Brazos Healthcare Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 3 of 3 shower rooms (A-Hall, B-Hall, and C-Hall) reviewed for cleanliness and sanitization. The facility failed to maintain clean and organized shower rooms, maintenance leaking shower head faucet, and properly dispose of dirty briefs and used linen. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or resident preferences indicated otherwise for 1 (Resident #1) of 6 residents reviewed for weight loss: The facility failed to provide weekly weights for Resident #1 on 10/27/2025, 11/10/2025, 11/17/2025, 11/24/2025, 12/08/2025, and 12/15/2025. Resident #1 was noted to have weight loss on 12/01/2025 and 12/17/2025 who had gastrostomy status (refers to a patient having a surgically placed tube (G-tube) into their stomach for feeding or draining, requiring ongoing care) diagnosis. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 shower rooms (A-Hall, B-Hall, and C-Hall) observed for infection control practices. The facility failed to maintain clean and organized shower rooms and avoid the development of legionella (a serious lung infection (pneumonia) caused by a bacteria, caught by inhaling mist from contaminated warm water sources like cooling towels and showers), repairing a leaking shower faucet, and not properly disposing of dirty briefs and linen. This failure could place residents at risk of cross-contamination from exposure to another's used personal items.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (CR#1) of 1 resident reviewed for baseline care plans. -CR#1 was admitted on [DATE] and his baseline care plan was not completed until 8/19/2025. This failure could lead to residents not receiving necessary care timely and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure and provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 for 54 of 54 residents in that: Facility failed to ensure Emergency Narcotic Kit kept in the facility medication room was permanently affixed. This failure could place residents at risk for misappropriation of property, and exploitation related to drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: - The facility failed to ensure the tabletop can opener blade and base were free of grime and debris.- The facility failed to ensure that the 3-compartment sink with wash-water and sanitizing solution was not used for food preparation.- The facility failed to label, and date left over food items in the refrigerator\freezer.- The facility failed to ensure that dented can goods were stored away from undented can goods. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on record review and interviews the facility failed to conduct a comprehensive assessment, within 14 calendar days after admission, for 2 of 13 residents (Resident #8 and resident #156) reviewed for comprehensive annual assessments and transmitted MDS data to the CMS System. The facility failed to complete Resident #8's admission MDS assessment within 14 days of admission. The facility failed to complete Resident #156's admission MDS assessment within 14 days of admission. This failure could place residents at risk of not having their assessments completed and transmitted timely which could result in a delay in treatment, denial of payment and or resident services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 20 residents (Resident #41) reviewed for care plans. The facility failed to revise Resident #41's comprehensive care plan to reflect the resident's discontinued catheter use. This failure could place resident at risk of isolation and not receiving needed care and services to improve their health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 17 of 39 residents reviewed for environmental concerns in that: The facility failed to provide hot running water in the bathrooms for 17 residents assigned to A-Hall for over a month. The facility failed to keep a safe and sanitary environment due to black substance being found in 3 of 39 resident's rooms. This failure placed residents at risk of living in an unsafe, unsanitary, and uncomfortable environment and could potentially cause a decline in their health.

Inspectors wroteACT - Actuation BIMS - Brief Interview for Mental Status EMR - Electronic Medical Record DON - Director of Nursing LVN - License Vocational Nurse MA - Medication Aide MAR - Medication Administration Record MCG - Microgram MDS - Minimum Data Set Q - Quarterly RAI - =Resident Assessment Instrument S/S= E Surveyor Name(s): [NAME] Immediate Supervisor: [NAME] Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for 1 of 3 residents (Resident #23) reviewed for unnecessary medications. -Facility failed to give Resident #23's Midodrine 10 mg medication as ordered by the physician. -The facility failed to check the resident's SBP level before administering Resident #23 her Midodrine 10mg medication. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure assessment accurately reflects the resident's status for 1 (Resident #9) of 13 residents reviewed for accuracy of assessments, in that -The facility failed to ensure Resident #9's Quarterly MDS assessment accurately reflected her bowel and bladder status. This failure could place residents at risk for inadequate care, diminished quality of life and decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. There were 2 errors out of 30 opportunities which resulted in a 6% error rate involving 2 of 3 residents (Resident #12, and Resident #20) and 1 of 2 employees (MA A) observed during medication administration reviewed for medication error , in that: -MA A omitted Resident #12's Bismuth/[NAME] pectate anti diarrheal medication. -MA A gave Resident #20 an incorrect dose of her nasal spray. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Residents #16 and #22) of fifteen residents reviewed for care plans. 1) The facility failed to ensure Resident #22's careplan addressed his tracheostomy, oxygen use or need for suctioning. 2) The facility failed to ensure Resident #16's careplan addressed her oxygen use. This failure could negatively impact the resident's quality of life, as well as the quality of care and services received if care planning is not complete or is inadequate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one of two residents (Resident #16) reviewed for respiratory care. The facility failed to ensure Resident #16's oxygen tubing was changed weekly per physician's orders. This deficient practice could place residents at risk for respiratory infections.