Health inspection·June 7, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **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 one of one facility reviewed for environment. 1. The facility failed to ensure resident rooms were safe and in good repair 2. The facility failed to ensure the smoking area had self-closing lids for discarded cigarette butts 3. The facility failed to ensure the maintenance log work orders were fulfilled before signing off 4. The facility failed to ensure resident closet ceilings and hallways were safe and in good repair These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Observations of the facility and hall 300 (locked unit) beginning on 06/04/24 at 10:00 am revealed the side lobby, employee restroom, and the 300 Hall including the activity area, rooms 304-316 revealed what appeared to be water damage in almost every resident's closet near the baseboards, as the sheetrock was bubbling and soft when pressed. The baseboards were buckling and peeling from the walls. Some of the closets had a plywood ceiling that had been removed and stored inside the closets with the resident's belongings and leaving the air conditioning ductwork exposed in the ceiling. The closet in room [ROOM NUMBER] had no door. The closet door in room [ROOM NUMBER] was very difficult to open, as it was stuck shut. There were yellow-grey stains on the bathroom floors and leaking toilets in rooms [ROOM NUMBER]. There was no inner knob on the closet door in room [ROOM NUMBER]. The bedside dresser in room [ROOM NUMBER] was missing the face of one of the drawers. The bedside dresser in room [ROOM NUMBER] was missing a knob on one of the drawers. There were electrical cords outside of the conduit protecting them in several rooms, and the thermostat was dangling from the wall in room Page 1 of 7 675717 675717 06/07/2024 San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415

F 0921 [ROOM NUMBER]. Level of Harm - Minimal harm or potential for actual harm Observation of the smoking area on 06/04/24 at 3:30 pm revealed 2 metal butt cans: one yellow for trash and one red for cigarette butts. Both cans had water in them, the lids were up, and both had trash and cigarette butts in them. There were also several discarded cigarette butts in various places on the ground under benches and strown about in the open. Residents Affected - Some Observation of room [ROOM NUMBER] on 06/05/2024 at 11:00 am revealed a ladder on top of blankets and sheets in the closet. The blankets and sheets were soaking wet. There was a plastic bucket catching dripping water near the ladder, on top of the wet blankets and sheets. The wooden ceiling of the closet was warped and dripping water. Observations of signed-off (closed) work orders and the rooms and areas coinciding with the closed work orders, with the ADM, MS A, and MS B on 06/06/24 beginning at 11:45 am revealed: work Order #3278 Replace broken and stained ceiling tiles was opened on 01/31/24 at 10:45 pm and closed on 04/ 24/24 by MS A at 5:38 pm. The ceiling tiles were still broken and stained. Order # 2962 Dresser needs replacement, needs new dresser second drawer trimming was opened on 07/31/23 at 02:22 pm and closed on 02/26/24 at 10:56 pm by ADM. Bed A in rm. 308 was still missing the trimming on the 2nd drawer of the dresser and there was a missing handle from the 3rd dresser drawer. Bed B was missing 2 drawer handles from the dresser-one from the 2nd drawer and one from the 3rd drawer. Order #3141 Base board fix 311 B was opened on 09/27/23 at 9:46 pm and closed on 04/24/24/ at 5:34 pm by MS A. The base board in room [ROOM NUMBER] B was still coming apart from the wall and the conduit covering electrical cords from the floor plug to the overbed light was dangling off the wall, leaving the electrical cords exposed. Order #3178 Wall between closets bulging was opened on 10/11/23 at 1:44 pm and closed on 3/15/24 at 7:57 pm by MS A. The closet walls in room [ROOM NUMBER] A, as well as the wall adjacent to the corridor were still bulging from appeared to be water damage. Order #3355 Broken blinds was opened on 3/22/24 at 1:46 pm and closed on 04/08/24 at 3:38 pm by ADM. The broken blinds in room [ROOM NUMBER] were now missing, and there were no handles on the dresser drawers. The toilet had thick caulking around the base and there was an odor of feces in the restroom. Order #3356 Closet door warped 316 B was opened on 03/22/24 at 1:47 pm and closed on 04/08/24 at 9:38 pm by ADM. The closet door in room [ROOM NUMBER] B was missing and the tiles around the closet door jamb were cracked and damaged, creating a possible trip hazard. Order #3416 Needs blinds 305 was opened on 04/26/24 at 1:17 pm and closed on 05/15/24 at 6:31 