Health inspection·August 19, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the residents were free from physical abuse for one (Resident #1) of four residents reviewed for abuse.The facility failed to ensure Resident #1 was not slapped by LVN A on 07/23/25.An Immediate Jeopardy (IJ) situation was identified on 08/15/25. While the IJ was removed on 08/17/25, the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury, hospitalization, trauma, and psychosocial injury.Findings included:Review of Resident #1's face sheet dated 08/15/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia (term for a decline in mental ability, affecting memory, thinking, and daily functioning), traumatic subdural hemorrhage (a dangerous collection of blood that forms between the brain's outer covering (dura) and the brain itself, often resulting from a severe head injury) and schizophrenia (a chronic mental disorder now understood as schizophrenia, marked by prominent, often persistent, delusions and hallucinations). Review of Resident #1's care plan dated 07/25/25 reflected a focus of Resident #1 had a behavior problem related to low frustration tolerance (an individual's difficulty in managing and accepting frustrating situations, leading to negative emotional reactions and difficulty coping with everyday challenges) with the following interventions dated 07/25/25:1. Assist the resident to develop more appropriate methods of coping and interacting2. Encourage the resident to express feelings appropriately3. Explain all procedures to the resident before starting and allow the resident time to adjust to changes4. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.5. Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention6. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.A review of Resident #1's care plan dated 07/25/25 reflected a focus of Resident #1 at risk for impaired communication with intervention dated 07/25/25 Spanish speaking.Review of Resident #1's Optional State Assessment MDS dated [DATE] reflected no BIMS score, Section A - Identification Information preferred language Spanish, Section E Behavior Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) behavior of this type occurred 1 to 3 days.Review of Resident #1's BIMS assessment dated [DATE] reflected Incomplete - Requires Further Assessment 99.0.A review in TULIP reflected on 07/25/2025 at 12:08 am the facility reported to HHSC:Resident/Client Information Resident # 11. Pertinent Medical Diagnosis: unspecified dementia, unspecified severity, without behavioral 06/19/2025 principal diagnosis (67) admission disturbance, psychotic disturbance, mood disturbance, and anxiety, paranoid schizophrenia2. Is special supervision required? If so, please specify: No special supervision Page 1 of 16 676355 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few required.3. Level of cognition: BIMS SCORE 04. Is there a history of similar or prior incidents, if so please specify: No Incident Details:1. Date/Time the incident occurred: 07/24/25 nurse cannot give definitive time frame states it was around 6:30 pm or after 2. Date/Time you first learned of incident: 7/24/25 at 9:49 pm3. Brief narrative summary of the reportable incident: The Charge Nurse reported that while attempting to administer medication, the resident bit her hand, prompting a reflexive response in which she slapped the resident in the face. The nurse stated the action was unintentional. She further stated that she immediately reported the incident to the Assistant Director of Nursing (ADON). However, the ADON stated that the Charge Nurse only reported the bite incident and did not disclose that the resident had been slapped.4. Witnesses name and title: Charge Nurse states that the incident was witnessed by another CNA [CNA B]. The administrator interviewed the CNA who reports that she didn't see the incident, but that the Charge Nurse showed her the bite mark and admitted to slapping the resident. Assessment Details:1. The date and time of the assessment: 07/24/25 (no time given)2. Name and title of person who completed the assessment: [Agency Nurse]3. Results of the assessment include the extent of injuries. Provide details of any physical harm, pain, or mental anguish including serious bodily injury, or other injuries including but not limited to measurements, location, color of bruises, scratches, lacerations, fractures, changes in residents' behavior that is different from the normal baseline: The resident was assessed by the licensed nurse on duty. No visible injuries were observed upon assessment-no redness, swelling, bruising, or open skin noted on the face or surrounding areas. Alleged Perpetrator # 21. LVN A 2. Was the alleged perpetrator removed, suspended or terminated? Suspended pending further investigation.Actions and Notifications1. Who did the facility/agency notify about the incident? Ex. physician, family, ombudsman: Family and Physician, both notified of incident2. Was the incident reported to the police? If so, provide case number: N/a3. If the Texas Department of Family and Protective Services was notified, please include the DFPS call ID reference number: N/a4. Provide all steps taken immediately to ensure resident(s) are protected including but not limited to evaluating if resident feels safe, room relocation, increased supervision and other measures to prevent further abuse, neglect, exploitation and misappropriation: Staff member suspended pending investigation, resident assessed with no visible signs of injury to facial area, MD notified, Resident is Responsible Party, Referral to Psych Evaluation and treat5. Was an in-service conducted? If so, provide topic of in-service: Abuse and Neglect, Behavior Management, Resident Safe Surveys, Improving Communication with Residents Who Have Limited English Proficiency.A review of facility Provider Investigative Report 08/01/25 reflected witness name [CNA B] Denies witnessing the incident but was aware of the incident.A review of facility Provider Investigative Report 08/01/25 reflected:Assessment: Upon learning of the alleged incident, the resident was assessed from head to toe by the licensed nurse on duty. No visible injuries were observed upon assessment - no redness, swelling, bruising skin noted on the [NAME] or surrounding areas. Resident [Resident #1] exhibited no adverse reactions and remains stable Upon investigation of the allegations, it was determined that Charge Nurse [LVN A] did, in fact, slap resident [Resident #1], as confirmed by her own admission, While the act was stated to be unintentional, the incident did occur and could not be negated. The alleged witness, [CNA B] reported that she was aware of the incident only through what the Charge Nurse had told her. Based on the Charge Nurse's admission of the offense, appropriate disciplinary action was taken, and her employment was terminated. Additionally, the Assistant Director of Nursing (ADON) and CNA [CNA B] were re-educated on Abuse and Neglect policies, including the importance of immediately report all allegations of the facility's Abuse Coordinator according with regulator requirements. Resident [Resident #1] continued to exhibit no adverse reactions and remains 676355 Page 2 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few stable at this time. A review of facility Provider Investigative Report 08/01/25 reflected MD and RP were notified. A review of facility Provider Investigative Report 08/01/25 reflected Resident Safe Survey dated 08/23/25 for 15 Residents. Resident #1 was not included in the safe survey. A review of facility Provider Investigative Report 08/01/25 included facility Abuse Policy dated 01/27/20.A review of facility Provider Investigative Report 08/01/25 included in-service dated 07/25/25:Department: nursing; AdministratorDate: 07/25/25 OngoingEmployee group(s) present: Administrator and Nursing DepartmentTopic: Abuse, Neglect, and Exploitation in the Community Contents or summary of training session: Abuse of any kind will never be tolerated. Abuse is any willful infliction of injury