Health inspection·August 14, 2025

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. The facility failed to ensure 8 confidential residents were provided, the Grievance Procedure, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance. Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 8 of 28 confidential residents. The facility failed to ensure 8 confidential residents were provided, the Grievance Procedure, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews and Record Review during Resident Council on, 08/13/2025 at 1:00pm, 8 confidential residents, stated they did not have access to a Grievance form, they did not know they could file a Grievance anonymously, and they had not observed a posting of the Grievance procedure in prominent locations. The 8 Residents in attendance had all been Residents of the facility for 6 plus months. Record Review of the facility Grievance policy reflected a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Observed prominent postings in the lobby of the facility on 8/14/2025 at 10:45am; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available to Residents in the facility and there was no access to submit a Grievance anonymously. Interview with the ADM on 8/14/2025 at 1:15pm; the ADM stated he was the Grievance Officer for the facility. The ADM stated he was responsible for the review of Grievances and to assign them to department heads. The ADM stated there are currently no Grievance forms. The ADM stated there was no procedure for Residents to submit Grievances anonymously. The ADM stated the facility had a responsibility to resolve Grievances promptly once they were submitted. The ADM stated he assigned the Grievance to the appropriate department, that department addressed the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook. The ADM stated he monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated he will also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated he was responsible for ensuring staff were trained on the Grievance process. Record Review of the Grievance Policy updated 2025 reflected the following Policy Statement:Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or their representative. The Resident and/or the representative has the right to voice grievances to the facility or other agency or entity that hears grievances without Page 1 of 6 675182 675182 08/14/2025 Brownfield Rehabilitation and Care Center 510 S First St Brownfield, TX 79316

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to file a grievance and prompt efforts must be made by the facility to resolve grievances the resident may have. Policy Interpretation and Implementation: 1. Any resident, family member, or representative may file a grievance or complaint.2. Residents, family, and representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal.3. All grievances from resident or family concerning issues of residents' care in the facility will be considered. Actions will be responded to in writing.4. Upon admission residents are provided with written information on how to file a grievance. 5. Grievances may be submitted orally or in writing and may be filed anonymously.6. The contact information for the individual with whom a grievance may be filed is provided to the resident or representative upon admission.7. The ADM has delegated the responsibility of grievance investigation to the ADM.8. The grievance officer will review and investigate the allegations and submit the written report of such findings to the ADM with five working days of receiving the grievance.9. The grievance officer will coordinate actions with the appropriate state and federal agencies depending on the nature of the allegations. 10. The ADM and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated.11. The ADM will review the findings with grievance officer to determine what corrective actions need to be taken.12. The resident or person filing the grievance on behalf of the resident, will be informed (verbally or in writing) of the findings of the investigation and actions will be taken to correct any identified problems. A written summary of the investigation will be provided to the resident and a copy will be filed in the business office. 13. If the grievance is filed anonymously the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance and report the findings. 14. The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.15. This policy will be provided to the resident or the resident's representative upon request. 675182 Page 2 of 6 675182 08/14/2025 Brownfield Rehabilitation and Care Center 510 S First St Brownfield, TX 79316

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for dietary services. 1) The facility failed to ensure foods were labelled & dated. 2) The facility failed to protect foods from potential contamination. 3) The facility failed to ensure foods were stored under sanitary conditions. These failures could place residents at risk for food-borne diseases.The findings included: - The following observations were made during a kitchen tour on 08/12/25 that began at 9:45 AM and concluded at 11:46 AM: - Dirty unknown black particles around the Ice Machine sink. - Dusty build up and cobwebs around the Range Hood. - Non-clean unknown black colored particles around the Dish & Pot Washing Area.- Dirty and sticky front doors of 1 freezer and 1 refrigerator. - Undated and unlabeled round shape vegetable inside the refrigerator- Undated Swiss cheese inside the refrigerator. - Undated Peas inside the refrigerator. - Unlabeled and undated oval pinkish raw meat like item covered in a clear plastic wrapping inside the refrigerator. - Unlabeled and undated red raw meat like item covered in a clear plastic wrapping inside the freezer.- Expired yellow short solid corn like items wrapped in a corn husk covered in a clear plastic inside the freezer. In a Phone Interview on 08/14/25 at 12:10 PM, [NAME] A stated the responsibilities for ensuring food items were labelled, and dated depended on the dietary staff that was on duty when the truck came in. [NAME] A stated the kitchen staff were responsible for ensuring that all expired food items were taken out/discarded from the fridge or freezer. She further stated, she was trained and had seen the policy on food storage/labelling and dating. [NAME] A stated serving the residents with unlabeled, undated, and expired food items, would make them sick. She stated, a lot could happen, I don't want to serve residents with food that's expired, even the ice machine that is very dirty, the dusty range hood with cobwebs, black colored particles around the Dish & Pot Washing Area, it just occurred to me that I haven't taken attention. [NAME] A confirmed the following items from the refrigerator/freezer as: undated and unlabeled round shape vegetable as Lettuce, undated and unlabeled oval pinkish raw meat like item covered in a clear plastic wrapping as Ham, unlabeled and undated red raw meat like item covered in a clear plastic wrapping as Ground beef, expired yellow short solid corn like items wrapped in a corn husk covered in a clear plastic as Tamales. Phone Interview was attempted on 08/14/25 at 12:39 PM, and [NAME] B was not accessible; message was left for her to return the call. In an interview on 08/14/25 at 12:47 PM, the ADM stated they did not have a Dietary Manager since May 2025, but a new one should be staring on the 18th of August 2025. He added, the Cooks were responsible for labelling and dating of food items. The ADM stated kitchen staff members had all been trained on discarding of expired food, labelling/dating of food items. The ADM stated food items should be labelled and dated, but the kitchen staff must have been in a hurry. The ADM stated the potential negative outcomes to the residents with expired, unlabeled/undated food, was it could get old and taste nasty and cause the residents to be sick. The ADM stated he did not notice the dirty ice machine, the dusty range hood with cobwebs, and black colored particles around the Dish & Pot Washing Area inside the kitchen. Record review of the facility policy and procedure titled, Food storage, dated 10/01/2018, revised date 06/01/2019, reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Code and HACCP guideline. Procedure:2. Refrigerators d. Date, label and tightly seal all refrigerated food using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. 3. Freezers e. Store frozen foods 675182 Page 3 of 6 675182 08/14/2025 Brownfield Rehabilitation and Care Center 510 S First St Brownfield, TX 79316

