Inspection·January 24, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm 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. Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in one (right side) of two shower rooms on Hall 400. Residents Affected - Few -The facility failed to clean the shower room on the right side of Hall 400 that was observed with soiled towels, gloves, empty containers of personal care items, hair on the floor, and the floor had brown and black stain marks. This failure placed residents at risk for receiving showers in an unclean and uncomfortable environment. Findings included: Observation on 01/24/25 at 10:38AM of the shower room on the right side of Hall of 400 with CNA S. The shower room had large, soiled towels on the floor, wood shelving, and shower bed. Further observation was made of used empty containers of personal care items (shower gel, etc.) sitting on wood shelving. CNA S immediately started placing the soiled towels inside of a plastic bag. CNA S proceeded throwing used resident care supplies inside of plastic bag and picking gloves up off the floor. Further observation was made of the shower room floor being dirty with brown and black stains on the floor. There was debris on the floor behind the wood shelving. Further observation was made of a ball of white hair on the floor. Interview on 01/24/25 at 10:40AM with CNA S said the floors were dirty and she did not know when the last time the shower room floors had been cleaned. CNA S said when the CNAs finish providing a shower to a resident, the CNA was not to leave anything behind such as towels or resident personal care items due to germs and infection control. CNA S said it was the resident's home and that it was important to keep the shower room clean and tidy. CNA S said the nursing staff and housekeeping were responsible in making sure that the shower rooms were being cleaned for resident use. CNA S said when the shower room needed to be clean the staff would write in the communication book at the nurse desk. When CNA S went to find the shower book at the nurse station, she could not locate the book. CNA S proceeded to say the way they communicate with housekeeping was in the computer but did not show the surveyor where in the computer the staff was communicating with housekeeping regarding cleaning the showers. Interview on 01/24/25 at 10:40AM with Housekeeper T after observing the shower room on the right side of Hall 400 said the shower room floor was dirty and needed to be . Housekeeper T said she did not work at the facility on 01/23/25. Housekeeper T said she was working Hall 400 and was responsible for cleaning the resident rooms and keeping the shower room clean. Housekeeper T said she worked (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 676258 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 676258 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Memorial City Nursing and Rehabilitation Center 1341 Blalock Houston, TX 77055 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)