Health inspection·April 29, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few up with residents' reasonable requests for nursing care. CNA A stated she had changed the brief of Resident #1 at about 6:00am and after that she could not visit him again until 10:30am as she was busy with other residents. She stated there was no replacement for the CNA who called sick as on that time and thus she was trailing behind with tasks. During an interview on 04/28/25 at 3:10 pm the DON stated she started the facility about one week ago and get to know the staff and facility operations well. She stated there was a staff member that called sick in the morning and there was no substitute made for that CNA. She stated she was identifying the issues at the facility as a newly appointed DON. One among that was of staffing scheduling. She stated as on now the scheduling was handled by the charge nurses however henceforth she would be taking over this role to ensure sufficient staff would be present in every shift. She stated she would make sure to maintain the required staffing level with appropriate replacements. DON stated it was unfortunate that Resident #1 had to wait very long time to get changed his soiled brief as it affected resident's comfort and hygiene. During an interview on 04/28/25 at 1:30pm ADM stated it was unfortunate that Resident #1 had to wait for long period for peri care. She stated, one of the CNA s called in sick last minute and an attempt for a replacement for unsuccessful. She stated such a situation happens very rarely and this day was one of them. She stated the facility made all efforts to maintain staff to resident ratio at the required level at all times. Record review of facility policy Abuse revised on 01/27/20 reflected : The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. Record review of facility policy Resident Rights revised in December 2016 reflected : Policy Interpretation and Implementation: I. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence. b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 2 of 12 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 676355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brenham Healthcare Center 1303 Hwy 290 E 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 0760 Ensure that residents are free from significant medication errors. 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 residents were free of any significant medication errors for four (Resident #2, Resident #3, Resident #4 and, Resident #5) of five residents reviewed for significant medication errors. Residents Affected - Some 1.The facility failed to administer medications Glargine and Lispro (Insulins to lower blood sugar), as prescribed for Resident #2 in January, February, and April 2025. 2.The facility failed to administer medications Glargine and Novolog as prescribed for Resident #3. in January, February, and April 2025. 3.The facility failed to administer medications Glargine and Lispro as prescribed for Resident #4 in January, February, and April 2025. 4.The facility failed to administer medication Lispro as prescribed for Resident #5 in January, February March, and April 2025. These failures could place the diabetic residents at risk of complications from not receiving the therapeutic effects of insulin. Findings included: 1. Record review of Resident #2's face sheet on 04/29/25 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses were, Hypertensive heart disease with heart failure, Type 2 diabetes mellitus, Obesity due to excess calories, Speech, and language deficits, Need for assistance with personal care, Unsteadiness on feet, Muscle weakness, Hypertension and Presence of heart assist device. Record review on 04/16/25 of Resident #2's quarterly MDS assessment, dated 02/04/25 revealed a BIMS score of 14 indicating his cognition was intact. Record review on 04/29/25 of Resident #2's care plan dated 03/30/25 reflected there was no care plan for his diagnosis of Diabetes Mellitus 2 and insulin therapy. Record review on 04/28/25 of Resident #2's medication order reflected the following: 1: Insulin Glargine Solution 100 UNIT/ML Inject 20 unit subcutaneously one time a day for diabetes. Revised on date:03/11/25 2. Admelog SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro). Inject as per sliding scale: if 0 - 200 = 0 units. 201 - 250 = 2 units; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 3 of 12 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 676355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brenham Healthcare Center 1303 Hwy 290 E 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 0760 251 - 300 = 4 units; Level of Harm - Minimal harm or potential for actual harm 301 - 350 = 6 units; 351 - 400 = 8 units; Residents Affected - Some 401 - 450 = 10 units Call physician for BS >400, subcutaneously before meals and at bedtime for Diabetes Mellitus.Revised on 03/11/25 Record review of Resident #2's January 2025 MAR reflected Insulin Glargine Solution 100 UNIT/ML was not administered on 01/03/25, 01/04/25, 01/05/25, 01/21/25, 01/22/25, 01/23/25, 01/27/25 and 01/31/25. Record review of Resident #2's February 2025 MAR reflected, Insulin Glargine Solution 100 UNIT/ML was not administered on 02/01/25, 02/02/25, 02/03/25. Record review of Resident #2's April 2025 MAR reflected the following: 1. Insulin Glargine Solution 100 unit/ml was not administered on 04/12/25 and 04/14/25. 