Inspection·May 5, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few leave him alone. This nurse was standing in between the 2 residents. This nurse could not get [Resident #1] to get away from the other resident so This nurse asked the other resident to stand up and go to his room for a few minutes. The other resident did get up and walk toward room. [Resident #1] then began to follow the other resident and was unable to redirect by this nurse. This nurse was in between the 2 residents and trying to redirect [Resident #1]. [Resident #1] kept saying that he just wanted to talk to the other resident because he needed the other resident to open the door. [Resident #1] was at the door of the other resident's room. The other resident wanted to get by and leave his room since [Resident #1] would not leave the doorway. [Resident #1] then slapped this nurse in the ear with his right closed hand. CNA came out of room and was able to get the other resident away and back into dining area. [Resident #1] kept following the other resident. The other resident went back into his room. [Resident #1] then went to a different resident asking if he could open the door. [Resident #1] did not listen to any redirection [Resident #1] remains on 1:1. Further review of progress notes dated 05/02/2024, revealed, Call to doorway of Hall 200 to assist nurse with [Resident #1] because he was trying to exit the hallway, [Resident #1] had nurse by wrist. While telling [Resident #1] to let go of nurse [Resident #1] began to hit this nurse. CNA was present who attempted to redirect resident so this nurse to exit hallway. [Resident #1] continued to try to corner the nurse and hit this nurse, alerted DON to assist with situation. Further review of progress notes dated 05/02/2024, revealed, [Resident #1's Responsible Party] notified of the situation and agreed to have [Resident #1] sent to [sic] psych hospital for evaluation. Explained we will notify her when a facility has been found, when he's accepted and when he will transfer . Further review of progress notes dated 05/03/2024, revealed, [Resident #1] transferred to [psychiatric hospital] via facility van accompanied by van driver . During an interview with the Facility Van Driver on 05/04/2024 at 2:02 p.m., the Van Driver stated that she was tasked with driving [Resident #1] to a psychiatric hospital for evaluation and treatment due to his recent display of aggressive behaviors toward peers and staff. The Van Driver stated she felt safe with the resident because they had a good relationship. The Van Driver stated she would personally calm him by playing dominoes and taking walks and was surprised by his behavior on the day of transport. The Van Driver confirmed that she was alone with Resident #1 during the transport and stated she would have asked for another staff member to accompany them if she had felt unsafe. During an interview with the DON on 05/05/2024 at 2:34 p.m., the DON stated that Resident #1 was being transported to a psychiatric hospital for evaluation and treatment due to recent displays of aggression toward peers and staff. The DON stated that the Van Driver had always calmed resident #1 in the past. The DON stated the Van Driver told her that Resident #1 approached the Van Driver while the vehicle was in motion, pulled the driver's hair, and choked her. The Van Driver told the DON that she parked in a convenience store parking lot and called the police. Police were able to calm Resident #1 who appeared to have no knowledge of the incident after a few minutes, and the Van Driver proceeded to transport Resident #1 to the psychiatric hospital without further incident. The DON confirmed that Resident #1 and the Van Driver were uninjured during the incident. During an interview with the Administrator on 05/05/2024 at 4:00 p.m., the Administrator stated the facility policy regarding sending staff to accompany residents during transport had been decided on a case-by-case basis depending on the circumstances in the past. The Administrator confirmed that due to the incident with Resident #1, the policy would change and that a staff member would accompany (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675159 If continuation sheet Page 2 of 3 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 675159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Southbrooke Manor Nursing and Rehabilitation Cente 1401 W Main St Edna, TX 77957 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the Van Driver when transporting residents in the future. The Administrator confirmed that while Resident #1 and the Van Driver were uninjured during the incident, they could have had an accident that injured themselves and others on the highway. During an interview with the Administrator 05/05/2024 at 5:15 p.m., the Administrator confirmed the facility did not have a written policy regarding accompanying residents during transport. Event ID: Facility ID: 675159 If continuation sheet Page 3 of 3