Inspection·December 1, 2022

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one (Resident #43) of three residents observed for infection control practices, in that: Residents Affected - Few The facility failed to ensure CNA A performed appropriate hand hygiene when providing care to Resident #43. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Review of Resident #43's Face sheet, dated 12/01/22, documented an [AGE] year-old male admitted on [DATE] and readmitted [DATE] with the diagnosis of Alzheimer's disease, dementia, anxiety, type 2 diabetes mellitus, dysphagia (difficulty swallowing), hypertension (high blood pressure), sacral (tailbone) pressure ulcer, and schizoaffective disorder (mood disorder). Record Review of Resident #43's Minimum Data Set assessment, dated 11/04/22, documented Resident #34 required extensive, two-person physical assistance for bed mobility. Resident #34 required total dependence for toilet use, one-person physical assist. Resident #34 required extensive assistance with one person physical assist for personal hygiene- how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers). An observation of personal care for Resident #43 on 11/30/22 at 4:05 PM by CNA A revealed the staff entered the resident's room and placed gloves on to perform the brief change. CNA A removed Resident #43's pants, removed the front part of the brief, cleaned the front perineal area, and threw away the dirty wipes. CNA A turned the resident towards his left side with the same gloves to remove the brief, threw away the brief, cleaned Resident #43's buttocks, and put the new brief under Resident # 43. CNA A continued to wear the same gloves and put the resident's pants back on, adjusted the blanket, and placed the call light within reach. She than removed her gloves, exited the room, and threw the trash in a bin outside of the room. CNA A performed hand hygiene after throwing away trash in the bin outside. During an interview on 11/30/22 at 04:14 PM, CNA A revealed she never changed her gloves during brief changing. She stated she would put on one pair of gloves for one brief change. She revealed she (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 3 Event ID: 675837 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 675837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/01/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kruse Village Senior Living Community 1700 E Stone St Brenham, TX 77833 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)