2. Admelog SoloStar Subcutaneous Solution Pen-injector 100 unit/ml was not administered on 04/12/25 at 7:30am, 11:30am and 4:30am and on 04/14/25 at 4:30 am. During an interview and observation on 04/29/25 at 1:30 pm Resident #2 was relaxing in front of the nursing station on his wheelchair. He was minimally interested to converse and stated he received all his medications on time. Resident #2 stated he took lots of medications and hoped all those medications in there while the staff giving him. 2. Record review of Resident #3's face sheet on 04/29/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were, Type 2 diabetes, Abnormalities of gait, Lack of coordination, Dementia, Hypertension and Adult failure to thrive. Record review on 04/16/25 of Resident #3's initial MDS assessment, dated 03/05/25 revealed a BIMS score of 13 indicating his cognition was intact. Record review on 04/29/25 of Resident #3's care plan dated 03/30/25 reflected he had Diabetes mellitus and was on insulin routinely and a po Anti-diabetic medication. The relevant intervention was monitoring blood sugars and administer insulin as ordered and notifying MD of any changes. Record review on 04/28/25 of Resident #3's medication order reflected the following: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 4 of 12 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 676355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brenham Healthcare Center 1303 Hwy 290 E 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 0760 Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine). Inject 70 unit subcutaneously two times a day for Diabetes.Start date: 07/12/23 Level of Harm - Minimal harm or potential for actual harm 2.NovoLOG FlexPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: Residents Affected - Some if 150 - 200 = 4; 201 - 250 = 8; 251 - 300 = 12; 301 - 350 = 16; 351 - 400 = 20 Call MD when >400, subcutaneously before meals for Diabetes Mellitus. Start date: 07/14/23. Record review of Resident #3's January 2025 MAR reflected the following: 1. Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) was not administered on 01/02/25, 01/03/25, 01/04/25 and 01/05/25. 2.NovoLOG FlexPen 100 UNIT/ML was not administered on 01/02/25, 01/03/25, 01/04/25 and 01/05/25. Record review of Resident #3's February 2025 MAR reflected Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML was not administered on 02/28/25. Record review of Resident #3's April 2025 MAR reflected Basaglar KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML was not administered on 04/14/25. During an observation and interview on 04/29/25 at 3:30 pm Resident #3 was laying in his bed. He stated the staff administer the medications on time and did not believe he missed any medications. Resident #3 stated he believed his diabetes was under control. 3. Record review of Resident #4's face sheet on 04/29/25 revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were, Type 2 diabetes, Muscle weakness, Obesity, Hypertension, Muscle wasting, Lack of coordination, Bed confinement status and Depression. Record review on 04/16/25 of Resident #4's initial MDS assessment, dated 02/07/25 revealed a BIMS score of 14 indicating her cognition was intact. Record review on 04/29/25 of Resident #4's care plan dated 03/24/25 reflected Resident #4 had hyperglycemia related to disease process Diabetes Mellitus 2, and the relevant intervention was checking blood sugar level twice a day. Record review on 04/28/25 of Resident #4's medication order reflected the following: 1. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 5 of 12 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 676355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brenham Healthcare Center 1303 Hwy 290 E 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 0760 Subcutaneous Solution Peninjector 300 UNIT/ML (Insulin Glargine) Inject 45 unit subcutaneously at bedtime for Diabetes.Start date: 11/26/24. Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Some Lyumjev KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale:Start date: 10/11/24 if 150 - 200 = 2 Units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units. Administer 10 Units and notify MD if BS greater than 400 for further instruction, subcutaneously before meals and at bedtime. Record review of Resident #4's January 2025 MAR reflected the following: 1.Insulin Glargine Max SoloStar Subcutaneous Solution Peninjector 300 UNIT/ML was not administered on 01/02/25 and 01/03/25. 