Health inspection·February 25, 2025

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many 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 comfortable and safe temperatures were maintained between 71F - 81F for 20 out of 20 residents (#2, #5, #9, #15, #17, #19, #21, #23, #24, #31, #35, #42, #45, #47, #49, #53, #57, #77, #140, and #190) reviewed for a safe and comfortable environment. - The facility failed to have a working heating system that provided heat to all resident rooms and used portable space heaters that did not monitor and adjust to room temperature but instead put out fixed heat, leaving some residents cold and room temperatures below 71 degrees Fahrenheit. - Observations and temperature measurements of resident rooms in the 100-hall ranged from 67.1 to 70.4 degrees Fahrenheit. - Observations and temperature measurements of resident rooms in the 200 hall ranged from 64.6 to 70.2 degrees Fahrenheit. - Facility records reported temperature measurements as low at 64 degrees Fahrenheit. An IJ was identified on (02/19/25). The IJ template was provided to the facility on [DATE]) at (06:15 PM). While the IJ was removed on (02/24/25), the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy. These failures placed residents at risk of hypothermia, illness, and a decline in their quality of life. Findings included: Record review of the facility census dated 02/18/2025 revealed out of 81 residents, 79 residents resided in private rooms. Observations and interview with the Administrator on 2/19/25 at 2:40PM revealed facility had a blanket warming unit set a 180F and extra comforters and linens in their linen storage. The Administrator revealed that this building was purchased and taken over by the company in the month of November. This occurred without knowledge of the failed heating/chiller system. She stated the system was so outdated, they do not have replacement parts to make repairs. She said ultimately the whole system would need to be replaced and that it would take a while to do so. She did not give a time frame. She Page 1 of 15 676236 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many stated in the meantime, they had ordered portable heaters and placed them in residents' rooms to keep them warm, they also had blankets and linens that can be put in the blanket warmer and given to residents who were cold. She stated staff check in on the residents often to ensure they were warm and they will also offer warm beverages to them. Observations and interviews from 2/19/25 from 2:10pm to 2:45pm of temperature measurements of resident rooms using Instant Read Digital Thermometer revealed: - Resident #23's room temperature was 69°F in the center of the room, 76°F near space heater. Resident was not present. - Resident #19's room temperature was 67.2°F in the center of the room. There was not a space heater, and the resident was not present. - Resident #41's room temperature was 70.4°F in the center of the room and 77°F near the space heater. - Resident #15's room temperature was 65.7°F in the center of the room with no space heater. - Resident #34's room temperature was 66.7°F in the center of the room with no space heater Observations and interviews on 02/19/25 from 11:00 PM through 02/20/24 at 12:30 AM revealed the following: - Resident #5's room temperature measured at 73.8 degrees Fahrenheit. She said previously she was freezing and was not used to the cold but then an angel brought her the heater so she was warm. She reported that it had been cold for the last 1-2 days. - Resident #140 room temperature was measured at 77.4 degrees Fahrenheit. The resident was accompanied by his family member. The resident said the temperature in his room was ok. The resident reported since she lost weight, she has been cold, and she had been cold ever since she came to the facility 5 days ago. The resident reported that facility staff gave her a heater today and she was warm. The resident reported that she informed a staff member in therapy that she was cold, so he brought her a heavy blanket as well as 2 heavy shirts and pants since all she had were gowns. - Resident #41's room temperature was measured at 77.5 degrees Fahrenheit. He said he felt good and warm, he was slightly chilly prior to receiving his heater 2 weeks ago. - Resident #77's room temperature was measured at 77.0 degrees Fahrenheit. He said he felt toasty but was cold in the past. Resident #2 Record review of Resident #2's admission Record revealed a [AGE] year-old female admitted on [DATE] and originally admitted on [DATE]. Her diagnoses included: heart failure, muscle weakness, high blood pressure, age related cognitive decline. Record review of Resident #2's MDS dated [DATE] revealed severely impaired cognition as indicated by a BIMS score of 05 out of 15. 