pm by MS B. The blinds in room [ROOM NUMBER] did not fit the window; they barely covered half of the entire width of the window. The drawer in room [ROOM NUMBER]A was missing the 2nd drawer from the dresser. The closet in room [ROOM NUMBER] B was missing the ceiling, approximately 4 feet by 2 feet, exposing the air conditioner vent. Order #3193 316 sink falling off was opened on 10/24/23 at 6:58 pm and closed on 01/31/24 at 8:22 pm by MS B. The sink in the restroom of room [ROOM NUMBER] could be lifted up and down approximately 675717 Page 2 of 7 675717 06/07/2024 San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1 inch-it was not fully secured to the wall. The restroom was a shared restroom with room [ROOM NUMBER]. In room [ROOM NUMBER], both closet doors were badly delaminated. #Order #3223 311 wall plug was opened on 11/13/23 at 5:40 pm and closed on 01/31/24 at 6:51 pm by MS B. The conduit covering electrical cords from the floor plug to the overbed light was dangling off the wall, leaving the electrical cords exposed. There was a strong odor of urine and what appeared to be urine on the floor around the base of the toilet. The restroom was a shared restroom with room [ROOM NUMBER]. The thermostat in rooms [ROOM NUMBERS] were hanging off the wall. In room [ROOM NUMBER] A, the conduit covering electrical cords from the floor plug to the overbed light was dangling off the wall, leaving the electrical cords exposed. Nearly the entire mattress in 306 A was badly stained with a yellow orange color. The resident in room [ROOM NUMBER]A was non interviewable. Interview with the ADM on 06/05/2024 at 9:15 am revealed he had initiated a 90-day plan beginning May 1st, 2024, and would end at the end of August 2024-his goal was Sept. 1, 2024, to repair the resident's rooms. He stated the residents were staying in their rooms during some of the construction such as working on the air conditioner, or work being done in their closets where the condensate pans were. He stated other residents were being temporarily (overnight) moved out of their rooms, depending on the type of construction, such as painting, stripping & waxing the floors. He stated he attended the resident council meeting this month and it was mostly positive, but they were concerned about what they saw on TV last week, where a couple of people were degrading the facility. He stated he told them the facility was working on repairs for the entire facility. He stated he was actively advertising on a job posting site for a permanent floor technician. He had received 3 resumes since yesterday (06/04/24) for the position. He stated a team could fix 4 rooms a day to include painting, floor repair, baseboards, ceilings, stains, toilets re-seated, if faucets corroded, replace them. He stated the FT was doing 2 rooms a day-the stripping and waxing. The ADM stated the water damage in room [ROOM NUMBER] A closet was from the air conditioner. However, the air conditioner vent was over the closet in room [ROOM NUMBER] B. Interview with Resident #1 on 06/05/2024 at 11:03 am in RM [ROOM NUMBER] stated the water had been leaking for about a week. She stated a staff member (did not know who) discovered the water today because the water had leaked from the closet to the middle of the floor. She stated she was concerned her clothes would get mold on them. Interview with HSK A on 06/05/2024 at 11:15 am stated she had been here for 4 years. She stated the building was very old and it needed a lot of work throughout. She stated she felt housekeeping did a good job on what they could clean. She stated there was a lot they had no control over, such as the walls (sheetrock) and the toilets. She stated she could not tell how the residents felt because they were in the memory care unit, and they would answer differently to every question. Interview with the ADM on 06/05/24 at 2:15 pm stated, The facility had a behavioral policy for the alert smokers to review and it had a little blurb about the smoking policy about abiding by it; what you might be safe from over others or not. He stated he told the smokers if they did not abide by the policy, they could lose their smoking privileges. He stated none of the residents had lost their smoking privileges. Regarding the disrepair of the building, he stated, he put himself on a 90-day plan because that was what they figured out how long it would take to fix everything. He stated he was advertising like crazy right now to get a dedicated floor tech. He stated, some of the residents were getting moved out of their rooms during some of the construction, depending on what they were 675717 Page 3 of 7 675717 06/07/2024 San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some