2.Lyumjev KwikPen 100 UNIT/ML Solution pen-injector was not administered on 01/02/25, 01/03/25, 01/04/25 and 01/05/25 and 01/17/25. Record review of Resident #4's February 2025 MAR reflected Insulin Glargine Max SoloStar Subcutaneous Solution Pen-injector 300 UNIT/ML and Lyumjev KwikPen 100 UNIT/ML Solution pen-injector were not administered on 02/28/25. Record review of Resident #4's April 2025 MAR reflected Insulin Glargine Max SoloStar Subcutaneous Solution Pen-injector 300 UNIT/ML and Lyumjev KwikPen 100 UNIT/ML Solution pen-injector were not administered on 04/14/25. During an observation and interview on 04/29/25 at 11:30 am Resident #4 laying in her bed. She was pleasant on approach and interacted in polite manner. She stated the staff were good at administering medications. She stated she received insulin on time however did not know how much she received every time. Residnt #4 stated she was unable to remember if there were any omissions in the past and stated she believe there was none. 4. Record review of Resident #5's face sheet on 04/29/25 revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses were, Type 2 diabetes, Muscle weakness, long term (current) use of insulin, Unsteadiness on feet, Cognitive communication deficit, Hypertension, Muscle wasting and Lack of coordination. Record review on 04/16/25 of Resident #5's initial MDS assessment, dated 02/07/25 revealed a BIMS score of 10 indicating her cognition was moderately impaired. Record review on 04/29/25 of Resident #5's care plan dated 04/25/25 reflected Resident #5 was on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 6 of 12 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 676355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brenham Healthcare Center 1303 Hwy 290 E 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 0760 Level of Harm - Minimal harm or potential for actual harm insulin S/Q and oral anti diabetic med and had risk for hypo/hyperglycemia related to disease process Diabetes Mellitus, and the relevant intervention was checking blood sugar level twice a day and administration of medications ordered. Record review on 04/28/25 of Resident #5's medication order reflected the following: Residents Affected - Some 1. Accuchecks two times a day if blood glucose greater than 250 notify MD/NP. 2. Insulin Lispro (1 Unit Dial) Subcutaneous Solution pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 70 - 150 = 0 no insulin; 151 - 200 = 2; 201 - 250 = 3; 251 - 300 = 5; 301 - 350 = 7, Notify MD, subcutaneously before meals and at bedtime for Diabetes Mellitus. Start date 03/28/24 Record review of Resident #5's January 2025 MAR reflected the following: 1. The Accu-Chek was not administered on 01/02/25, 01/03/25, 01/04/25, 01/05/25. 2. Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen injector 100 UNIT/ML was not administered on 01/02/25, 01/03/25, 01/04/25, 01/05/25 and 01/17/25. Record review of Resident #5's February2025 MAR reflected the accucheck and Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen injector 100 UNIT/ML were not administered on 01/28/25. Record review of Resident #5's March2025 MAR reflected Insulin Lispro (1 Unit Dial) Subcutaneous Solution pen injector 100 UNIT/ML was not administered on 03/12/25. Record review of Resident #5's April 2025 MAR reflected the Accu-Chek and Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen injector 100 UNIT/ML were not administered on 04/14/25. During an observation and interview on 04/29/25 Resident #5 was in the dining hall in her wheelchair with a book in hand. She was pleasant and welcoming. She stated she received all her medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 7 of 12 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 676355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brenham Healthcare Center 1303 Hwy 290 E 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on time and believed she received her insulin also on time. She stated she could not say if she missed any doses of insulin in the past. Resident #5 stated she never had any episode of hyper glycemia while at the facility. During a phone interview on 04/29/25 at 9:00 am RN B sated she was the ADON in January,25. She stated there were issues with PCC (Where resident medical information was kept) in the month of January 2025 due to the change of ownership process. She said there were many of the MAR documentations were not displayed in the PCC and brought this issue to the attention of the management. She said this issue was only in the month of January 2025 and she was not sure if the insulin administration documentation was affected by this. She stated she had not worked in the month of March and April 2025 at the facility and was unaware of any issues during this period. RN B stated she was aware of the serious adverse effect if insulin was not administered as ordered and stated she believed she administered the insulins per the order while she was working at the facility. During a phone interview on 04/29/25 at 9:10 am LVN C stated she worked from January 25 to April 25 in Hall 200. She said there were Resident #3, Resident #4 and Resident #5 in Hall 200 with Diabetes Mellitus 2, who needed their blood sugar level checked and administer insulin accordingly. LVN B stated she was sure she never missed these tasks anytime while she was on duty. She stated she was sure she entered the administration of medications in the MAR and did not remember there was any issues with PCC other than one day the internet went off for a while that was rectified the same day evening. During a phone interview on 04/29/25 at 9:27am LVN D stated she was a day nurse however since 03/06/25 she worked at the facility in the