or neglect. The resident as the right to be free from Any type of abuse, neglect, intimidation, involuntary, seclusion/confinement and/or misappropriation of monies/funds.Conducted by: Administrator Evaluations, comments, suggestions: The Abuse Coordinator is [Administrator] followed by DON, ADON, Charge nurse. You should ALWAYS Alert the Abuse Coordinator of Abuse allegations Immediately. There is a 2 hour window for immediate reporting and a 24 hour window for report of abuse with/without injury or unknown injury. Signature of person completing report: unsigned A review of facility Provider Investigative Report 08/01/25 included signatures of staff in-service dated 07/25/25 Topic: Abuse, Neglect, and Exploitation in the Community signed by 20 staff members with no designation if staff were agency employees and some signatures did not state job title. A review of facility Provider Investigative Report 08/01/25 included a copy of the facility Behavioral Management Policy dated 04/19/05.A review of facility Provider Investigative Report 08/01/25 included in-service dated 07/25/25:Department: nursingDate: 07/25/25 OngoingEmployee group(s) present: Administrator, nursing, dietary, housekeeping Topic: Behavioral Management Contents or summary of training session: Behavior Management Behavior management included the management of anger, confusion, Hallucination and other behaviors by utilizing techniques such as group interactions, limit setting and behavior modification depending on resident needs. Establish rapport with a calm approach and supportive attitude. Place resident on frequent checks to ensure safety Conducted by: Administrator Allow wandering if it's safe and not exit seeking for those with dementia to prevent frustration and anger. Refrain from [sic] that residents take medications - stop - allow time - then revisit resident. Provide structure with routines and low to moderate stimulation to the environment. Signature of person completing report: AdministratorA review of facility Provider Investigative Report 08/01/25 included staff signatures of in-service dated 07/25/25 Topic: Behavioral Management signed by 20 staff members with no designation of if staff were agency employees some signatures did not state job title. The in-service signature sheet was identical to the staff in-serviced signature sheet on the Abuse, Neglect, and Exploitation in-service dated 07/25/25. A review of facility Provider Investigative Report 08/01/25 reflected memos to the ADON and CNA B from the Administrator stating, This letter serves as a reminder of the critical importance of immediately reporting any allegations or suspicions of abuse, neglect, or exploitation to the facility's Abuse Coordinator, in accordance with the state and federal regulations. Timely reporting is essential to the safety and well-being of our residents and to maintain compliance with all regulatory requirements. Failure to promptly report can place residents at risk and may result in disciplinary action. Please continue to follow facility policy by reporting all incidents immediately and accurately, ensuring that our residents remain safe and always protected signed by the Administrator, the ADON, and CNA B. A review of facility Provider Investigative Report 08/01/25 reflected in-serviced dated 07/25/25 Inservice Topic: Overcoming Language Barriers in Nursing Homes. Purpose: To Educate staff on the importance of effective communication with residents who have limited English proficiency and strategies to ensure quality care and understanding. A review of facility Provider 676355 Page 3 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Investigative Report 08/01/25 included staff signatures of in-service dated 07/25/25 Topic: Overcoming Language Barriers in Nursing Homes signed by 20 staff members with no designation of if staff were agency employees some signatures did not state job title. The in-service signature sheet was identical to the staff in-serviced signature sheet on the Abuse, Neglect, and Exploitation, and Behavioral Management in-services dated 07/25/25.Review of Resident #1's nurses note dated 07/23/25 by LVN A reflected handed resident his medication cup, resident would not take, kept encouraging resident to take his medication, since resident would not take his medication this writer reached to take the cup of meds and dispose of properly, resident bent forward and bit this writers thumb on my left hand, ADON, notified, p.c.p.Review of Resident #1's nurses note dated 07/25/25 by agency nurse reflected, Head to Toe Assessment Completed. Spanish speaker only, Alert and Awake. PERRLA. Skin Warm and Dry. Equal hand grips. Capillary refill less than 3 sec. No edema present. Respirations even and unlabored. No s/s of distress observed. Abdomen soft, round nontender - nondistended. Bowel sounds active x4 (This medical notation indicates that bowel sounds are present in all four quadrants of the abdomen (right upper, right lower, left upper, left lower). Pt. wheelchair bound, x1 assist. Scratch noted to right lower extremity. CNA [C] reports the scratch has been there. Bed in lowest position. Call light and personal belongings at bedside. Safety precautions in place. No safety hazards observed. No further concerns at this time. ADON Notified of scratch to RLE. Review of Resident #1's progress notes did not reflect facility contacted MD after incident, attempted to contact Resident #1's RP, or communications with Resident #1 about being slapped by LVN A. Record review of Resident #1's initial psychiatric evaluation dated 07/25/25 reflected no reference to Resident #1 being slapped by LVN A and states, particular attention will be paid to possible environmental factors contributing to agitation.Record review of MD Home Visit dated 07/24/25 reflected, [Resident #1] is seen and examined today at bedside for face redness due to an incident with Charge Nurse that occurred on 07/23. An assessment was performed, and we found no adverse s/s. Treatment 1. Contusion of other part of head, initial encounter Notes: no injuries noted. monitor at this time. Advised [Resident #1] to notify me if another incident. Interview on 08/16/25 at 10:50 am with Resident #1 with his RP as an interpreter via telephone reflected, he confirmed that a lady slapped him, but he said it did not hurt, and he is okay. He said no one at the facility talked to him about it after it happened, and he had not seen the lady who slapped him at the facility anymore. Interview on 08/15/2025 at 12:57 pm with CNA C reflected she did not know details of what happened between Resident #1 and LVN A, she only heard that Resident #1 bit LVN A and LVN A slapped him. She said she did not see or hear anything else about the incident. She said she was with the agency nurse when Resident #1 had a skin assessment. She said the agency nurse did not tell her why Resident #1 was having a skin assessment, but Resident #1 did sometimes have a lot of aggression towards the staff and the ADON asked her to go in with the agency nurse for the skin assessment. She said when they entered his room he was laying down on the bed. CNA C said the agency nurse did tell Resident #1 what they were doing but there was a communication barrier. She said they didn't understand what he was saying to them because he did not speak English. She said she did not use the communication board, and she had never seen a communication board. She said previously she gestured things to communicate with him. She said the agency nurse asked him how he was feeling and did anything hurt. The agency nurse did tell Resident #1 I heard you got hit do you want to tell me anything about that. She said the facility trained her in abuse and neglect and reporting abuse and neglect. Interview on 08/15/2025 at 1:00 pm with the ADON reflected when she learned of the incident, she asked an agency nurse to do a head-to-toe assessment.Interview on 08/15/2025 at 1:13 pm with the agency nurse revealed she did not work at the facility; she was 676355 Page 4 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few