676236 Page 2 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many In an interview and observation on 02/19/2025 at 2:25 pm, Resident #2 stated she was comfortable. The resident's room contained a heater that the caregiver in the room at the time of the observation stated was supplied by the family. The temperature measured was 65.5 degrees Fahrenheit with an Instant Read Digital Thermometer. In an interview and observation on 02/20/25 at 9:48 am, with Resident #2 reported she had no signs and symptoms of flu, cold or pneumonia. The temperature in the resident's room was measured with an Infrared Thermometer by door on floor 63.2 degrees Fahrenheit, and by window on floor 61.5 degrees Fahrenheit. Resident #9 Record review of Resident #9's face sheet dated 02/23/2025, revealed a [AGE] year-old female who admitted on [DATE] with diagnosis that included Parkinson's Disease and Type 2 Diabetes. Record review of Resident #9's MDS assessment, dated 11/21/2024, revealed a BIMS score of 8, indicating moderate cognitive impairment. Observations of Resident #9's room on 2/20/2025 at 10:26AM, revealed the temperature was 70.3 degrees. Resident #9 was sleeping in bed. Resident #15 Record review of Resident #15's face sheet dated 02/23/2025, revealed a [AGE] year-old female who admitted on [DATE] with diagnoses that included Adjustment Disorder with Mixed Anxiety and Depressed Mood, Morbid (Severe) Obesity Due to Excess Calories, and Type 2 Diabetes. Record review of Resident #15's BIMS assessment dated [DATE], revealed a BIMS score of 14, indicating resident was cognitively intact. Observations and Interview of Resident #15 on 2/20/2025 at 10:16AM, revealed the temperature in the resident room was 74.8 degrees. Resident #15 reported the temperature in the room was fine for the last month. It was a little chilly this morning but they adjusted the temp on the space heater and now it's great. Resident #17 Record review of Resident #17's admission Record revealed a [AGE] year-old male admitted on [DATE] and originally admitted on [DATE]. His diagnoses included: obesity, abnormal gait, unsteady on feet, and high blood pressure. Record review of Resident #17's MDS dated [DATE] revealed a BIMS score of 12 out of 15 indicating he had moderately impaired cognition. Record review of Resident #17's undated Care Plan revealed resident refused to turn heater on. In an interview and observation on 02/19/2025 at 2:40 pm, Resident #17 stated he didn't want a heater and he felt comfortable. The resident's room was observed to not contain a heater and the temperature measured was 67.1 degrees Fahrenheit with an Instant Read Digital Thermometer. 676236 Page 3 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 Resident #19 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #19's face sheet, dated 02/25/2025, revealed an [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with hypertension and left femur fracture. Residents Affected - Many Record review of Resident #19's BIMS score, dated 02/02/2025, reflected a score of 15, indicating the resident's cognition was intact. Observations of Resident #19's room on 02/19/2025 at 2:10PM, revealed the resident's room was temped at 67.2F Resident #21 Record review of Resident #21's admission Record revealed a [AGE] year-old-female re-admitted on [DATE] and initially admitted on [DATE]. Her diagnoses included: low back pain, abnormal gait, muscle weakness, obesity, swelling. Record review of Resident #21's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. In an interview and observation on 02/19/25 at 2:19 pm, Resident #21 said she was cold. The resident's room did not contain a heater and the temperature was measured at 64.6 degrees Fahrenheit with an Instant Read Digital Thermometer. Resident #24 Observation an Interview with Resident #24 on 02/19/25 at 01:45 PM revealed, the resident's room measured 67.4 degrees Fahrenheit and there was no heater present in the room. The resident did not speak English and translation was performed by the Case Manager. The Case Manager reported that the resident did not have any issues with the temperature in her room and the resident did not feel cold at any time. Resident #31 Record review of Resident #31's face sheet dated 02/21/2025 indicated a [AGE] year-old male readmitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included dementia, stroke, hemiplegia (paralysis on one side of the body), hypertension, acute kidney failure. Record review of Resident #31's comprehensive MDS dated [DATE] indicated under section C - cognitive patterns, he had short term and long-term memory problems. He also had moderately impaired cognitive skills for daily decision making. The BIMS summary score was blank. Observation and interview with Resident #31 on 02/19/25 at 01:23 PM revealed, a portable heater in use in the resident room. Measurement revealed the room temperature to be 70.3 degrees Fahrenheit. The resident was only able to communicate with head and hand gestures, the resident gestured that he did not feel cold by shaking his head from left to right when asked if he felt cold. Observations and interview with Resident #31 on 2/20/25 at 2:30PM, using instant read digital 676236 Page 4 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 thermometer, the heat of Resident 31's heater, that was in use at the time, Resident #31 gestured that he felt cold using body language and limited verbal communication. Level of Harm - Immediate jeopardy to resident health or safety Resident #35 Residents Affected - Many An observation and interview of Resident #35 on 02/19/25 at 01:20 PM revealed, the room temperature measured at 67.3 and there was no heater present in the resident's room. Resident #35 stated that she