Inspection·July 6, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's comprehensive care plan, target date [DATE], reflected Resident #1 had impaired cognition and impaired thought process related to dementia. Intervention: she required supervision/assistance with all decision making. Resident #1 was care planned to be at risk for shortness of breath/difficulty breathing related to asthma, and chronic congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should). Intervention: monitor/document breathing patterns. Report abnormalities to MD. Resident #1 had a terminal prognosis related to congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and pulmonary embolism (as sudden blockage in a lung artery). Resident was receiving hospice care. Intervention: keep the environment quiet and calm. Provide maximum comfort for the resident. Resident #1 was at risk for falls related to confusion, deconditioning, gait/balance problems, poor communication/comprehension, unaware of safety needs and disease process. Intervention: anticipate and meet her needs. Encourage her to participate in exercise, physical activity for strengthening. Resident had an ADL self-care performance deficit. Resident required assistance with bed mobility, bathing, dressing, eating, and transfers. Resident #1 was on diuretic therapy related to congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should). Intervention: may cause dizziness, fatigue, and an increased risk for falls. Observe for possible side effects every shift. Resident had functional bladder. Intervention: Resident #1 will be checked and changed as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. Record review of Resident #1's nurse's progress note, dated [DATE], at 5:52 PM reflected while assisted patients in dressing and toileting, CNA stated that patient (Resident #1) had been up in her chair all night and was not in bed. Assessment patient and vital signs taken, found no acute injuries, notified administrator and assistant administrator of incident, per facility protocol. Administrator spoke with family on incident. 9:00 AM daughter at bedside with patient, patient resting quietly with no s/s of distress/discomfort noted at this time. 7:00 PM patient remained stable today with no outwardly s/s of distress/discomfort noted. Continues with oxygen at 2 Liters per NC sat 96%. Vital signs 98.6 72-20-169/88. Incontinent care every 2 hr. and prn. Signed By LVN A. Record review of alleged neglect assessment, dated [DATE] at 10:01 AM, reflected Resident #1 was not assisted to bed and sat in her broda chair throughout the entire 10:00 PM -6:00 AM shift ([DATE]-[DATE]). Resident #1 does not communicate therefore she was unable to provide any information pertaining to the incident. Resident #1 was assessed to have injury to the right and left thigh. Resident #1's mental status was at baseline. Resident #1 was incontinent and had impaired memory. Agencies/People Notified were the following: Physician, State Survey Agency, Ombudsman, Administrator, and DON. Signed by Assistant Administrator/RN B. Record review of statement dated [DATE] reflected Resident #1 had been placed in bed. Resident was assessed from head-to-toe. There were two red areas, both measuring four inches to the posterior thighs. Both sites were blanchable upon palpation. The areas on the resident were cleaned and barrier ointment was applied. All pressure areas were offloaded. Resident #1 did not have any pain per painad scale. Resident #1's daughter was at bedside. Signed by Assistant Administrator/RN B Record review of an individual staff in-service and statement with RN C, dated [DATE] (the statement /in-service was related to the incident with Resident #1 on [DATE] - [DATE] during the 10:00 PM to 6:00 AM shift) reflected the Nurse was required to check all residents every two hours and the residents identified on the falling star program was required to be checked every hour. Resident #1 sat in the broda chair (during the shift of 10:00 PM - 6:00 AM on [DATE]- [DATE]). The staff failed to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675837 If continuation sheet Page 2 of 7 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 07/06/2023 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)