employed by an agency, and she was asked by the ADON on 07/24/25 to do a head-to-toe assessment (a systematic, comprehensive physical examination of a patient's entire body and all major body systems, performed to identify health problems and establish a baseline of the patient's current health status) on Resident #1 but was not given any additional information. She said she had never worked at the facility before and had never worked with Resident #1. She did the head-to-toe assessment with CNA C who informed her Resident #1 did not speak English. She used an English/Spanish translation telephone application to speak with him and was able to communicate with him. She was not aware of the incident that prompted the assessment, she said she performed a generic head to toe assessment. She said she looked at his skin and asked if he was in any pain. She said it would have been very important to know if Resident #1 had been slapped because she would have conducted a different assessment than a head-to-toe assessment. She stated she would have asked if anyone harmed him or hurt him. She said her questions during the assessment would have been different. She would have asked him in more detail about what happened and asked him if he felt safe at the facility with the team of people who were at the facility and if he felt safe at that time. She said her questions during the assessment would have been targeted towards abuse and neglect. She said she did not know Resident #1 had been slapped prior to her conducting the head-to-toe assessment and she felt blindsided because she did not receive this information prior to Resident #1's assessment. She said she did not have any orientation about what happened with Resident #1, she did not feel comfortable taking over to do a head-to-toe assessment with no information communicated to her about what occurred. She said it was not fair for her and not fair for Resident #1 because he did not receive an appropriate assessment. She said she did not want to work at a facility that did not share this information with nurses who came into their facility.Interview on 08/15/2025 at 2:06 pm with the ADON reflected she was the charge nurse on 07/23/25 from 6:00 am until 6:00 pm but she stayed after 6:00 pm. LVN A was the nurse from 6:00 pm until 6:00 am and at approximately 8:00 pm LVN A approached her at the nurse's station. The ADON said LVN A looked upset. The ADON said LVN A told her that Resident #1 bit her, but LVN A did not tell her that she slapped Resident #1. The ADON said on 07/24/25 she, the Administrator, and LVN C were on a conference call and LVN C asked them if they heard that LVN A slapped a resident. The ADON said LVN C was asked who told him a resident was slapped, but LVN C did not want to tell who told him. The ADON said at that point she wanted to get off the phone with LVN C and the Administrator and call LVN A. The ADON said there was not an additional witness interview or statement taken from LVN C after this conference call. The ADON said neither she nor the Administrator were in the building. The ADON said she called LVN A who was working at the facility and asked her to walk outside of the facility to talk on the phone. During that phone call the ADON said LVN A told her she slapped Resident #1, it was witnessed by CNA B, and LVN A told CNA B that she slapped Resident #1. The ADON said on 07/23/25, that LVN A came to her and said Resident #1 bit her, but LVN A did not tell her she slapped Resident #1. After hearing that CNA B witnessed the incident the ADON called CNA B who was leaving the facility because her shift ended. The ADON spoke to CNA B who initially said she saw LVN A slap Resident #1 then later in the conversation CNA B said she did not see LVN A slap Resident #1. The ADON said she can't remember exactly what CNA B said during the conversation from first saying CNA B witnessed the incident to then saying CNA B did not witness the incident, the ADON said CNA B changed her story. She said they did not take a written statement from CNA B. She said Resident #1 was his own RP because they did not have any information for an RP when he came to the facility directly from the hospital. The ADON confirmed the facility telephone number was the correct telephone number to call the facility. After Resident #1's RP was added, they did not contact the RP and tell 676355 Page 5 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the RP that Resident #1 was slapped because the addition of the RP happened after the incident.Interview on 08/15/2025 at 3:55 pm with the Administrator reflected on 07/24/25 she and the ADON were on a conference call with LVN C. LVN C asked them if they heard LVN A slapped Resident #1. The Administrator said she called LVN A and asked LVN A if she slapped Resident #1 and LVN A said yes. The Administrator told LVN A by phone her employment was terminated. The Administrator asked if someone saw LVN A slap Resident #1 and LVN A said CNA B saw her slap Resident #1. The Administrator said she called CNA B who said she confirmed that she saw LVN A slap Resident #1 but she did not report it because LVN A said she told the ADON. CNA B's employment was not terminated. The Administrator said she told CNA B that it was her job to follow up and make sure that abuse and neglect was reported, and the Administrator did an in-service with CNA B on reporting abuse and neglect. She said Resident #1 did not have an RP at the time of the incident, he was like a loner but there was now something in the system for whom to contact. She wanted to say the nursing department did call the RP and tell the RP what happened but if they did not, she does not know why.Interview on 08/15/2025 at 4:08 pm via telephone with LVN A reflected on 07/23/25 she was in the hallway with Resident #1, and she handed him his medications in a cup. Resident #1 did not want to take his medications, and she reached to take the cup with the medications away from Resident #1 and Resident #1 bit her and she slapped him on the chin. LVN A said the slap was a reaction to being bitten and she knew it was wrong and felt terrible about it. CNA B was in the hallway with her, and she said to CNA B, did you see that, I slapped that man, I am going to lose my job. LVN A said she immediately walked down the hall and told the ADON that Resident #1 bit her and she slapped Resident #1. LVN A said the ADON told her, I did not hear a thing. LVN A said she did not know what the ADON meant when she told her I did not hear a thing. LVN A said she worked the remainder of her shift until 6:00 am and the following day and on 07/24/24, she returned to the facility a 6:00 pm to begin her shift. She received a phone call from the ADON but did not remember the time. She told the ADON on the phone that she slapped Resident #1 when he bit her, and she knew CNA B saw her slap Resident #1 and she told CNA B she slapped Resident #1. LVN A said her job was terminated by telephone that evening.Interview on 08/15/2025 at 4:23 pm with the CNA B reflected she did not see anything but was told by LVN A Resident #1 bit her and she had hit him. She said LVN A said she told the ADON that she slapped Resident #1. CNA B she did not hear LVN A report it to the ADON. CNA B did see her go to the nurse's station. She said she did not witness anything and supposedly LVN A told on herself. She said Resident #1 only speaks Spanish and they communicated with him through gestures or translation with the laundry ladies. She said she was trained in abuse and neglect and reporting through facility in-services and was trained to report abuse and neglect when it happened. She said the only reason she did not report it to the Administrator was because the LVN A told her she was going to tell the ADON. She said after LVN A went to the nurse's station and spoke with the ADON, LVN A continued working her shift that evening. Interview on 08/15/2025 at 4:41 pm with the facility MD reflected was he was notified about the nurse slapping the resident but forgot the name of the person