Health inspection·April 9, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 5 of 26 residents (Residents #23, #35, #37, #46 and #52) reviewed for resident rights. The facility failed to maintain resident-use water to be above 100 degrees Fahrenheit. This deficient practice could place residents at risk of discomfort and unsanitary washing conditions . Findings include: Observation on 04/09/25 at 1:22 PM in resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 76.2 degrees Fahrenheit, when tested with a state-issued digital thermometer. Observation on 04/09/25 at 1:25 PM in resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 76.0 degrees Fahrenheit, when tested with a state-issued digital thermometer. Observation on 04/09/25 at 1:28 PM in resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 74.4 degrees Fahrenheit when tested with a state-issued digital thermometer. Observation on 04/09/25 at 1:31 PM in resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 74.1 degrees Fahrenheit, when tested with a state-issued digital thermometer. During a group interview on 04/08/2025, at 10:00AM, Resident #37 and Resident #35 said they did not have hot water in their room. Resident #37 said the water had been out for several weeks. She said she would let it run for a long time , but the water never got warm or hot. During interview on 04/09/25 at 2:21 PM, with the Maintenance Director, he said a water heater went out and a new one was installed . He said he thought the issues had been corrected and his maintenance assistant had been checking the water temperatures daily and recording the temperatures on the water temperature log. The Maintenance Director said it was his responsibility to adjust the water regulator, to provide the proper temperature water for resident-use water . During interview on 04/09/2025 at 2:28 PM, the Maintenance Assistant said the problem with the water heater started 2.5 weeks ago. He said they had a new water heater installed and he had been Page 1 of 3 455753 455753 04/09/2025 Oak Brook Health Care Center 107 Stacy Whitehouse, TX 75791

F 0584 checking and documenting the water temperatures on the water temperatures log. Level of Harm - Minimal harm or potential for actual harm During observation and interview, on 04/09/2025 at 2:57 PM, the ADM was observed checking water temperatures in resident rooms. Resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 80.0 degrees Fahrenheit, when tested without a state-issued digital thermometer . Resident room [ROOM NUMBER] revealed the hot water at the sink fixture measured 80.2 degrees Fahrenheit, when tested without a state issued digital thermometer. The ADM said they had just purchased a new water heater and the problem had been corrected at that time . The ADM said they will have to get the company to come back out . Residents Affected - Some Record review of a water temperature log, dated, April 2nd, 3rd, 4th and 9th, revealed the Maintenance Assistance recorded the water temperatures of 2 rooms on the 200 hall daily. April 2nd, room [ROOM NUMBER]- 73 degrees Fahrenheit / room [ROOM NUMBER]-75 degrees Fahrenheit, April 3rd, room [ROOM NUMBER]- 72 degrees Fahrenheit / room [ROOM NUMBER] -73 degrees Fahrenheit, April 4th, room [ROOM NUMBER] - 74 degrees Fahrenheit / room [ROOM NUMBER] - 73 degrees Fahrenheit April 9th, room [ROOM NUMBER] - 74 degrees Fahrenheit / room [ROOM NUMBER] - 72 degrees Fahrenheit. Record review of the facility policy titled Water Temperatures, Safety of, revision date of December 2009, indicated: 1. Water heaters that serve resident rooms, bathroom, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees Fahrenheit (____degrees C), or the maximum allowable temperature per state regulation. The policy did not address water temperatures in resident rooms, bathroom, common areas, and tub/shower areas, that measure below 100 degrees Fahrenheit. 455753 Page 2 of 3 455753 04/09/2025 Oak Brook Health Care Center 107 Stacy Whitehouse, TX 75791

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal, such grievances include those with respect to care and treatment which were furnished as well as that which were not furnished, the behavior or staff and of other residents, and other concerns regarding their LTC facility stay, for 8 of 8 residents reviewed for grievances. The facility failed to ensure residents were informed of their right during their stay in the facility. This failure could place residents at risk of a decreased quality of life, decreased awareness of their right and decreased execution of their rights. Findings include: During record review of resident council meeting minutes, on 04/08/2025 at 10:00 AM, revealed a grievances form had not been explained to the residents or how to use the form, over the past six months of residential council minutes reviewed for, April 2025, March 2025, February 2025, January 2025, December 2024 and November 2024. During interview on 04/08/2025 at 10:00 AM, Residents #14, #22, #30, #35, #37, #54, #62 and #65, said they did not know how to file a grievance. They said they had never had a grievance form reviewed with them. The residents said the Activity Director never reviewed or explained a grievance form with them . During an interview on 04/08/2025 at 11:15 AM, the Activity Director said she did not handle grievances or the grievance forms . She said she was not familiar with the form, had not explained the form to the residents and had never seen a grievance form. She said if the residents had a grievance, they would go to the ADM, all grievances went to the ADM. During interview on 04/09/2025 at 11:30 AM, the Administrator said, residents could express a concern to him, and he would use a complaint/concern form to document the issue. He said he attended the residential council meeting and reviewed resident rights with the residents. The ADM provided minutes from 4 resident council meetings, which which demonstrated, resident rights, had been reviewed. The ADM's signature was not indicated on any of the signature logs, of the 4 months provided and reviewed for; April 2025, March 2025, February 2025 and January 2025. The minutes provided by the ADM, did not indicate a grievance form had been an agenda item, that a grievance form had been shared with the residents, or had been explained to the residents. The ADM said he did not sign in on the signature log. Record review of the facility's, undated, document titled Policy/Procedure, Subject: Resident Right Grievances: 6. Residents, resident representatives and staff will be information on how to file a grievance. 455753 Page 3 of 3