F 0600 complete frequent checks. Signed by RN C and the Administrator. Level of Harm - Minimal harm or potential for actual harm Record review of with CNA D, dated [DATE] (the statement/in-service was related to the incident with Resident #1 on [DATE] - [DATE] during the 10:00 PM to 6:00 AM shift) reflected Resident #1 was not assisted to bed and was in her room sitting on her broda chair from 10:00 PM - 6:00 AM shift. All residents will be checked every 2 hours (minimum) and the residents identified on the falling star program was required to be checked every hour. Signed by Assistant Administrator RN B and CNA D. Residents Affected - Few Record review of the paper 24-hour report dated [DATE] and [DATE] reflected Resident #1's name was not listed on the 24-hour report. Record review of an in-service Importance of Rounding, dated [DATE], reflected rounds should be made at least every 2 hours on all residents by CNA and Charge Nurse. This can help reduce skin breakdown and reduce risk of falls. Record review of an in-service Abuse and Neglect dated, [DATE] , reflected Neglect: the failure by the nursing home, its staff, or outside service providers to provide services and goods to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record Review of the facility investigation completed on [DATE] reflected the facility did not have a system in place to monitor for compliance. Observation on [DATE] at 9:45 AM revealed Resident #1 was in bed with her eyes opened. Resident was unable to communicate verbally or written communication. Resident was well groomed. She had a fall mat beside her bed. In an interview on [DATE] at 10:05 AM, CNA E stated she worked during the shift 6:00 AM - 2:00 PM on [DATE]. She stated she entered Resident #1's room approximately 7:00 AM and observed Resident #1 sitting in her specialty chair. She stated another CNA F entered the room and she asked CNA F if she and someone else assisted Resident #1 out of bed into her chair. CNA E stated CNA F stated no. CNA E stated no one on day shift had assisted her out of bed the morning of [DATE]. She stated she noticed Resident #1 was soiled with urine and there was urine in her chair. She stated Resident #1 was assisted to bed by herself and CNA F. She stated the only issues she noticed with Resident #1 was her feet was more swollen than usual. She also stated when Resident #1 was in bed she was soiled with urine and had yellowish/brownish stains around the urine on the brief. She stated she had to get a towel to clean Resident #1 chair there were a lot of urine in the seat of the chair. She stated Resident #1 was cleaned and changed. She also stated LVN A came into the room and looked at Resident #1. She stated at this time she exited Resident #1's room. She stated Resident was sleepy throughout the day. She stated they attempted to feed her breakfast and Resident #1 could not stay awake long enough to eat. She stated she checked on Resident #1 every 30 minutes on the day of [DATE]. CNA E stated during her rounds Resident #1 was asleep. She stated she did wake up for lunch and did eat approximately 75 % of her meal. She stated her daughter came to the facility in the morning and was there during lunch meal. She stated Resident #1 was required to be out of bed for meals. CNA E stated the CNAs have been instructed numerous times during in services and during report to make rounds on residents every 2 hours. She stated if a resident was at risk for falls and on the falling star program, they were expected to be checked on every hour. She stated Resident #1 was at risk for falls, however, she was not on the falling star program (a program for residents with a high risk for falls). She stated after she clocked in for work (on [DATE] approximately 6:00 AM), she went on the 200 hall and the CNA assigned to that hall had already clocked out and left the facility. She stated no one had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675837 If continuation sheet Page 3 of 7 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 07/06/2023 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)

F 0600 mentioned to her of any physical issues with Resident #1. Level of Harm - Minimal harm or potential for actual harm In an interview on [DATE] at 11:00 AM, LVN A stated she worked the shift 6:00 AM - 6:00 PM on [DATE]. She stated she received report from the outgoing nurse RN C. She stated Resident #1 was not mentioned in the report. LVN A stated the only people was mentioned in 24-hour report was the ones with some type of physical or any type of issue. She stated she did review the 24-hour report. LVN A also stated the only report she looked at with RN C was the paper 24-hour report and not the report in the electronic medical record. She stated when she comes on duty the paper 24-hour report is the only one the nurse's use. She stated the nurses very seldom used the 24-hour report in the electronic medical record. LVN A stated she did not observe anything written about Resident #1 on the report. She also stated she began making her rounds and she walked down the 200 hall the same hall where Resident #1 resides. She stated she entered Resident #1's room approximately 6:30 AM to obtain her oxygen Sat. She