who called to tell him about the incident. Record review of policy Accidents and Incidents Investigating and Reporting dated February 2014 reflected all accidents or incidents involving residents, employees, visitors, vendors, occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director shall promptly initiate and document investigation of the accident or incident.Interview on 08/15/2025 at 4:48 pm with the LVN C reflected he was on a phone conference with the Administrator and the ADON and he said an aide told him that LVN A hit Resident #1. He said the facility did not ask him any additional information or to make a statement after the telephone call. He said 676355 Page 6 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few he was trained in abuse and neglect and reporting abuse and neglect when he began to work for the facility. He said the Administrator was the abuse and neglect coordinator and abuse should be reported immediately. He said he did not witness the incident and did not have any additional information about the incident. Interview on 08/15/2025 at 5:15 pm with Resident #1's RP, she said on 07/30/25 she received an email from the facility requesting her permission and signature on documents for approval for Resident #1 to receive psychiatric medication. The RP stated Resident #1 had never been able to make his own decisions. She said she had a disability and lived far from the facility, but a family member was in the area, and she asked the family member to go to the facility to check on Resident #1. She said the family member told a nurse (name unknown) that the RP had tried calling multiple times using the number that was confirmed at the facility as their telephone number, and no one answered the phone. The RP said the facility did not call her and tell her that Resident #1 was slapped. The RP said Resident #1 called her a little while back and told her a lady slapped him really hard, but she thought he was making it up because of his history of behavioral issues.Interview on 08/17/25 at 11:10 am with the DON reflected she had worked at the facility since 08/06/25 and had been a DON for approximately 2.5 years. She said there was literally no consistency at the facility because staff were agency and prn apart from herself and the ADON. It contributed to the issues that involved the abuse and neglect with LVN A and Resident #1. She said there should have been written statements taken from LVN A, CNA B and CNA C and all of the staff who worked that evening. She said statements needed to be taken before the staff left the facility and when the information was fresh on peoples' minds. She said if you took statements later the stories could change a million times. She said it was part of the facility abuse and neglect policies and procedures to take statements. She said CNA B should have reported to the Administrator about the resident being slapped. CNA B should have received disciplinary action for not reporting. She was told by LVN A that she slapped Resident #1 and CNA B was told by LVN A that LVN A was going to report the incident. She said they should have assessed all the residents for pain and trauma. She said if staff don't talk to the other residents, you don't know if other residents could have been abused. She said the incident was not handled well and it left the residents open to possible concerns of abuse. She said someone should have spoken to the resident immediately when they learned of the incident and he should have had a trauma assessment, pain assessment, skin assessment and his statement about what happened should have been taken, and the police should have been notified. She said a head-to-toe assessment was not enough. She said there was no mention of a slap to the Resident #1 when he was assessed by the agency nurse, and that was crucial information. She said the abuse should have been assessed and addressed with Resident #1. She said if the agency nurse had the information about Resident #1 being slapped by a nurse she would have known what to ask him and how to approach the situation. She said it was a problem that the agency nurse did not know that Resident #1 did not speak English because she was not informed about communication challenges. She said this investigation was not handled in a way where the residents were not exposed or free from abuse. She said it was not possible for a person who had a BIMS of 99 to advocate for themselves, make their own decisions, and be their own RP. She said as soon as the facility obtained information for a RP for Resident #1, the RP should have been called and informed that Resident #1 was slapped by a nurse. She said all steps in the facility policies for investigating abuse and neglect should have been followed and documented.Interview on 08/17/25 at 12:48 pm ADON reflected she was responsible for the investigation, and she looked at the facility abuse and neglect policy concerning what to do when there was abuse and neglect. The ADON said there were no written statements from any staff, but the facility policy said to take written statements. She said 676355 Page 7 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the day after she learned of the incident, she was not at the facility and the Administrator was there and the Administrator did everything. She was not aware of anyone speaking to Resident #1 about the incident except he had a head-to-toe assessment. She said a head-to-toe assessment was different than a trauma assessment. She said Resident #1 being slapped was trauma. The ADON gave instructions by telephone to the AN to give Resident #1 the head-to-toe assessment. A head-to-toe assessment was different than a trauma assessment. In a trauma assessment, when the resident was slapped, the number one question you would ask was if the resident felt safe. She did not know if the nurse asked him that question. In a trauma assessment you would want to ask if the resident was okay. The ADON said maybe Resident #1 should have had a head to toe and trauma assessment, but she just told the AN to do a head-to-toe assessment. She said the negative effect of not doing a trauma assessment would be you do not know if he felt safe or had information about previous abuse that might have affected his behavior. There was no documentation that shows that someone asked him if he felt safe in the facility, a trauma informed assessment should have been done. She said because it was not documented did not mean that he was not asked if he felt safe but stated that nursing policy was that if it was not documented, it did not happen. The ADON said Resident #1 was not a fluent English speaker and if he was going to understand someone it needed to be spoken to him in Spanish. The primary way of communicating with him was using the communication binder and when the AN administered his head-to-toe assessment, she should have had the communication binder. The ADON said that LVN A said she slapped Resident #1, and that was assault and maybe the police should have been called. She said more things should have been done and she did not know if everything was done to make sure that there was no additional abuse in the facility. She said the possible negative effect of not following the procedures in the facility abuse and neglect investigation was that they were not making sure Resident #1 was okay and they were not making sure there was not any additional abuse. The ADON said when she obtained information to contact Resident #1's RP, she should have contacted her and let her know that he was slapped by a nurse.Interview on 08/17/25 at 1:55 pm with the facility former SW reflected she was unaware of the incident involving LVN A and Resident #1 and the Resident Safe Survey she conducted on 07/23/25 for 15 Residents were safe surveys she conducted periodically, every 1 to 2 weeks, and not associated with any specific facility incident.Interview on 08/17/2025 at 5:42 pm with the Administ[TRUNCATED] 676355 Page 8 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0610 Respond appropriately to all alleged violations. