Inspection·August 1, 2023

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many room [ROOM NUMBER] had no blinds at the window, baseboard was off the wall at the bathroom door and peeling paint in the room. The blue mattress was stripping, exposing the white fabric under the blue plastic. The pillow on the bed was torn exposing the sponge in the pillow. room [ROOM NUMBER], the metal strip at the wall at the bathroom was not affixed to the wall and the sheetrock was broken. The baseboard of the hallway parallel to room [ROOM NUMBER] and the side opposite to the exit door was off the wall. room [ROOM NUMBER]'s baseboard was off the wall at the bathroom and the blind was broken. room [ROOM NUMBER]'s floor had brown stains rooms [ROOM NUMBERS] had missing strips on the floor between the room and the closet. room [ROOM NUMBER] baseboard was off the wall under the sink. The floor dining room had marks and brown stains on it In an interview and observation on 7/28/2023 at 3:30pm with Resident #1, he said that the sheets and towels on the floor was due to a leak in the bathroom. He said they were going to fix it. No maintenance personnel were observed in the room at the time of the interview. No leak was observed at the time of interview. In an interview on 7/28/2023 at 4:00pm LVN C said she did not know what time the general cleaning was done. She said housekeeping usually comes after each meal and sweep and clean the floor. She said the floor looked like it needed cleaning. Observation on 7/28/2023 between 4:10pm - 4:45pm of the 3rd floor revealed the following: room [ROOM NUMBER]'s sheetrock was torn behind the bed, the cover of the cable was broken, and the sheetrock was cracked. The baseboard was not affixed to the wall. room [ROOM NUMBER]'s baseboard was off the wall at the bathroom door. In an interview on 7/28/2023 at 5:30pm with the Administrator, he said they were doing repairs but it's a whole lot and it will take time to address all the maintenance issues. He said the floors were old and they were going to replace them. He said he had the approval for repairs to be done and was working on getting more help to get the repairs done faster. In an interview on 8/01/2023 at 11:00am with the Plant Manager, he said they were working on doing repairs to the building, but it's an ongoing project and they had gotten the approval. He said they were trying to get things done as quickly as possible. Observation on 8/1/2023 at 1:30pm of room [ROOM NUMBER] revealed a hole in the sheetrock at the entrance to the bathroom. The wall beside the window had torn sheet rack like it was punched. There was a hole at the bottom near the baseboard. The floor had brown stains on it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 2 of 3 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 675743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Phoenix Post-Acute 519 Ninth Ave N Texas City, TX 77590 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)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many In an interview on 8/1/2023 at 1:35 pm with Resident #2, he said he was admitted about three weeks ago to the facility and the wall was like that when he was admitted . He said they told him they were going to fix the wall. Observation on 08/01/2023 at 1:55pm of the lounge area of the 300 floor revealed peeling paint on the walls and brown stains on the floor. In an interview with the Housekeeping Supervisor on 8/1/2023 at 2:00pm she said that they check the rooms daily and if repairs needed to be done, they report it to maintenance. In an interview on 8/1/2023 at 2:15pm, Contractor A said he usually comes in to do repairs. He said was in to do repairs on the sheetrock and replacing the baseboards. Observation on 8/1/2023 at 4:30pm of the area to the elevator on the 2nd floor to the west side revealed peeling paint and damaged sheetrock. In an interview on 8/1/2023 at 4:55pm with Maintenance Man B said there was a book at each nurse's station and the staff were expected to document repairs that needed to be done. He said they would check the book daily and would address repairs as needed. He said repairs were prioritized and completed as needed. In an interview on 08/1/2023 at 5:45pm with the Administrator he said that he was going to ensure that the repairs were done a quickly as possible. He said he had the funds to do repairs but needed to get some more help. Record review of the Facility Repairs and Maintenance Service dated December 2009 read in part . Maintenance service shall be provided to all areas of the building grounds and equipment. This is to ensure the upkeep and maintaining of a safe environment and aesthetics for all facility interior and exterior areas. Policy Interpretation and Implementation The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include, but are not limited to: . Maintaining the building in compliance with federal, state and local laws, regulations and guidelines. . Maintaining the buildings in good repair and free from hazards. . Establishing priorities in providing repair service. . Provide routinely scheduled maintenance service to all areas. . Maintaining walls and ceilings in good repairs by way of Maintenance Personnel and contracted vendor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675743 If continuation sheet Page 3 of 3