was cold in her room and would have to get under her blankets to get warm. Resident #42 Record review of Resident #42's admission Record revealed a [AGE] year-old-female readmitted on [DATE] and originally admitted on [DATE]. Her diagnoses included: stroke, muscle weakness, left leg below knee absence, lack of coordination, high blood pressure. Record review of Resident #42's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating she was cognitively intact. In an Interview and observation on 02/19/25 at 2:14 pm, Resident #42's room did not have a heater. She stated she did not ask for a heater and she was cold. The residents room measured 67.2 degrees Fahrenheit with an Instant Read Digital Thermometer. In an interview and observation on 02/20/25 at 9:43 am with Resident #42, she stated she slept well, was comfortable and had no concerns about her environment. The temperature measured with an Infrared Thermometer with Laser by floor by the door 65.3 degrees Fahrenheit. Resident #45 Record review of Resident #45's face sheet, dated 02/25/2025, revealed a [AGE] year-old male who was admitted into the facility on [DATE] and was diagnosed with vascular dementia and cerebral infarction. Record review of Resident #45's BIMS score, dated 02/02/2025, reflected a score of 7, indicating the resident had moderate cognitive impairment. Observation of Resident #45's room on 02/19/2025 at 2:14PM, revealed resident's room was temped at 67.1F with a space heater not in use. Resident #45 reported feeling comfortable in her room at this time. Observation and interview with Resident #45 on 02/19/2025 at 3:10PM, revealed the resident lying in bed awake and he reported his room felt cold. The resident's space heater was in use at this time. Resident #47 Record review of Resident #47's face sheet, dated 02/25/2024 revealed an [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with high blood pressure and emphysema. Record review of Resident #47's BIMS score, dated 01/07/2025, reflected a score of 13, indicating the resident had no cognitive impairment. 676236 Page 5 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 Observation and interview with Resident #47 on 02/19/2025 at 9:30AM, she stated a family member brought a personal space heater for her in January of 2025 because it was cold in her room. Level of Harm - Immediate jeopardy to resident health or safety Resident #49 Residents Affected - Many Observation and Interview of Resident #49 on 02/19/25 at 01:00 PM revealed, the temperature measured 68.2 Fahrenheit and there was an unplugged heater in the room. The resident stated she had a heater and did not need it and she had no problems with the room temperature. Resident #53 Observation of Resident #53's room on 02/19/25 at 01:30 PM revealed, the resident was asleep. A heater was observed in box and the temperature was measured at 67.9 degrees Fahrenheit. Resident #57 Record review of Resident #57's admission Record revealed a [AGE] year-old-male readmitted on [DATE] and initially admitted on [DATE]. His diagnoses included: stroke, muscle weakness, difficulty with swallowing, high blood pressure. Record review of Resident #57's MDS dated [DATE] revealed a BIMS score of 12 indicating he had moderately impaired cognition. In an interview and observation on 02/19/2025 at 2:30 pm, Resident #57 stated he was cold. There was no heater observed in the resident's room and she stated the facility took the heater away yesterday. The temperature in the resident's room measured 65.5 degrees Fahrenheit with an Instant Read Digital Thermometer. In an interview and observation on 02/20/25 at 9:52 am, Resident #57 stated he rested comfortably, he liked it cool and did not feel cold. The temperature in the resident's room was measured with an Infrared Thermometer with as 69.8 degrees Fahrenheit Laser by door on floor, and 67.5 degrees Fahrenheit on floor by bed. Resident #190 Record review of Resident #190's face sheet, dated 02/25/2024 revealed an [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with a cerebral infarction and stage 3 kidney disease. Record review of Resident #190's BIMS score, dated 02/03/2025, reflected a score of 2, indicating the resident had severe cognitive impairment. Observation and interview with Resident #190's, on 02/19/2025 at 2:23PM, revealed resident's room was temped at 69.7F while using a space heater that was emitting heat around 89F. In an interview on 2/19/2025 at 5:09 pm, the Administrator stated there could be harm to residents if temperatures go below 68 degrees Fahrenheit. The potential harm could be difficulty with breathing, and hypothermia. The plan for nursing facility was to monitor ambient temperatures every 2 hours. If temperatures go below 60 degrees Fahrenheit, the residents would be transferred to the assisted 676236 Page 6 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many living side. Temperatures at 60 degrees Fahrenheit and above, the facility was to offer warm blankets and hot beverages. Nursing and CNA staff were monitoring resident vital signs two times a shift or every 6 hours. Temperature checks were occurring every two hours throughout the building. In an interview on 2/19/2025 at 5:15 pm, the DON reported potential harm for residents if temperatures