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure alleged violations were thoroughly investigated for one (Resident #1) of four residents reviewed for abuse.The facility failed to ensure the facility conducted a thorough investigation when Resident #1 was slapped by a facility nurse on 7/23/25. The facility did not notify law enforcement, did not take statements from witnesses and other staff working at the same time as the incident, did not interview Resident #1 in his native language, did not complete a trauma-based assessment, and did not notify Resident #1's responsible party.An Immediate Jeopardy (IJ) situation was identified on 08/15/25. While the IJ was removed on 08/19/25, the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place residents at risk of additional exposure for abuse and neglect.Findings included:Review of Resident #1's face sheet dated 08/15/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia (term for a decline in mental ability, affecting memory, thinking, and daily functioning), traumatic subdural hemorrhage (a dangerous collection of blood that forms between the brain's outer covering (dura) and the brain itself, often resulting from a severe head injury) and paranoid schizophrenia (a chronic mental disorder now understood as schizophrenia, marked by prominent, often persistent, delusions and hallucinations). Review of Resident #1's care plan dated 07/25/25 reflected a focus of Resident #1 had a behavior problem related to low frustration tolerance (an individual's difficulty in managing and accepting frustrating situations, leading to negative emotional reactions and difficulty coping with everyday challenges) with the following interventions dated 07/25/25:1. Assist the resident to develop more appropriate methods of coping and interacting2. Encourage the resident to express feelings appropriately3. Explain all procedures to the resident before starting and allow the resident time to adjust to changes4. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.5. Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention6. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.A review of Resident #1's care plan dated 07/25/25 reflected a focus of Resident #1 risk for impaired communication with intervention dated 07/25/25 Spanish speaking.Review of Resident #1's Optional State Assessment MDS dated [DATE] reflected no BIMS score, Section A - Identification Information preferred language Spanish, Section E - Behavior Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) behavior of this type occurred 1 to 3 days.Review of Resident #1's BIMS assessment dated [DATE] reflected Incomplete Requires Further Assessment 99.0.A review in TULIP reflected on 07/25/2025 at 12:08 am the facility reported to HHSC:Resident/Client Information Resident # 11. Pertinent Medical Diagnosis: unspecified dementia, unspecified severity, without behavioral 06/19/2025 principal diagnosis (67) admission disturbance, psychotic disturbance, mood disturbance, and anxiety, paranoid schizophrenia2. Is special supervision required? If so, please specify: No special supervision required.3. Level of cognition: BIMS SCORE 04. Is there a history of similar or prior incidents, if so please specify: No Incident Details:1. Date/Time the incident occurred: 07/24/25 nurse can not give definitive time frame states it was around 6:30 pm or after 2. Date/Time you first learned of incident: 7/24/25 at 9:49 pm3. Brief narrative summary of the reportable incident: The Charge Nurse reported that while attempting to administer medication, the resident bit her hand, prompting a reflexive response in which she slapped the Residents Affected - Few 676355 Page 9 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few resident in the face. The nurse stated the action was unintentional. She further stated that she immediately reported the incident to the Assistant Director of Nursing (ADON). However, the ADON stated that the Charge Nurse only reported the bite incident and did not disclose that the resident had been slapped.4. Witnesses name and title: Charge Nurse states that the incident was witnessed by another CNA [CNA B]. The administrator interviewed the CNA who reports that she didn't see the incident, but that the Charge nurse showed her the bite mark and admitted to slapping the resident. Assessment Details:1. The date and time of the assessment: 07/24/25 (no time given)2. Name and title of person who completed the assessment: [Agency Nurse]3. Results of the assessment include the extent of injuries. Provide details of any physical harm, pain, or mental anguish including serious bodily injury, or other injuries including but not limited to measurements, location, color of bruises, scratches, lacerations, fractures, changes in residents' behavior that is different from the normal baseline: The resident was assessed by the licensed nurse on duty. No visible injuries were observed upon assessment-no redness, swelling, bruising, or open skin noted on the face or surrounding areas. Alleged Perpetrator # 21. LVN A 2. Was the alleged perpetrator removed, suspended or terminated? Suspended pending further investigation.Actions and Notifications1. Who did the facility/agency notify about the incident? Ex. physician, family, ombudsman: Family and Physician, both notified of incident2. Was the incident reported to the police? If so, provide case number: N/a3. If the Texas Department of Family and Protective Services was notified, please include the DFPS call ID reference number: N/a4. Provide all steps taken immediately to ensure resident(s) are protected including but not limited to evaluating if resident feels safe, room relocation, increased supervision and other measures to prevent further abuse, neglect, exploitation and misappropriation: Staff member suspended pending investigation, resident assessed with no visible signs of injury to facial area, MD notified, Resident is Responsible Party, Referral to Psych Evaluation and treat5. Was an in-service conducted? If so, provide topic of in-service: Abuse and Neglect, Behavior Management, Resident Safe Surveys, Improving Communication with Residents Who Have Limited English Proficiency.A review of facility Provider Investigative Report 08/01/25 reflected witness name [CNA B] Denies witnessing the incident but was aware of the incident.A review of facility Provider Investigative Report 08/01/25 reflected:Assessment: Upon learning of the alleged incident, the resident was assessed from head to toe by the licensed nurse on duty. No visible injuries were observed upon assessment - no redness, swelling, bruising skin noted on the [NAME] or surrounding areas. Resident [Resident #1] exhibited no adverse reactions and remains stable Upon investigation of the allegations, it was determined that Charge Nurse [LVN A] did, in fact, slap resident [Resident #1], as confirmed by her own admission, While the act was stated to be unintentional, the incident id occur and could not be negated. The alleged witness, [CNA B] reported that she was aware of the incident only through what the Charge Nurse had told her. Based on the Charge Nurse's admission of the offense, appropriate disciplinary action was taken, and her employment was terminated. Additionally, the Assistant Director of Nursing (ADON) and CNA [CNA B] were re-educated on Abuse and Neglect policies, including the importance of immediately report all allegations of the facility's Abuse Coordinator according with regulator requirements. Resident [Resident #1] continued to exhibit no adverse reactions and remains stable at this time. A review of facility Provider Investigative Report 08/01/25 reflected MD and RP were notified. A review of facility Provider Investigative Report 08/01/25 reflected Resident Safe Survey dated 08/23/25 for 15 Residents. Resident #1 was not included in the safe survey. A review of facility Provider Investigative Report 08/01/25 included facility Abuse Policy dated 01/27/20.A review of facility Provider Investigative Report 08/01/25 included