Brazos Healthcare Center

Based 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.Findings included: During an observation on 12/19/2025 at 01:12 p.m.in unlocked shower room A-Hall (across from the nurse's station) had leaking water dripping from shower head faucets. Floor and wall tiles were discolored under leaking water. During an observation on 12/19/2025 at 01:14 p.m. in unlocked shower room on B-Hall (resident's hall) were 2-open wall cabinets that were full of unorganized items consisting of loose gloves, unfolded towels, 1 of 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. These failures had the potential to affect other residents requiring weight management, especially those who have weight loss and weight gain and who could be at risk of serious harm due to poor nutrition and weight loss. Findings Included: Record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings included: During an observation on 12/19/2025 at 01:12 p.m. of A-Hall's unlocked shower room (across from the nurse's station) faucet water dripping from 1 of 1 shower heads. Water accumulating on discolored floor and wall tiles near drip water.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include:Record review of CR#1 admission record dated 8/8/2025 revealed an [AGE] year-old male admitted to the facility on [DATE] at 5:30 pm and was discharged on 8/12/2025. His diagnoses included: Left intertrochanteric femur fracture (left hip fracture), metabolic encephalopathy (refers to change in brain function due to metabolic disturbances in the body), chronic kidney disease 4 with acute kidney injury now with end stage renal disease (gradual kidney damage with a sudden…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: Observation and interview with ADON on [DATE] at 10:19 am of facility's only medication room that was key locked and secured, located behind the nursing station desk of B hall/unit. There was a small approximately 10X10X10 bright red metal box with a keypad coded front, which was closed and sealed, located on an upper cabinet shelf. The box had 2 small holes on the back side of the box and a red sticker tag labeled Brazos. Another side of the box had a sticker labeled with Pharmacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included: Observation and interview on 06/30/25 beginning at 8:30 AM revealed the following:-One of one can opener in the kitchen had dark brownish looking substance around the cutting blade and the blade holder. The Dietary Manager took it out for wash.-Observation of one of one Deep fryer revealed it was 3\4 filled dark looking grease and whitish floating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Record review of Resident #8's face sheet dated 07/02/25 revealed a -[AGE] year-old male admitted to the facility on [DATE]. Her diagnoses included cerebral palsy, (a group of neurological disorders that appear in infancy and permanently affect body movement and muscle coordination.), abnormalities of gait and mobility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: 1. Record review of Resident #41's face sheet dated 07/02/25 revealed a-[AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Essential (primary) hypertension (High blood pressure), major depressive disorder), morbid obesity due to excess calories, retention of urine, type 2 diabetes (A chronic condition characterized by insulin resistance and elevated blood sugar levels). intertrochanteric fracture of left femur,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Observation on 06/30/2024 at 12:44p.m., revealed black substance around the sprinkler head in room [ROOM NUMBER]. Observation on 6/30/2024 at 1:13p.m., revealed black substance around the sprinkler head in room [ROOM NUMBER]. Observation on 6/30/2024 at 1:16p.m., revealed a broken water heater. During an interview on 6/30/2024 at 1:17p.m. with the Floor Tech, he said the water pipe was out of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY ACT - 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. This deficient practice could place residents in the facility at risk of having the use of an unnecessary drug without adequate indications for its use, and a decline in their health. Findings include: Record review of Resident #23's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Record review of Resident #9's admission Record revealed she was an [AGE] year old female that readmitted to the facility on [DATE] with diagnoses of hyperlipidemia (high cholesterol), dysphagia (difficulty or discomfort in swallowing), bipolar disorder (a condition associated with episodes of mood swings ranging from depressive lows and manic highs), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures and can be genetic or as a result of injury). Her BIMS score was 15 out of 15 indicating she had no cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings were: Resident #12 Record review of Resident #12's admission Record revealed she was a [AGE] year old female who admitted to the facility on [DATE] with the following diagnoses: diarrhea (a condition of having loose, watery stools, three or more times in a day, or more frequently than usual for the individual), dementia (a condition…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. 1) Review of Resident #22's admission Record dated 04/06/23 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #22 had diagnoses of chronic obstructive pulmonary disease, chronic respiratory failure, bacterial pneumonia, heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #16's face sheet, dated 04/06/2023, reflected a [AGE] year-old female who was admitted on [DATE] with an original admission date of 05/20/2020, with diagnoses that included Chronic Obstructive Pulmonary Disease, mild intermittent asthma, and congestive heart failure. Review of Resident #16's Annual MDS dated [DATE] reflected a BIMS score of 13, which indicated the resident's cognition was intact.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.