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in moisture-proof wrap or containers that are labeled and dated. Record review of the facility policy and procedure titled, General kitchen sanitation, dated 10/01/2018 reflected the following: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Food service employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes to minimize the risk of infection and food borne illness. Procedure:1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware, and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. 7. Store, handle and dispense all single-service article in a sanitary manner and use only once. 675182 Page 4 of 6 675182 08/14/2025 Brownfield Rehabilitation and Care Center 510 S First St Brownfield, TX 79316

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 laundry room in that:1. The facility failed to maintain clean lint traps in 1 of 2 dryers in the laundry room by failing to clean the lint traps per policy. This failure could place residents at risk for fire emergencies.The findings include: During an observation on 8/13/2025 at approximately 10:20AM, the Housekeeping/Laundry staff member revealed the lint trap of the dryer to have excess amounts of lint. Lint was noted on the lint trap and on the floor below the lint trap. During an interview on 8/13/2025 at approximately 10:20AM with LS, she stated she had been trained by someone who no longer worked at the facility. She stated she had been trained in the past but had recently returned to work on Saturday 8/9/2025 but she had done housekeeping before. She stated she had been gone for two months. She stated she would have to look up what the potential negative outcome of not cleaning the lint trap could be. She stated she was waiting to hear from the ADM if she needed to get a new screen for the lint trap or how to clean it out. She stated she was not sure what the clipboards with the logs were for. She stated she just signed it every day. Record Review of facility document titled Dryer Lint trap Log dated August 2025 did not reveal any signatures August 1 to August 13, 2025. During an interview on 8/14/2025 at 10:59AM with the ADM, he stated he had two laundry staff who were responsible for checking the dryer lint traps every two hours. He stated LS had been hired Saturday [8/9/2025], but had previously been working at the facility with a contracted company that would do the facility laundry. He stated she had not been trained by the facility because he assumed she had been trained by the previous company. He stated she had now been in-serviced and the Maintenance Supervisor would be in charge of checking the dryers and ensuring they are getting cleaned out. He stated they did not have a Housekeeping Supervisor, and the Maintenance Supervisor would be assuming that role and be responsible for future trainings and in-services. The ADM stated he was not aware she had not been checking the lint traps every two hours and that she had not been documenting on the lint trap logs. He stated he was not aware she had only been checking the lint trap at the end of her day. He stated the potential negative outcome of not cleaning the lint traps every two hours could be a fire hazard. Record review of facility policy titled Dryer Vent Cleaning and Maintenance Policy dated 9/1/2023, revealed: The facility will maintain all dryer vents, lint traps and associated ductwork in a clean, unobstructed condition. Cleaning will occur at regular intervals and be document to ensure compliance with applicable regulatory and safety standards.2. Daily Cleaning. Remove and discard lint from the lint screen/trap after each dryer load. Residents Affected - Few 675182 Page 5 of 6 675182 08/14/2025 Brownfield Rehabilitation and Care Center 510 S First St Brownfield, TX 79316

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide 80 square feet of floor space per resident in 24 of 24 semiprivate resident rooms containing two beds (Rooms 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34). Rooms 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34 semi- private rooms did not have 80 square feet per resident. This failure could result in overcrowding in resident rooms and possible diminished quality of life. The findings included: Record review of CASPER 3 during preparation for survey revealed a waiver for room size requirements had been done yearly by the facility. Record review of Room Size Wavier for Facilities dated 05/06/22, during preparation for survey, revealed a wavier for rooms #s 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34. Record review of Texas Health and Human Services Form 3740 (Bed Classifications (Numbers and Location) dated 09/20/22 documented that rooms #1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34 were listed as a Title 18/19 bed classification semi-private rooms for two residents. During an interview on 08/13/25 at 10:15am with the Administrator regarding the square footage for room [ROOM NUMBER], 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34. When asked if he wanted to apply for the room size waiver he stated, Yes, I want to apply for the waiver. He stated room [ROOM NUMBER], 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34 had a waiver for years and there has been no change to the floor plan. During a general observation tour on 08/13/25 between 11:30am and 12:00pm, it was noted that 24 of 24 semi-private rooms had 156 square feet instead of the required 160 square feet for 2 residents: (Rooms) 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34. During an interview on 08/14/25 at 1:15am with the Administrator, regarding the risk of residents not having the appropriate space, he stated it had not been a problem in the past . He stated there was no facility policy for room size wavier. 675182 Page 6 of 6