go below 68 degrees Fahrenheit were hypothermia, potential falls, and difficulty with breathing. The plan for the facility if temperatures are at or above 60 degrees Fahrenheit is to place portable heaters in resident rooms, offer warm blankets, warm drinks, and temperature checks every two hours by maintenance director. If temperatures go below 60 degrees Fahrenheit, the plan would be to transfer residents to the assisted living side. In an interview on 2/20/25 at 9:34 am, LVN G stated residents were monitored every two hours with regards to comfort level as far as temperatures. LVN G stated no resident had any temperature under 97 physically and rooms were warm, if resident complained of being cold, a warm blanket, warm liquids were administered. LVN G reported CNA's reported any concerns regarding environmental temperatures to her. In an interview and observation on 2/20/25 at 9:37 am the maintenance director. He stated temperatures were taken every two hours by CNA's and nurses and logged overnight. Temperatures were maintained between 68 degrees Fahrenheit and 73 degrees Fahrenheit last night and there were no concerns regarding resident comfort. In an interview on 02/20/25 at 9:59 pm, LVN S, stated he had been monitoring residents with CNA's every two hours. LVN S asked residents if they felt cold or too hot and if they reported if they were feeling chilly would give them a blanket and warm liquids if needed. CNA's reported to him any concerns that residents had and none of his residents had had any signs of symptoms of cold, flu, or pneumonia. In an interview on 02/20/25 at 10:27am with the Director of Rehab, she stated that only one resident had complained to her about the temperature in their room in the last 30 days. Resident #15 had complained she was cold this morning. The space heater temperature was adjusted. She reported that she was not aware of any residents that had suffered any adverse effects due to the temperature in their room. In an interview and observation on 2/20/2025 at 10:40 AM, CNA V stated she started working at the facility two months ago. She stated the heating issue just happened due to the snow and indoor temperatures were fine before when it was warm. She stated that she makes sure plenty of blankets were available for her residents. She stated the laundry staff stock the linen closet with blankets and was never short of blankets. In an interview and observation on 2/20/2025 at 10:50 AM, Laundry B was observed re-stocking blankets in the linen closet near Room134. She stated she had been working at the facility since July 2024. A blanket warmer tower was in the closet with blankets on the shelves. She stated the laundry room was in another building. She stated she would load the warm blankets from the drier into a clean container for transport covered then restocks the closets. She stated she ensures the blanket warmer was well stocked. She stated she understood that the residents were elderly and often get cold easily. She stated she restocked closets often as soon as the blankets were ready from dryers. In an interview on 2/20/2025 at 10:54 AM RN D stated she started working at the facility eight 676236 Page 7 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many weeks ago. She stated she would check her residents often and communicates with CNAs regarding comfort and safety of residents who have portable heaters. She was able to verbalize signs and symptoms of drops in resident temperatures such as confusion, signs, and symptoms of PNA (pneumonia) or colds. She denied any issues with blankets for the residents. She stated she checked residents regularly and assessed for change of condition and seeing to their needs. In an interview on 2/20/2025 at 11:10 AM the Unit Manager stated she started working at the facility in July 2024. She stated even before the extreme cold weather, they had conducted trainings for emergency extreme weather preparedness. She stated she checked residents and continues to check often for signs and symptoms of PNA, colds or changes in comfort level. She was able to verbalize signs and symptoms appropriately. In an interview on 2/20/2025 at 11:17 AM RN D stated due to the extreme cold weather, they also have a blanket warmer. She stated she frequently assessed her residents for changes in temperature and comfort level. She stated all her residents had no complaints and had no concerns with their health during the extreme cold weather. She was able to verbalize signs and symptoms of hypothermia, PNA, colds, flu signs and symptoms. In an interview and observation on 2/20/2025 at 11:38 AM CNA S stated she started working at the facility one month ago. She was able to verbalize her understanding of monitoring her residents for comfort and safety. She was observed to check on room [ROOM NUMBER] and asked the resident if she needed anything and reminded the resident to use the call light when needed. She stated she would go to Hall #3 on the first floor to retrieve blankets from the blanket warmer and had no issues with supplies of blankets. She stated that she would report to her nurse any change of condition in her residents especially during this time of extreme cold. She stated she would observe the environment and would use her