night shift. She stated she was not remembering omission of any doses of insulin of any residents she worked with. She stated she used to record in the MAR whenever she administered medications and unable to explain why there were no administration entry on the MAR for insulins. During an interview on 04/29/25 at 9:41am LVN E stated she worked mostly in the weekends and also few weekdays in a month. She stated there was a system issue when Resident #2 changed his room in January 25 and the system was not populating his name. She stated she and the ADON at that time had fixed it and entered all the missed documentations back dated. She stated she was not sure about other days. LVN E stated she was particular in documenting medication administration in the MAR and stated she was unable to comment on why it was shown as not administered on some days. During an interview on 04/29/24 at 11:45 am DON stated she was new at the facility and started working one week ago. She stated there were blank boxes in the MAR for insulin of the residents . DON stated as per the record RN B , LVN C, LVN D and LVN E were working on those days and shifts, when the omissions of insulin administrations were identified. She stated she tried to talk these nurses and they were unable to explain satisfactorily what had happened on those days. She stated , most likely the medication might have been given and then forgotten to document. When the investigator requested for any other proof showing the insulin administrations on those days when it was missing as it was shown in the MAR ,she stated she looked for that and could not find any. She stated missing insulin doses could be dangerous for insulin dependent residents as it could leads to hyper glycemia and related complications. DON stated that her expectation was to notify the MD/NP if there were any missed doses of insulin. DON stated , moving forward she would audit the MARs for documentation of medication administration to identify any missed medications or documentations of administered medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 8 of 12 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 676355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brenham Healthcare Center 1303 Hwy 290 E 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 0760 Level of Harm - Minimal harm or potential for actual harm During a phone interview on 04/29/25 at 4:43 pm MD stated he visits the facility twice a month. He stated he believes the diabetic residents who were on insulin therapy were managing well at the facility. When the investigator asked about the omissions noted on the MARs from January to April 25, he stated he was not sure about what had happened. He stated there were no incidents of hospital admission of any residents for hyper or hypo glycemia in 2025, made him to believe that the staff were doing a good job. Residents Affected - Some During an interview on 04/29/25 at 3:30 pm the ADM stated there was some confusion related to PCC documentation in January 2025 during the change of ownership. She stated the documentation of MAR also might have affected by this. When investigator stated that there were omissions in subsequent months as well, ADM stated she would not be able to explain how that happened. ADM stated the accuracy of documentation was important to maintain the quality of care of the residents at the facility. She stated she was unable to say if it was medication error or documentation error. Record review of facility policy pharmacy policy and procedure Manual 2003 revised on 03/06/14 reflected : . Facility staff administering medication shall comply with the following: a. No medication shall be given to any resident unless ordered by a Physician. b. Medications shall be administered unless the resident refuses or exhibits symptoms that contraindicate medication administration. c. If a medication is not administered, the staff member shall document in the resident's record why the medication was not administered . . The facility shall maintain an individual medication record for each resident to whom the facility administers medication in which: a. Physician orders are recorded and signed. b. All medications are recorded as given, documenting name of the medication, date and time given and signed by the individual administering the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 9 of 12 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 676355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brenham Healthcare Center 1303 Hwy 290 E 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 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 #1) of 3 residents reviewed for infection control practices, in that: Residents Affected - Few 1. The facility failed to ensure CNA A performed hand hygiene while providing peri care to Resident #1 on 04/28/25. This failure could place residents that require peri care at risk for healthcare associated cross-contamination and infections. The findings included: Record review of Resident #1's face sheet on 04/29/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were, Alcoholic cirrhosis of liver, Acute respiratory failure, Chronic kidney disease, Hypertension, Dependence