stated Resident #1 was sitting in her specialty chair beside her bed and she was asleep entire time she was in her room. LVN A stated she did not have time to make any other observations on Resident #1. She stated she thought the morning CNAs had assisted Resident #1 out of the bed. LVN A also stated she exited Resident #1 room and continued to make rounds. She stated she was walking up the 200 hall and heard staff talking near Resident #1's door and she entered the room to determine if anything happened to Resident #1. She stated this was when she learned Resident #1 was possibly not assisted to bed all night. She stated she assessed Resident #1 and observed her feet was more swollen than usual. She stated she did a skin assessment on her and observed 2 red areas above the back of her knees around her thighs. LVN A stated she did not observe any other injury or concern on Resident #1. She did state she was very sleepy. When asked LVN A about her eating meals, LVN A stated I was not focused on Resident #1 eating her meals. She stated she did make rounds on Resident #1 every hour in the morning and every 2 hours in the afternoon [DATE]. She stated she called the Administrator and reported the incident of Resident #1 being up all night in her specialty chair. She stated the Assistant Administrator came to the facility approximately 9:30 AM and completed another assessment on Resident #1. She stated the family was at the facility in the morning and was informed of the incident by the Assistant Administrator. LVN A stated she had been in service on Resident Abuse and Neglect numerous times and most recent was on [DATE]. She stated she was in service on making rounds every 2 hours. She stated it was expected for the nurses and the CNAs to make rounds every 2 hours on residents they are assigned to for that day. LVN A stated she had not been instructed by any staff on how to monitor the CNAs to ensure they were making their rounds every 2 hours. She stated it was the nurse's responsibility to ensure the CNAs were making rounds and completing their tasks on each resident. She stated she did complete an assessment on Resident approximately 7:00-7:30 and her assessment was documented in her nurses note. She stated RN C worked on the night shift on [DATE]. Residents Affected - Few In an interview on [DATE] at 11:45 AM. CMA G stated she did work the day shift on [DATE]. (6:00 AM - 2:00 PM). She stated she did observe Resident #1 when she gave medications to her in the morning. She stated Resident #1 was sleeping in her bed. She stated the nurse supervisor for the previous shift was RN C and the CNA D was assigned to the 200 hall where Resident #1 resided. She stated she had been in service on abuse and neglect in 07/2023 and within the past 3 or 4 months. She stated she did not make rounds on residents. CMA G stated during in services in the past few months it was discussed for CNAs and nurses to make rounds on residents every 2 hours. In an interview on [DATE] at 2:45 PM, RN C stated she did work from 6:00 PM until 6:00 AM from [DATE] [DATE]. She stated the first time she observed Resident#1 was approximately 6:30 PM. She stated Resident #1 was sitting in her broda chair near her bed and she did not notice if she was awake or asleep. She stated she did not observe Resident #1 again until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675837 If continuation sheet Page 4 of 7 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 07/06/2023 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 11:00 PM and she stated Resident #1 was in her room sitting in the broda chair beside her bed. She stated she assumed the CNAs had not had time to assist Resident #1 to bed. She stated they were not short of staff. RN C stated she did not observe Resident #1 until approximately 4:00 AM. She stated Resident #1 was sitting her broda chair and she was sleepy. She stated she thought the CNAs assisted her out of bed for breakfast. RN C stated she did not ask CNA D if she assisted Resident out of bed around 4:00 AM. She stated sometimes residents is assisted out of bed around 5:00 or 5:30 AM if that is their preference for breakfast. RN C stated she did not think about it being too early to be out of bed for breakfast. She stated she did not know if this was unusual for Resident #1 to be up for breakfast early because she usually worked on the rehabilitation unit. RN C stated she should have asked CNA D at 11:00 PM if she needed assistance with transferring Resident #1 from her chair to bed. RN C stated she never questioned anyone why Resident #1 was out of bed. She stated when it was change of shift she gave a report to LVN A. She stated the nurses' documents on the paper 24-hour sheet and very seldom