doing, like when they were painting and until the paint dried, or when using any chemicals. He stated, some of the residents were staying in their rooms during some of the construction, depending on what they were doing, such as while working on an air conditioner over the closets where the condensate pans start dripping in them there, and that was up to the resident's. He stated, when we do the floors now, they need to leave the room for a little bit until we strip and re-wax. Some residents relocate just temporarily overnight and then go back to their rooms, others if they don't need to be out of the room, we just got it done then, like all those flush mounted receptacles of fourplex things (electrical boxes and conduits), they will catch those on beds and things and yank them off the wall so we would fix those while they were in there still too, and like a hole in the wall or a cove base (base boards). Those were things we could do. It was up to them if they want to be in their rooms or not. We did not use anything that had any type of fumes or whatever. He stated, we have a resident we were gonna put plastic up on the wall because he spits on the wall. Housekeeping can't clean it but so many times, so we're going to get the plastic-not plexiglass. With the plastic siding stuff that you can wash. He stated he went to the smoking area and picked up any visible trash, including soda cans. He stated he would go back out there and find more cans and cups strown about and in the metal butt cans. He stated his 90-day renovation plan was an active 90-day plan so we got as many rooms done as we could, trying to focus on the ones that needed the most work to begin with. It ends at the end of August 2024, but his goal was to be ready by September 1st 2024. He stated he firmly believed they could do it. The person he had doing floors right now would get one or two rooms done but he knew they could get at least four of them done in a day. He stated, one of his maintenance workers could whip out painting rooms very, very quickly depending on how much they had to patch and retexture and wait for the mud to dry to get 4 rooms a day going, starting with the ones that need more work. He stated, we completed a bunch of rooms on 200 hall and some of those floors don't look that bad right now. He stated, right now the floor tech was only getting two done, because he was hired as a janitor. He stated that was why he was advertising for the floor tech. He stated he did not have that person in place yet but that was the plan. The goal was to do 4 rooms a day. He stated he had a Maintenance Room Rounds form to utilize so the rooms would be ready for repair, depending on what needed to be done. He stated they could just rattle it (the work) off the form. He stated some of the repairs already identified were painting the walls, patching the holes in the walls, the cove base (baseboards), anything with the ceiling, such as staining or leaking, the bathrooms-pulling the commodes because they had all that thick caulk around them that did not fix the leaks, corroded or leaking faucets. He stated he wanted to just get it all done at once. He stated they needed to either patch the holes or replace the sheetrock. When asked if he had been checking the patches that were on the walls now, he stated, yeah, yeah. Do you have something that I need to go look at that are not properly patched? Like maybe just have the tape on there or the mud ? That's not from my current guys then, I don't think it is. I don't think it's from the current house but if it's not painted and it has mud, it may be. He stated the floor tech he was advertising for would be an additional person, they could do more than just work on floors. He stated this building-there's so many little fires that pop up right and left and maintenance getting pulled so he had to be pretty well dedicated to this. Interviews with MS A, MS B, and the ADM on 06/06/24 at 12:25 pm regarding closed work orders that were still needing repair revealed they all stated that all work orders signed off by MS A, MS B and the ADM, they thought they had completed the orders. When asked if the orders appeared to be complete, they all said no and made no other remarks. Interview with HSK B on 06/07/24/at 12:30 pm revealed she had worked at the facility for 6 years as a housekeeper. She stated she worked 675717 Page 4 of 7 675717 06/07/2024 San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on the 200 hall. She stated the plaster and the toilets had already been fixed on her hall. She stated the process she used to get things done was to ask the maintenance man to fix it directly and they would usually do it right then and there. She stated the CNAs