Inspection·October 4, 2023

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being, for one1 of 5 residents (Resident #1) reviewed for treatment and services. Residents Affected - Few The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #1's continuous intermittent aggressive behaviors toward male residents. This failure placed residents at risk for their medical, physical, and psychological needs not being met. Findings included: Review of Resident #1's Face Sheet dated 10/04/2023 reflected a [AGE] year-old female admitted to the facility 09/01/2022 with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.) Major Depression (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.) Adjustment Disorder (A short term condition arising due to difficulty in managing the stressful life changes such as coping with work-related problems, loss of loved ones, or relationship issues that leads to significant impairment in functioning.) and Impulsiveness (acting or doing without forethought). Review of Resident #1's Annual MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 99 indicating severe cognitive impairment. Resident #1 was assessed to have physical, verbal, and other behavioral symptoms directed toward others that occurred one to three days a week during the assessment period. Resident #1 was further assessed to require minimal assist with mobility and was assessed to be independent in locomotion on and off the unit. Review of Resident #1's Comprehensive care plan with the initiation date of 09/07/2022 reflected a focus area Resident #1 has delirium, or an acute confessional episode related to acute disease process Dementia. The only intervention for the focus area was consult with family and interdisciplinary team, review chart to establish baseline level of functioning. Further review reflected a focus area dated 10/24/2022 reflected Resident #1 is an elopement risk/wanderer as evidence by disoriented to place, impaired safety awareness, resident wanders aimlessly. Further review of Resident #1's plan of care reflected no plans for aggressive behaviors. (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 2 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 10/04/2023 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)