Health inspection·June 23, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all alleged violation which involved abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24-hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the administrator of the facility and to other officials, which included the State Survey Agency in accordance with State law through established procedures for 1 of 6 air conditioning units (600 Hallway) reviewed for abuse and neglect. The facility failed to report the non-functioning air conditioning unit on Hall 600 to the State Survey Agency. This failure could place residents at risk of heat related complications and dehydration. Findings include: Record review of Resident #1's face sheet, dated 6/23/23, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Urinary tract infection, unsteadiness on feet, weakness, and muscle weakness. During an observation of Hall 600 on 6/22/23 at 11:45 AM revealed the area felt warm. The thermostat on the wall by the nurses' station showed the room temperature to be 76 degrees F and the thermostat was set to 73 degrees. During an observation of Hall 600 on 6/23/23 at 10:30 AM revealed the area felt warm. Fans were observed in the hallway to keep it cool. The AC had not been fixed at this time. There were two total fans set up in the hallway. There were no residents on this hallway. During an interview on 6/22/23 at 9:45 AM, Resident #1 stated her hallway started to get warm on 6/16/23 in the afternoon. She stated LVN-B came to her and let her know the AC unit for her hallway had gone out. She stated she never started to sweat but it did get warm. She stated the facility did offer her to move but was happy because it was finally warm in the facility. During an interview on 6/22/23 at 9:15 AM, MS-A stated he received a call late on 6/16/23 by LVN-B informing him hallway 600 was warmer than the rest of the hallways. He stated he was not at the facility at the time. He stated he stopped what he was doing and immediately went to the facility to start working on the AC unit. He stated the entire time the AC unit was out on hallway 600 and had Page 1 of 2 675944 675944 06/23/2023 Oak Ridge Manor 2501 Morris Sheppard Dr Brownwood, TX 76801

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few never gone over 80 degrees. He stated he and staff offered to move the residents. He stated some of the residents at first refused to move because they liked the warmth. He stated by 6/19/23 all residents had been moved to other halls for their safety, even though some were still refusing. He stated he was waiting for an entire new unit to come in, the expectation was for the AC unit to be installed on 6/27/23. During an interview on 6/22/2023 at 11:00 AM, LVN-B stated she worked the day the AC went out because she was helping maintenance try and figure out why it went out. She stated no matter what they did anytime the AC unit would come on it would immediately kick off and flip the breaker off. She stated on 6/16/23 the facility went to each resident's room and explained to them what was going on. She stated the residents stated they did not want to move because this was the warmest, they had ever been. She stated the only reason they ultimately moved the residents from hallway 600, on 6/21/23, was because the temperature did get to 80 degrees in the hallway. During an interview on 6/23/2023 at 12:15 PM, the ADMIN stated she did not report the AC going out because she did not feel any of the residents were at risk in any way. She stated it was also only one hallway the AC went out-on, and they were able to move the residents before any resident got to hot. She stated she understood PL 19-17 and that was one of the guidelines she followed but did not find the situation emergent, so she did not report the AC going out. Record review of the city's temperatures for the dates of 6/16/23 to 6/20/23 was accessed at https://weather.com revealed the following temperatures: Friday, 6/16/23- 96 degrees F Saturday, 6/17/23- 96 degrees F Sunday 6/18/23- 94 degrees F Monday 6/19/23- 104 degrees F Tuesday 6/20/23- 107 degrees F 675944 Page 2 of 2