normally cleaned the beds and did the linen changes, but if she saw they were busy, she would do it, and that was most of the time. She stated if there was a mattress with stains on it, she would scrub it with wipes. She stated if the stains did not come off, she would tell her supervisor. She stated her supervisor would have the mattress changed or it might need to be thrown away. She stated the mattress would be thrown away if it was peeling really bad or torn. Interview with the HS on 06/07/24 at 12:34 pm stated she noticed there was some painting, baseboards, and some dressers throughout the building that needed repairs. She stated hall 200 was mostly done. Regarding mattresses, she stated stained or [NAME] looking mattress were out the door. She stated she took it upon herself to swap out or throw mattresses away. She stated the process for getting mattresses changed was by word of mouth-she usually did not know unless the nurse called her and let her know or a CNA might mention it to her, and she would swap it out in a heartbeat. She stated sometimes she would go and change linens, or her housekeepers would if the bed had not been made or if the CNAs were busy. She stated she would rather have a made bed than an unmade bed and make sure it was clean and safe. She stated if a mattress was [NAME] looking it was supposed to go. She stated she had new mattresses on site she could use to replace the ones that need to be replaced. Record review of facility timeline dated 05/28/24 for QAPI 90-day plan revealed: QAPI Maintenance 90-day Plan 80 patient rooms 13 weeks from June 3rd to August 30th Average 6 rooms per week to ensure repairs as needed to: o Bed lights o Call lights o Privacy curtains o Windows and window blinds o Cove base o Walls and ceilings no penetrations o Walls and ceiling finish intact, painting as needed o Floors intact o Bathroom lights, bulbs covered o Bathroom wall finish 675717 Page 5 of 7 675717 06/07/2024 San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415

F 0921 o Bathroom sink and faucet Level of Harm - Minimal harm or potential for actual harm o Toilets sealed o Closets, no leaks, painting as needed Residents Affected - Some o Grab bars secure o Any other items noted in need of repair. Hiring of floor tech, committed to stripping and refinishing floors as needed. Minimum two per day X 5 days per week. Record review of the facility timeline dated 05/28/24 for QAPI 90-day plan revealed: Maintenance Room Rounds Worksheet Room Number: --------- Item Yes, Okay No, Needs Comments, Details, Work Bed light working? Pull Chain? Call light working? Clips on cords? Privacy Curtain Window and window blinds working, no, broken or missing slates? Cove base intact? Walls & ceiling intact, no penetration? Resident Room wall finish intact, no painting needed? Floors intact, no uneven surfaces? Bathroom light working, bulbs covered? Bathroom wall finish intact, no painting needed? Bathroom sink and faucet, working, no corrosion? Toilet, caulked, caps on floor bolts? Closet, no leaks, wall and ceiling intact? Grab bar secure? Record review of the facility resident council meeting minutes revealed on 11/03/23, the residents complained of housekeeping not cleaning or sanitizing the restrooms. Housekeeping was mopping the restrooms first, and not changing out the mop head before moving on to another area. On 11/21/23, they complained about the 100 hall not being cleaned and room [ROOM NUMBER]'s closet was always leaking. On 11/28/23, they complained about the 200 hall not being cleaned. 675717 Page 6 of 7 675717 06/07/2024 San Rafael Nursing and Rehabiliation 3050 Sunnybrook Rd Corpus Chrisit, TX 78415

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the facility policy for smoking titled Smoking Policy-residents revised July 2017 revealed the policy statement: This facility shall establish and maintain safe resident smoking practices. 4. Metal containers, with self-closing cover devices, are available in smoking areas. 5. Ashtrays are emptied only into designated receptacles. 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation) Record review of the undated facility smoking agreement revealed 2. Abide by the facility's smoking policy. While you may be perfectly capable of smoking safely and without risk to others, others may not. Abiding bby the facility smoking policy ensures the safety of all residents. There was a signature box for the resident under the last paragraph that revealed I have read and understand the above-listed behavioral expectations. I also understand that failure to meet these expectations may result in immediate termination of the relationship between me and this provider/organization. 675717 Page 7 of 7