on renal dialysis and Syncope (fainting) and collapse. Record review on 04/16/25 of Resident #1's initial MDS assessment, dated 04/17/25 revealed a BIMS score of 8 indicating his cognition was moderately impaired. Record review on 04/29/25 of Resident #1's care plan dated 04/24/25 reflected he had risk for Constipation and the expected outcome is Resident #1 will pass soft, formed stool at a frequency perceived as normal for resident. During an observation on 04/28/25 at 10:50 am CNA A was providing peri care for Resident #1. She put on gloves without washing her hands. After that she opened the brief and cleaned Resident #1's front and back with wet wipes dispensed directly from the wipe's packet. In that process she touched the whole wipe packet with the soiled gloves. After the completion of wiping the Resident #1 she picked up new brief with the same soiled gloves and applied on Resident #1. She then with the same dirty gloves while she went on and adjusted the bed and the bed sheets, brought the call light closer to the resident and finally pulled up the blanket over the Resident #1. CNA A then removed her soiled gloves and donned ( wearing) another pair of gloves and cleaned and adjusted the side table and collected the dirty items and left the room. It was observed that CNA A had not washed her hands after the completion of the process prior to leaving the room. During an interview on 04/28/25 at 11:35am CNA A stated she started at the facility two months ago. CNA A stated she received a training on peri care during the orientation. CNA A stated she did the peri care as it was taught during the orientation training. She stated following infection control protocol, and the peri care procedure was necessary to minimize spreading germs through contamination. She stated she was sure she did the peri care as per the training she received. When the investigator walked through the peri care that she had completed on Resident #1 , she stated she should have changed the gloves every time when handling fresh items, after handling dirty items and surfaces. She stated she contaminated the whole packet of wet wipe that she saved for future use, by handling it with soiled gloves. CNA A stated she forgot to wash her hands before and after the procedure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 10 of 12 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 676355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brenham Healthcare Center 1303 Hwy 290 E 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 04/28/25 at 3:10pm the DON stated she started the facility about one week ago and has gotten to know the staff and facility well. When walked through the peri care done by CNA A , DON stated, before and after the peri care CNA A should have washed her hands. DON added, CNA A did not change her dirty gloves every time when handling new items and clean surfaces. DON stated she already completed a one-to-one in service with CNA A and would be doing an in service for all the staff members for peri care. DON stated she had plan to monitor routinely the infection control practices at the facility through observation. She said incorrect infection control practices promotes spreading diseases through contamination. Record review of facility's undated policy Perineal care reflected : Procedure: 1. Set up basin of arm water (100 to 105 degrees F) or perinea! cleansing solution. 2. Offer bedpan to resident or toilet prior to beginning perineal care. 3. Perform hand hygiene. Put on disposable gloves. 4. Drape resident for privacy exposing only perinea! area and fold top linen to the bottom of the bed. Explain procedure to the resident. 5. Turn resident on back. 6. Instruct resident to raise hips while bed protector is placed underneath resident's buttocks . 8.Male perineal care a. If resident is soiled with feces, place him on side and clean perineum and rectal area. b. Change water and discard soiled linen appropriately. c. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 11 of 12 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 676355 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brenham Healthcare Center 1303 Hwy 290 E 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 0880 Change gloves. Perform hand hygiene before donning fresh gloves. Level of Harm - Minimal harm or potential for actual harm d. Turn resident on his back. Residents Affected - Few e. Ask resident to separate his legs and flex knees. If he is unable to spread his legs and flex knees, the perinea! area can be washed with the resident on the side with legs flexed. f. Gently wash pubis and penis. If uncircumcised, pull back foreskin and wash gently. Carefully dry and return foreskin to normal position. Make sure shaft of penis is dry. g. Ask resident to bend and separate knees. Help resident if required. Wash scrotum carefully. Rinse and pat dry. 9. Help position resident onto back. 10. Remove protective pad under buttocks, remove gloves and dispose properly. Perform hand hygiene. 11. Replace top bed linen. 12. Make resident comfortable. 13. Place call light in reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676355 If continuation sheet Page 12 of 12