in-service dated 07/25/25:Department: nursing; AdministratorDate: 07/25/25 676355 Page 10 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few OngoingEmployee group(s) present: Administrator and Nursing DepartmentTopic: Abuse, Neglect, and Exploitation in the Community Contents or summary of training session: Abuse of any kind will never be tolerated. Abuse is any willful infliction of injury or neglect. The resident as the right to be free from Any type of abuse, neglect, intimidation, involuntary, seclusion/confinement and/or misappropriation of monies/funds.Conducted by: Administrator Evaluations, comments, suggestions: The Abuse Coordinator is [Administrator] followed by DON, ADON, Charge nurse. You should ALWAYS Alert the Abuse Coordinator of Abuse allegations Immediately. There is a 2 hour window for immediate reporting and a 24 hours window for report of abuse with/without injury or unknown injury. Signature of person completing report: unsigned A review of facility Provider Investigative Report 08/01/25 included signatures of staff in-service dated 07/25/25 Topic: Abuse, Neglect, and Exploitation in the Community signed by 20 staff members with no designation of if staff were agency employees and some signatures did not state job title. A review of facility Provider Investigative Report 08/01/25 included a copy of the facility Behavioral Management Policy dated 04/19/05.A review of facility Provider Investigative Report 08/01/25 included in-service dated 07/25/25:Department: nursingDate: 07/25/25 OngoingEmployee group(s) present: Administrator, nursing, dietary, housekeeping Topic: Behavioral Management Contents or summary of training session: Behavior Management Behavior management included the management of anger, confusion, Hallucination and other behaviors by utilizing techniques such as group interactions, limit setting and behavior modification depending on resident needs. Establish rapport with a calm approach and supportive attitude. Place resident on frequent checks to ensure safety Conducted by: Administrator Allow wondering if its safe and and not exit seeking for those with dementia to prevent frustration and anger. Refrain from [sic] that residents take medications - stop - allow time - then revisit resident. Provide structure with routines and low to moderate stimulation to the environment. Signature of person completing report: AdministratorA review of facility Provider Investigative Report 08/01/25 included staff signatures of in-service dated 07/25/25 Topic: Behavioral Management signed by 20 staff members with no designation of if staff were agency employees some signatures did not state job title. The in-service signature sheet was identical to the staff in-serviced signature sheet on the Abuse, Neglect, and Exploitation in-service dated 07/25/25. A review of facility Provider Investigative Report 08/01/25 reflected memos to the ADON and CNA B from the Administrator stating, This letter serves as a reminder of the critical importance of immediately reporting any allegations or suspicions of abuse, neglect, or exploitation to the facility's Abuse Coordinator, in accordance with the state and federal regulations. Timely reporting is essential to the safety and well-being of our residents and to maintain compliance with all regulatory requirements. Failure to promptly report can place residents at risk and may result in disciplinary action. Please continue to follow facility policy by reporting all incidents immediately and accurately, ensuring that our residents remain safe and always protected signed by the Administrator, the ADON, and CNA B. A review of facility Provider Investigative Report 08/01/25 reflected in-serviced dated 07/25/25 Inservice Topic: Overcoming Language Barriers in Nursing Homes. Purpose: To Educate staff on the importance of effective communication with residents who have limited English proficiency and strategies to ensure quality care and understanding. A review of facility Provider Investigative Report 08/01/25 included staff signatures of in-service dated 07/25/25 Topic: Overcoming Language Barriers in Nursing Homes signed by 20 staff members with no designation of if staff were agency employees some signatures did not state job title. The in-service signature sheet was identical to the staff in-serviced signature sheet on the Abuse, Neglect, and Exploitation, and Behavioral Management in-services dated 07/25/25.Review of Resident #1's nurses note dated 07/23/25 by LVN A reflected handed resident his 676355 Page 11 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few medication cup, resident would not take, kept encouraging resident to take his medication, since resident would not take his medication this writer reached to take the cup of meds and dispose of properly, resident bent forward and bit this writers thumb on my left hand, ADON, notified, p.c.p.Review of Resident #1's nurses note dated 07/25/25 by agency nurse reflected, Head to Toe Assessment Completed. Spanish speaker only, Alert and Awake. PERRLA. Skin Warm and Dry. Equal hand grips. Capillary refill less than 3 sec. No edema present. Respirations even and unlabored. No s/s of distress observed. Abdomen soft, round nontender - nondistended. Bowel sounds active x4 (This medical notation indicates that bowel sounds are present in all four quadrants of the abdomen (right upper, right lower, left upper, left lower). Pt. wheelchair bound, x1 assist. Scratch noted to right lower extremity. CNA [C] reports the scratch has been there. Bed in lowest position. Call light and personal belongings at bedside. Safety precautions in place. No safety hazards observed. No further concerns at this time. ADON Notified of scratch to RLE. Review of Resident #1's progress notes did not reflect facility contacted MD after incident, attempted to contact Resident #1's RP, or communications with Resident #1 about being slapped by LVN A. Record review of Resident #1's initial psychiatric evaluation dated 07/25/25 reflected no reference to Resident #1 being slapped by LVN A and states, particular attention will be paid to possible environmental factors contributing to agitation.Record review of MD Home Visit dated 07/24/25 reflected, [Resident #1] is seen and examined today at bedside for face redness due to an incident with Charge nurse that occurred on 07/23. An assessment was performed and we found no adverse s/s. Treatment 1. Contusion of other part of head, initial encounter Notes: no injuries noted. monitor at this time. Advised [Resident #1] to notify me if another incident. Interview on 08/16/25 at 10:50 am with Resident #1 with his RP as an interpreter via telephone reflected, he confirmed that a lady slapped him, but he said it did not hurt, and he is okay. He said no one at the facility talked to him about it after it happened, and he had not seen the lady who slapped him at the facility anymore. Interview on 08/15/2025 at 12:57 pm with CNA C reflected she did not know details of what happened between Resident #1 and LVN A, she only heard that Resident #1 bit LVN A and LVN A slapped him. She said she did not see or hear anything else about the incident. She said she was with the agency nurse when Resident #1 had a skin assessment. She said the agency nurse did not tell her why Resident #1 was having a skin assessment, but Resident #1 did sometimes have a lot of aggression towards the staff and the ADON asked her to go in with the agency nurse for the skin assessment. She said when they entered his room he was laying down on the bed. CNA C said the agency nurse did tell Resident #1 what they were doing but there was a communication barrier. She said they didn't understand what he was saying to them because he did not speak English. She said she did not use the communication board, and she had never seen a communication board. She said previously she gestured things to communicate with him. She said the agency nurse asked him how he was feeling and did anything hurt but she did tell him I heard you got hit do you want to tell me anything about that. She said the facility trained her in abuse and neglect and reporting abuse and neglect. Interview on 08/15/2025 at 1:00 pm with the ADON reflected when she learned of the incident, she asked an agency nurse to do a head-to-toe assessment.Interview on 08/15/2025 at 1:13 pm with the agency nurse revealed she did not work at the facility; she was employed by an agency, and she was asked by the ADON on 07/24/25 to do a head-to-toe assessment (a systematic, comprehensive physical examination of a patient's entire body and all major body systems, performed to identify health problems and establish a baseline of the patient's current health status) on Resident #1 but was not given any additional information. She said she had never worked at the facility before and had never worked with Resident #1. She did the head-to-toe assessment with CNA C who informed her Resident #1 did not speak English. 