03:56 p.m. ADM stated that the leaking shower head in A-Hall's shower room had been addressed by the Maintenance Director and if a plumper was needed, one would be contacted. He stated a list of the staff that performed showers in shower room B-Hall would be provided. During an interview on 12/19/2025 at 03:59 p.m. ADON stated that that the last shower in shower room C-Hall performed on 12/19/2025 was completed by a hospice nurse. She stated that cleaning protocols after providing a resident with a shower would be provided to the hospice nurses. During an interview on 12/19/2025 at 04:05 p.m. HS stated that on 12/19/2025 no staff had checked off on the Daily Shower Room Check List (DSRCL) that the shower rooms were cleaned. She stated the importance of keeping the showers room clean was due to infection control to keep the residents from risk of illness. During an interview on 12/19/2025 at 04:40 p.m. CNA A stated that she had worked a rotating day shift from 6 a.m. to 6 p.m. She stated that the night shift CNAs had been known in the past (no specific staff or dates/times provided) not to clean up the shower room after use. She stated that she had used the shower room A-Hall on the morning of 12/19/2025. She stated she had cleaned and sanitized the shower chair, floor, bed once completed with the resident's shower. She stated on 12/19/2025, CNA C provided a shower to a resident and had not cleaned up the shower room after completion. She stated she had not been made aware that a DSRCL existed. She stated that as a CNA C had been responsible for not cleaning A-Hall's shower room o 12/19/2025. During an interview on 12/19/2025 at 05:01 p.m. CNA B stated that CNA C had last provided a shower to a resident in A-Hall's shower room and had left the room uncleaned. During an interview on 12/19/2025 at 05:24 p.m. CNA C stated she had been responsible for the uncleaned unkept shower room on A-Hall. She stated her apologies and stated the importance of cleaning up the shower rooms was to follow infection control protocols and keep residents free from infections. During an interview on 12/23/2025 at 03:09 p.m. CNA D stated that the importance of maintaining clean shower rooms was related to infection control protocols and keeping residents free of infections. During an interview on 12/23/2025 at 03:20 p.m. CNA E stated that the water leaking from the B-Hall's shower faucet had been leaking since she began working with the facility in April of 2025. She stated the facility had been made aware of the leak, but she had not provided by who, to who or what date/time they were made aware. During an interview on 12/23/2025 at 03:30 p.m. Maintenance Director stated he had been on with the facility for 10 years. He stated he had not been made aware of B-Hall's leaking shower room faucet. He stated he had checked the main request book daily located at the 1-nursing station in the facility. He stated that he inspected the faucet and found it required a replacement value that had been put in place by an outside plumper on 12/22/2025 and the faucet was no longer leaking. He stated the risk of water leaks put the residents at risk of legionella, infections, and exposure to molds and mildew. During an interview on 12/23/2025 at 6:04 p.m. ADM and ADON stated an in-service training was provided for the staff on the new policy for shower rooms. Record review of an email dated 12/19/2025 at 04:13 p.m. ADM indicated that the following CNAs provided residents with a shower on 12/19/2025: CNA A, CNA B, and CNA C. Record review of DSRCL date beginning 11/25/2025 - 12/19/2025 reflected that on 12/19/2025 shower room A-Hall was cleaned and checked off by housekeeping 455477 Page 10 of 11 455477 12/23/2025 Brazos Healthcare Center 413 Garland Dr Lake Jackson, TX 77566

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff A and verified by licensed vocational nurse (LVN) A. No time was noted. In-service training for new shower policy was not provided. Record review of the Policy titled and Infection Prevention and Control Program and revised dated 06/2025 reflected:Policy StatementAn infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.2. The program is based on accepted national infection prevention and control standards.3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.5. Coordination and Oversighta. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist).b. The qualifications and job responsibilities of the Infection Preventionist are outlined in the Infection Preventionist Job Description.c. The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include:(1) documented IPCP incidents and corrective actions taken;(2) whether physician management of infections is optimal;(3) whether antibiotic usage patterns need to be changed because of the development of resistant strains;(4) whether information about culture results or antibiotic resistance is transmitted accurately and in a timely fashion; and(5) whether there is appropriate follow-up of acute infections.d. The committee meets regularly, at least quarterly, and consists of team members from across disciplines, including the Medical Director. 6. Policies and Proceduresa. Policies and procedures are utilized as the standards of the infection prevention and control program.b. Policies and procedures reflect the current infection prevention and control standards of practice.c. The infection prevention and control committee, Medical Director, Director of Nursing Services, and other key clinical and administrative staff review the infection control policies at least annually. The review will include:a. Updating or supplementing policies and procedures as needed;b. Assessment of staff compliance with existing policies and regulations; andc. Any trends or significant problems since the previous review. 455477 Page 11 of 11