uses the electronic medical record. She stated she did not document in the electronic 24-hour record on that shift. She stated she reviewed the 24-hour report with LVN A and there was not anything on the 24-hour report related to Resident #1. She stated prior to her clocking out she heard staff talking about Resident #1 not being assisted to bed the entire night. RN C stated she did enter Resident #1 room and realized Resident #1 had been sitting in her broda chair all night and was never assisted to bed. She stated CNA D had already clocked out and left the facility. She also stated she had been in service few months ago of nursing staff making rounds every 2 hours. She stated she thought they were talking about CNAs and not nurses. She stated she knew CNAs were expected to make rounds on every resident they were assigned to every 2 hours, and it was the nurse supervisor duty to ensure the CNAs were making rounds and completing all their ADL care on every resident they were responsible for on their assignment sheet. She stated she did not know why she didn't question CNA D at 11:00 PM and at 4:00 AM. She stated Resident #1 was neglected. RN C also stated she had been in service on abuse and neglect numerous times (in 07/2023 and within the past three months). She also stated she received one- on- one in-service and counseling. She stated she had been an employee at the facility as a nurse since [DATE]. She also stated the incident with Resident #1 would be considered neglect. She stated she did return to work on [DATE] 10:00 PM -6:00 AM. In an interview on [DATE] at 4:17 PM, CNA D stated she worked 10:00 PM - 6:00 AM shift on [DATE][DATE]. She stated she was assigned to Resident #1 for the entire shift. She stated the first time she saw Resident #1 was approximately 10:30 PM- 11:00 PM and she was sitting in her specialty chair near her bed. She stated this was unusual for Resident #1 to be up at that time of night. CNA D stated she did not question why Resident #1 was in her chair and not in bed. She stated she did not discuss Resident #1 with anyone her entire shift. She stated RN C did not ask her any questions about Resident #1 the entire shift. She stated she did not assist Resident #1 to bed and Resident #1 was in her specialty chair all night. CNA D stated she did realize approximately 5:50 AM she did not assist Resident to bed the entire night. She stated she did not report this to anyone. CNA D stated she clocked out and left the facility and did not speak to any of the oncoming staff or to RN C prior to her leaving the facility. She stated she had been in serviced few months ago on making rounds every 2 hours and on abuse/neglect. She stated it was expected for CNAs to make rounds every 2 hours on residents and the residents on the falling star program the CNAs were to make rounds on these residents every hour. She stated Resident #1 was a fall risk, but she was not on the falling star program. CNA D stated she did not know why she forgot Resident #1. CNA D stated she never checked on Resident #1 after seeing her at 11:00 PM. She stated Resident #1 did not receive any ADL care while she was on duty. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675837 If continuation sheet Page 5 of 7 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 07/06/2023 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)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated she had been in serviced one-on- one on making rounds every 2 hours and abuse/neglect in the past few days and she stated she thought she had been in serviced in the past few months. CNA D stated not assisting Resident #1 to bed was considered neglect. In an interview on [DATE] at 4:45 PM The Administrator stated after Resident #1's investigation it was determined Resident #1 was in a broda chair all night and was not assisted to bed. He stated the results of the investigation was neglect. The Administrator stated the expectations of the CNAs, and the Nurses was to make rounds every 2 hours and if a resident was on falling star program the CNAs and Nurses would make rounds every hour. He stated it was the nurse's responsibility to monitor the CNAs on completing their ADL care. He also stated it was the responsibility of the DON and ADON to in-service the nursing staff and to randomly make rounds to ensure the staff was properly completing their assignments. He stated if staff did not make rounds on the resident there was a possibility a resident develop wounds or skin concerns if the resident was not changed after being soiled, a resident may fall and lay on the floor for a long period of time, a resident may need CPR or require care at a hospital. He stated he did interview RN C and forgot to ask her to write