senses in assessing a resident who cannot verbalize comfort or discomfort with the room temperature. In an interview on 2/20/2025 at 12:07 PM LVN C stated she has been working at this facility for one month but had worked for the company many years in another state. She stated all her residents in Hall 3 have portable heaters and AC units. She stated she had no resident concerns and said she sees residents frequently on her shift and always assesses her residents for signs and symptoms of PNA, cold and flu including assessing non-verbal residents. She said she communicates with CNAs regularly to ensure resident comfort and safety. She had no issues with supply of blankets. She stated some residents like it cold, others want room warm therefore some want more blankets others may not want them at all. Record review of facility 'Temperature and Room Safety Check' dated 01/21/25 revealed: - room [ROOM NUMBER] at 08:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 02:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 02:00 AM- 70 degrees Fahrenheit 676236 Page 8 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 - room [ROOM NUMBER] at 10:00 PM- 70 degrees Fahrenheit Level of Harm - Immediate jeopardy to resident health or safety - room [ROOM NUMBER] at 12:00 AM- 70 degrees Fahrenheit Residents Affected - Many - room [ROOM NUMBER] at 08:00 PM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 69 degrees Fahrenheit Record review of facility ' 100 Hall Temperature and Room Safety Check' dated 02/18/25 revealed: - room [ROOM NUMBER] at 08:00 PM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 12:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 02:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 02:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 12:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 02:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 12:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 70 degrees Fahrenheit 676236 Page 9 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 - room [ROOM NUMBER] at 06:00 AM- 70 degrees Fahrenheit Level of Harm - Immediate jeopardy to resident health or safety - room [ROOM NUMBER] at 08:00 PM- 69 degrees Fahrenheit Residents Affected - Many - room [ROOM NUMBER] at 12:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 12:00 AM- 68 degrees Fahrenheit Record review of facility ' 200 Hall Temperature and Room Safety Check' dated 02/18/25 revealed: - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 64 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 62 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 67 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM and 10:00 PM- 70 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 10:00 PM- 71 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 61 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 61 degrees Fahrenheit - room [ROOM NUMBER] at 08:00 PM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 67 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 67 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 66 degrees Fahrenheit 676236 Page 10 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 - room [ROOM NUMBER] at 06:00 AM- 65 degrees Fahrenheit Level of Harm - Immediate jeopardy to resident health or safety - room [ROOM NUMBER] at 04:00 AM- 68 degrees Fahrenheit Residents Affected - Many - room [ROOM NUMBER] at 04:00 AM- 68 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 67 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 69 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 64 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 63 degrees Fahrenheit - room [ROOM NUMBER] at 04:00 AM- 67 degrees Fahrenheit - room [ROOM NUMBER] at 06:00 AM- 66 degrees Fahrenheit Record review of the 10 Day weather forecast at the facility location dated 02/19/25 at 04:04 PM revealed, -Wednesday 02/19/25: the low would be 20 degrees Fahrenheit - Thursday 02/20/25: 28 to 37 degrees Fahrenheit - Friday 02/21/25: 31 to 37 degrees Fahrenheit - Saturday 02/22/25: 39 to 44 degrees Fahrenheit - Sunday 02/23/25: 41 to 60 degrees Fahrenheit - Monday 02/24/25: 47 to 70 degrees Fahrenheit - Tuesday 02/25/25: 53 to 76 degrees Fahrenheit Record review of the facility's policies on a Homelike Environment, dated October 2009, reflected, .1. Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Cleanliness and order; b. Comfortable (minimum glare) yet adequate (suitable to the task) lighting; c. Inviting colors and decor; d. Pleasant, neutral scents; 676236 Page 11 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 e. Plants and flowers, where appropriate; Level of Harm - Immediate jeopardy to resident health or safety f. Comfortable temperatures . An immediate jeopardy (IJ) was identified on 02/19/2025. The IJ template was provided to the facility on [DATE] at 6:15PM. Residents Affected - Many On 02/21/2025 at 7:29PM, the following Plan of Removal was accepted: Monitoring for Plan of Removal: . F 584 The facility failed to ensure resident comfort and safety by failing to maintain a temperature range between 71-81 degrees Fahrenheit. The facility census is 81 and consists of 80 rooms with malfunctioning centralized heating and are unable to control