Brazos Healthcare Center

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

an interview on 12/23/2025 at 6:04 p.m. ADM and ADON stated that staff received in-service training on the new shower room policy (but had not provided the in-service for review). Record review of an email dated 12/19/2025 at 04:13 p.m. ADM indicated that there were 3-CNA A, CNA B, and CNA C who performed showers for residents on 12/19/2025. Record review of the DSRCL date beginning 11/25/2025 - 12/19/2025 reflected that on 12/19/2025 A-Hall's shower room was checked off as being cleaned by housekeeping staff

A and verified by licensed vocational nurse (LVN) A, but there had been no time listed. Record Review Policy titled: Shower Room Cleaning Policy Purpose To ensure shower rooms are cleaned and disinfected consistently to prevent the spread of infection and maintain a safe, sanitary environment for residents, staff, and visitors. Policy: All resident shower rooms at the facility will be cleaned and disinfected after each resident use and daily at minimum, using facility-approved disinfectants and following infection prevention standards.Procedure: After Each Resident UseThe following surfaces must be cleaned and disinfected either by EVS or Nursing staff immediately after use: Shower chair / shower stretcher Grab bars Shower controls and handles Walls within splash zone Floors and drains Any reusable equipment used during bathing Steps:1. [NAME] appropriate PPE (gloves; gown and face protection if splashing is anticipated).2.

Remove visible soil using approved cleaner.3. Apply facility-approved disinfectants to all required surfaces.4. Allow disinfectants to remain wet for required contact time per manufacturer instructions.5.

Rinse surfaces if required and allow area to air dry.6. Remove PPE and perform hand hygiene. Daily Cleaning (Even If Not Used)EVS staff will clean and disinfect: Floors Walls Grab bars Door handles Light switches Trash receptacles (No razors should be discarded in the trash; please use sharps receptacles) Terminal CleaningShower rooms will receive enhanced cleaning: After use by a resident on isolation precautions Following a known or suspected infectious outbreak As directed by Infection Prevention or Nursing Leadership

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brazos Healthcare Center

413 Garland Dr Lake Jackson, TX 77566

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)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded.8. Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems.a. Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse.b. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian.9. Meals are scheduled at regular times to ensure that each resident receives at least three (3) meals per day. Mealtimes are posted in common areas.10. Nourishing snacks are available to the residents 24 hours a day. The resident may request snacks as desired, or snacks may be scheduled between meals to accommodate the resident's typical eating patterns.

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If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Brazos Healthcare Center

413 Garland Dr Lake Jackson, TX 77566

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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

staff A and verified by licensed vocational nurse (LVN) A. No time was noted. In-service training for new shower policy was not provided. Record review of the Policy titled and Infection Prevention and Control Program and revised dated 06/2025 reflected:Policy StatementAn infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation1. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.2. The program is based on accepted national infection prevention and control standards.3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.4. The elements of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety.5. Coordination and Oversighta. The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist).b. The qualifications and job responsibilities of the Infection Preventionist are outlined in the Infection Preventionist Job Description.c. The infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Some examples of committee reviews may include:(1) documented IPCP incidents and corrective actions taken;(2) whether physician management of infections is optimal;(3) whether antibiotic usage patterns need to be changed because of the development of resistant strains;(4) whether information about culture results or antibiotic resistance is transmitted accurately and in

a timely fashion; and(5) whether there is appropriate follow-up of acute infections.d. The committee meets regularly, at least quarterly, and consists of team members from across disciplines, including the Medical Director. 6. Policies and Proceduresa. Policies and procedures are utilized as the standards of the infection prevention and control program.b. Policies and procedures reflect the current infection prevention and control standards of practice.c. The infection prevention and control committee, Medical Director, Director of Nursing Services, and other key clinical and administrative staff review the infection control policies at least annually. The review will include:a. Updating or supplementing policies and procedures as needed;b.

Assessment of staff compliance with existing policies and regulations; andc. Any trends or significant problems since the previous review.

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