Health inspection·July 2, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm 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 observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for 1 of 2 shower rooms reviewed for environment. Residents Affected - Some The facility failed to ensure station 2's second shower room was clean and free of a black substance on the ceiling and tiles on the wall. This could place residents at risk for respiratory infections and a decrease in quality of life. Findings included: Observation on 07/02/2024 at 5:04 PM, one of station 2's shower rooms revealed a musty, moldy odor. There were different sized round specks of a black substance near the edges and corners on the ceiling directly above the shower. Interview on 07/02/2024 at 5:08 PM, the Housekeeping Supervisor stated when the ceiling was repainted, whoever painted it did not use [Name of primer]. He stated it looks like mold but not was not mold, and it bled back through the paint. When asked if he smelled an odor, he said no it was the soap residents use. He said every night the shower room was cleaned with a disinfectant. He said they were supposed to use primer to cover the ceiling. When asked when it was last painted, he stated that would be Maintenance. Observation and interview on 07/02/2024 at 5:17 PM, revealed CNA A cleaning the second shower room. Observation revealed the tiles on the wall and floor had a brown and black, slimy substance on the grout. Round specks of a black substance were also on the tiles closest to the floor. CNA A stated she gave showers in the room and was cleaning and picking up the towels. She said it should be cleaned every time after a shower and showed the disinfectant bottle they used. She stated she had not noticed the black substance on the tiles or the ceiling before. She said no residents had complained about the black substance before to her. Interview on 07/02/2024 at 5:41 PM, the DON stated she went to the second shower room and did not smell anything but saw the tile. She said it had brown grout, like it needed to be cleaned and some discoloration. She said she did not know how long it had been like that. She stated her expectation was the shower room be clean and disinfected and the room was able to be used to provide ADL care at all times. She said the CNA should clean and disinfect after residents, and deep cleaning was done by housekeeping. The DON stated if it were mold, the risk could be respiratory issues possibly. (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 2 Event ID: 455592 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 455592 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Side Campus of Care 1950 S Las Vegas Trail White Settlement, TX 76108 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)