temperatures within individual resident rooms placing resident at risk of feeling cold, worsening health conditions, pain and hypothermia. The facility needs to develop and implement a system ensuring that all resident rooms are within safe and comfortable temperatures of 71-81 degrees Fahrenheit. Immediate action: 1. The Medical Director was notified by the Executive Director on 2/19/2025 at 8:18pm. 2. The Extreme Cold Procedure was reviewed by Executive Director, DON, Maintenance Director and Medical Director. The Cold Alert Procedure was reviewed by ED, DON, Maintenance Director and Medical Director, temperature was changed to 65F on 2/20/25. The temperature was changed from 60F to 65F. 3. Executive Director, DON and Maintenance Director were reeducated on regulations re: resident room comfortable temperature range and a Comfortable Room Temperature Policy was written by the Life Safety Resource on 2/19/25. The education was provided by the Life Safety Resource. 4. Room Temperatures were audited by Department Heads to identify rooms needing space heaters on 2/19/25. [name of company] repaired the condensing loop system on 2/10/25. They provided a quote for an upgrade on 2/13/25. [name of company] is a licensed professional HVAC company. [name of company] is the company under contract to complete the current repairs. The repair timeline is dependent on parts availability, it could be 3-4 weeks. The facility is planning on upgrading to PTAC 676236 Page 12 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 units starting in Spring. Level of Harm - Immediate jeopardy to resident health or safety 5. Space heaters provided to all residents who agreed to have it, completed Residents Affected - Many by Nursing Staff/ Maintenance. Maintenance Director is responsible for the 2/19/25. Space Heaters are monitored during room temperature checks or rounds oversight of the space heaters. The list of Heaters: Magnavox gDual Quartz Fan Radiant Heater Model No. QGW15-607 SKU#:127473 Adjustable Thermostat Two settings: High {1500 [NAME]} Low (750 [NAME]} Top Mounted Control Panel Power indicator Light Safety Overheat protection. Safety Tip-over Protection Convenient Stay cool carry handle Quiet high efficiency fan assisted. 120V A.C. 60Hz 12.SA, 5120 BTUs [NAME] Digital Ceramic Tower Heater Model #CC23645 Top Mounted Control Panel Power indicator Light 676236 Page 13 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 Safety Overheat protection. Level of Harm - Immediate jeopardy to resident health or safety Safety Tip-over Protection Residents Affected - Many Model # CT32791 [NAME] Revolution II Full room Heater Power indicator Light Safety Overheat protection. Safety Tip-over Protection Utilitech Fan-Forced heater Model BNS 15-JW 120VAC 60 Hz 1500W Power indicator Light Safety Overheat protection. Safety Tip-over Protection Maintenance monitors for tipping hazards, positioning of the heater that it is not to close to the bed or other furniture; check for cracked or damaged cords and plugs, condition of the unit; The heaters are plugged into the outlet; heater placed securely away from bed or other furniture; extension cords not in use. 6. Commercial grade heaters have been located and are being placed on hallways to maintain temperatures per regulation. Upon completion of HVAC contractors, heaters will be removed. While heaters are in place, ongoing monitoring of temps and safety will be completed by walking rounds by Maintenance personnel or trained designee. 7. Room temperatures will be audited every 2 hours by CNAs/ Maintenance. The Maintenance Director will be notified when temperatures are below 71. The Executive Director will be notified if room temperatures are below 65 and remain below 65 for one hour. Completion every 2 hours are until the temperatures are maintained >71, then, every shift during the inclement weather. If a room is less than 71F, Maintenance is to be notified; room temperature will be rechecked; nursing will offer the resident warm blankets and warm beverages; resident vital signs are being monitored at least twice per shift 676236 Page 14 of 15 676236 02/25/2025 Champions Healthcare at Willowbrook 13500 Breton Ridge Houston, TX 77070

F 0584 and the Charge Nurse will assess for change of condition as needed. Level of Harm - Immediate jeopardy to resident health or safety 8. All residents who prefer a cooler room temperature will be identified and their care plans updated by 2/20/25. Residents are allowed to have cooler rooms within reason/based on their wishes/ resident rights. The Nursing staff will monitor the residents vital signs twice per shift and Charge Nurses will assess as indicated. Resident preference will be identified in the care profile. Residents Affected - Many 9. Residents will be offered warm blankets; warm beverages to prevent hypothermia. Nursing staff are monitoring resident during rounds and vital signs; Charge Nurses will assess as indicated. 10. Windows were checked for air leaks by Maintenance Director on 2/19/25. 11. Portable AC Units were removed 2/19/25 and windows sealed by Maintenance Director. (Unless resident declined the removal) The windows was closed which sealed itself, no other sealant was used. No resident was at a safety risk 676236 Page 15 of 15