a statement of what happened with Resident #1 on [DATE]- [DATE]. In an interview on [DATE] at 5:45 PM The Assistant Administrator, RN B stated the Administrator notified me on [DATE] approximately 9:45 AM about the incident and I entered the facility approximately 10:00 AM. She stated she went to Resident #1's room and began a head-to-toe assessment on her. She stated Resident #1 had some redness across posterior part of the right and left thigh. She stated the red area was approximately four inches on each thigh. The Assistant Administrator/RN B stated the stated both sites were blanchable upon palpation. She stated Resident #1's daughter was in the room during the skin assessment, and she did speak to the daughter about the incident. She also stated she began an investigation on Resident #1. She stated she interviewed CNA D on [DATE] and learned the CNA D did not assist Resident #1 to be all night on [DATE]- [DATE]. She stated CNA D saw Resident #1 approximately 10:30 PM -11:00 PM and this was the only time CNA D saw Resident #1. She stated upon her investigation RN C did observe resident in her broda chair near her bed around 10:00 PM - 11:00 PM on [DATE] and later saw her at 4:30 AM on [DATE]. She stated RN C did not question why Resident #1 was not in bed. The Assistant Administrator/ RN B stated after interviews and record reviews it was determined Resident #1 had not been changed after 11:00 PM until the 6:00 AM - 2:00 PM shift on [DATE] changed her approximately 7:00 AM. She stated after the investigation the Administrator, the ADON and herself compiled the information during a meeting. She stated all three of us did determine Resident #1 was neglected based on the evidence, Resident #1 was not assisted to bed the entire night and was not provided with ADL care from 10:00 PM on [DATE] until approximately 7:00 AM on [DATE]. She stated the staff had been in serviced few months ago on making rounds every two hours and on abuse / neglect. She also stated it was the nurses and CNAs responsibility to make rounds on all residents they are assigned to every 2 hours and the residents on the falling star program (residents with a high risk for falls) they were required to make rounds on these residents every hour. She stated this was the facility practice. She also stated it was the nurse's responsibility to monitor the CNAs and it was the DONs and ADONs responsibility to in-service and train the staff. She stated if staff did not make rounds there was a potential a resident may fall or have any type of injury and require immediate nursing care. She stated there were all types of situations may happen with a resident related to their physical or personal needs if the staff did not make rounds every 2 hours. She stated RN C and, CNA D was suspended depending on the outcome of the investigation. She stated CNA D had not returned to work from her suspension, however, RN C did return to work on [DATE] and there was not an issue of her returning to work prior to the investigation being finished. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675837 If continuation sheet Page 6 of 7 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 07/06/2023 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)

F 0600 stated there was not a written statement completed by RN C of the incident with Resident #1. Level of Harm - Minimal harm or potential for actual harm Record review of facility document (used during in-service) of Importance of Rounding, not dated, reflected: Residents Affected - Few 1. Rounding is an important tool for resident care and can improve organizational efficiency when performed effectively. 2. Provides a focus on patient safety and patient assistance. 3. Nurses should be making walking rounds together during report. This helps establish clear communication between nurses. 4. Aides should be making walking rounds with oncoming staff. This helps to meet residents' immediate needs and ensure their safety. 5. Walking rounds can help notice any change of condition, resident needs, resident safety and can reduce the risk of falls. 6. For aides if your coverage will be here late then rounds need to be made with your charge nurse prior to you leaving. 7. Rounds should be made at least every 2 hours on all residents by CNA and charge nurse. This can help reduce skin breakdown and reduce risk of falls. 8. Offer toileting to resident's wo hare able to toilet. 9. Follow up as appropriate and always ensure the patient has what is needed. 10. Rounding gives the nurses or aides more time for patient care tasks and you are more in control of your time by being proactive rather than reactive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675837 If continuation sheet Page 7 of 7