676355 Page 12 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few She used an English/Spanish translation telephone application to speak with him and was able to communicate with him. She was not aware of the incident that prompted the assessment, she said she performed a generic head to toe assessment. She said she looked at his skin and asked if he was in any pain. She said it would have been very important to know if Resident #1 had been slapped because she would have conducted a different assessment than a head-to-toe assessment. She stated she would have asked if anyone harmed him or hurt him. She said her questions during the assessment would have been different. She would have asked him in more detail about what happened and asked him if he felt safe at the facility with the team of people who were at the facility and if he felt safe at that time. She said her questions during the assessment would have been targeted towards abuse and neglect. She said she did not know Resident #1 had been slapped prior to her conducting the head-to-toe assessment and she felt blindsided because she did not receive this information prior to Resident #1's assessment. She said she did not have any orientation about what happened with Resident #1, she did not feel comfortable taking over to do a head-to-toe assessment with no information communicated to her about what occurred. She said it was not fair for her and not fair for Resident #1 because he did not receive an appropriate assessment. She said she did not want to work at a facility that did not share this information with nurses who came into their facility.Interview on 08/15/2025 at 2:06 pm with the ADON reflected she was the charge nurse on 07/23/25 from 6:00 am until 6:00 pm but she stayed after 6:00 pm. LVN A was the nurse from 6:00 pm until 6:00 am and at approximately 8:00 pm LVN A approached her at the nurse's station. The ADON said LVN A looked upset. The ADON said LVN A told her that Resident #1 bit her, but LVN A did not tell her that she slapped Resident #1. The ADON said on 07/24/25 she, the Administrator, and LVN C were on a conference call and LVN C asked them if they heard that LVN A slapped a resident. The ADON said LVN C was asked who told him a resident was slapped, but LVN C did not want to tell who told him. The ADON said at that point she wanted to get off the phone with LVN C and the Administrator and call LVN A. The ADON said there was not an additional witness interview or statement taken from LVN C after this conference call. The ADON said neither she nor the Administrator were in the building. The ADON said she called LVN A who was working at the facility and asked her to walk outside of the facility to talk on the phone. During that phone call the ADON said LVN A told her she slapped Resident #1, it was witnessed by CNA B, and LVN A told CNA B that she slapped Resident #1. The ADON said on 07/23/25, that LVN A came to her and said Resident #1 bit her, but LVN A did not tell her she slapped Resident #1. After hearing that CNA B witnessed the incident the ADON called CNA B who was leaving the facility because her shift ended. The ADON spoke to CNA B who initially said she saw LVN A slap Resident #1 then later in the conversation CNA B said she did not see LVN A slap Resident #1. The ADON said she can't remember exactly what CNA B said during the conversation from first saying CNA B witnessed the incident to then saying CNA B did not witness the incident, the ADON said CNA B changed her story. She said they did not take a written statement from CNA B. She said Resident #1 was his own RP because they did not have any information for an RP when he came to the facility directly from the hospital. The ADON confirmed the facility telephone number was the correct telephone number to call the facility. After Resident #1's RP was added, they did not contact the RP and tell the RP that Resident #1 was slapped because the addition of the RP happened after the incident.Interview on 08/15/2025 at 3:55 pm with the Administrator reflected on 07/24/25 she and the ADON were on a conference call with LVN C. LVN C asked them if they heard LVN A slapped Resident #1. The Administrator said she called LVN A and asked LVN A if she slapped Resident #1 and LVN A said yes. The Administrator told LVN A by phone her employment was terminated. The Administrator asked if someone saw LVN A slap Resident #1 and LVN A said CNA B saw her slap 676355 Page 13 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1. The Administrator said she called CNA B who said she confirmed that she saw LVN A slap Resident #1 but she did not report it because LVN A said she told the ADON. CNA B's employment was not terminated. The Administrator said she told CNA B that it was her job to follow up and make sure that abuse and neglect was reported, and the Administrator did an in-service with CNA B on reporting abuse and neglect. She said Resident #1 did not have an RP at the time of the incident, he was like a loner but there was now something in the system for whom to contact. She wanted to say the nursing department did call the RP and tell the RP what happened but if they did not, she does not know why.Interview on 08/15/2025 at 4:08 pm via telephone with LVN A reflected on 07/23/25 she was in the hallway with Resident #1, and she handed him his medications in a cup. Resident #1 did not want to take his medications, and she reached to take the cup with the medications away from Resident #1 and Resident #1 bit her and she slapped him on the chin. LVN A said the slap was a reaction to being bitten and she knew it was wrong and felt terrible about it. CNA B was in the hallway with her, and she said to CNA B, did you see that, I slapped that man, I am going to lose my job. LVN A said she immediately walked down the hall and told the ADON that Resident #1 bit her and she slapped Resident #1. LVN A said the ADON told her, I did not hear a thing. LVN A said she did not know what the ADON meant when she told her I did not hear a thing. LVN A said she worked the remainder of her shift until 6:00 am and the following day and on 07/24/24, she returned to the facility a 6:00 pm to begin her shift. She received a phone call from the ADON but did not remember the time. She told the ADON on the phone that she slapped Resident #1 when he bit her, and she knew CNA B saw her slap Resident #1 and she told CNA B she slapped Resident #1. LVN A said her job was terminated by telephone that evening.Interview on 08/15/2025 at 4:23 pm with the CNA B reflected she did not see anything but was told by LVN A Resident #1 bit her and she had hit him. She said LVN A said she told the ADON that she slapped the resident. CNA B she did not hear LVN A report it to the ADON. CNA B did see her go to the nurse's station. She said she did not witness anything and supposedly LVN A told on herself. She said Resident #1 only speaks only Spanish and they communicated with him through gestures or translation with the laundry ladies. She said she was trained in abuse and neglect and reporting through facility in-services and was trained to report abuse and neglect when it happened. She said the only reason she did not report it to the Administrator was because the LVN A told her she was going to tell the ADON. She said after LVN A went to the nurse's station and spoke with the ADON, LVN A continued working her shift that evening. Interview on 08/15/2025 at 4:41 pm with the facility MD reflected was he was notified about the nurse slapping the resident but forgot the name of the person who called to tell him about the incident. Record review of facility policy Accidents and Incidents - Investigating and Reporting dated February 2014 reflected all accidents or incidents involving residents, employees, visitors, vendors, occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director shall promptly initiate and document investigation of the accident or incident.Interview on 08/15/2025 at 4:48 pm with the LVN C reflected he was on a phone conference with the Administrator and the ADON and he said an aide told him that LVN A hit Resident #1. He said the facility did not ask him any additional information or to make a statement after the telephone call. He said he was trained in abuse and neglect and reporting abuse and neglect when he began to work for the facility. He said the Administrator was the abuse and neglect coordinator and abuse should be reported immediately. He said he did not witness the incident and did not have any additional information about the incident. Interview on 08/15/2025 at 5:15 pm with Resident #1's RP, she said on 07/30/25 she received an email from the facility requesting her permission and signature on documents for approval for Resident #1 to receive 676355 Page 14 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few psychiatric medication. The RP stated Resident #1 had never been able to make his own decisions. She said she had a disability and lived far from the facility, but a family member was in the area, and she asked the family member to go to the facility to check on Resident #1. She said the family member told a nurse (name unknown) that the RP had tried calling multiple times using the number that was confirmed at the facility as their telephone number, and no one answered the phone. The RP said the facility did not call her and tell her that Resident #1 was slapped. The RP said Resident #1 called her a little while back and told her a lady slapped him really hard, but she thought he was making it up because of his history of behavioral issues.Interview on 08/17/25 at 11:10 am with the DON reflected she had worked at the facility since 08/06/25 and had been a DON for approximately 2.5 years. She said there was literally no consistency at the facility because staff were agency and prn apart from herself and the ADON and it contributed to the issues that involved the abuse and neglect with LVN A and Resident #1. She said there should have been written statements taken from LVN A, CNA B and CNA C and all of the staff who worked that evening. She said statements needed to be taken before the staff left the facility and when the information was fresh on peoples' minds. She said if you took statements later the stories could change a million times. She said it was part of the facility abuse and neglect policies and procedures to take statements. She said CNA B should have reported to the Administrator about the resident being slapped. CNA B should have received disciplinary action for not reporting she was told by LVN A that she slapped Resident #1 even though CNA B was told by LVN A that said she was going to report the incident. She said they should have assessed all the residents for pain and trauma. She said if you don't talk to the other residents, you don't know if other residents could have been abused. She said the incident was not handled well and it left the residents open to possible concerns of abuse. She said someone should have spoken to the resident immediately when they learned of the incident and he should have had a trauma assessment, pain assessment, skin assessment and his statement about what happened should have been taken, and the police should have been notified. She said a head-to-toe assessment was not enough. She said there was no mention of a slap to the Resident #1 when he was assessed by the agency nurse, and that was crucial information. She said the abuse should have been assessed and addressed with Resident #1. She said if the agency nurse had the information about Resident #1 being slapped by a nurse she would have known what to ask him and how to approach the situation. She said it was problem that the agency nurse did not know that he did not speak English because she was not informed about communication challenges. She said this investigation was not handled in a way where the residents were not exposed or free from abuse. She said it was not possible for a person who had a BIMS of 99 to advocate for themselves, make their own decisions, and be their own RP. She said as soon as the facility obtained information for a RP for Resident #1, the RP should have been called and informed that Resident #1 was slapped by a nurse. She said all steps in the facility policies for investigating abuse and neglect should have been followed and documented.Interview on 08/17/25 at 12:48 pm ADON reflected she was responsible for the investigation, and she looked at the facility abuse and neglect policy concerning what to do when there was abuse and neglect. The ADON said there were no written statements from any staff, but the facility policy said to take written statements. She said the day after she learned of the incident, she was not at the facility and the Administrator was there and the Administrator did everything. She was not aware of anyone speaking to Resident #1 about the incident except he had a head-to-toe assessment. She said a head-to-toe assessment was different than a trauma assessment. She said Resident #1 being slapped was trauma. The ADON gave instructions by telephone to the AN to give Resident #1 the head-to-toe assessment. A head-to-toe assessment was different than a trauma 676355 Page 15 of 16 676355 08/19/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assessment. In a trauma assessment, when the resident was slapped, the number one question you would ask was if the resident felt safe. She did not know if the nurse asked him that question. In a trauma assessment you would want to ask if the resident was okay. The ADON said maybe Resident #1 should have had a head to toe and trauma assessment, but she just told the AN to do a head-to-toe assessment. She said the negative effect of not doing a trauma assessment would be you do not know if he felt safe or had information about previous abuse that might have affected his behavior. There was no documentation that shows that someone asked him if he felt safe in the facility, a trauma informed assessment should have been done. She said because it was not documented did not mean that he was not asked if he felt safe but stated that nursing policy was that if it was not documented, it did not happen. The ADON said Resident #1 was not a fluent English speaker and if he was going to understand someone it needed to be spoken to him in Spanish. The primary way of communicating with him was using the communication binder and when the AN administered his head-to-toe assessment, she should have had the communication binder. The ADON said that LVN A said she slapped Resident #1, and that was assault and maybe the police should have been called. She said more things should have been done and she did not know if everything was done to make sure that there was no additional abuse in the facility. She said the possible negative effect of not following the procedures in the facility abuse and neglect investigation was that they were not making sure Resident #1 was okay and they were not making sure there was not any additional abuse. The ADON said when obtained information to contact Resident #1's RP, she should have contacted her and let her know that he was slapped by a nurse.Interview on 08/17/25 at 1:55 pm with the [TRUNCATED] 676355 Page 16 of 16