Health inspection·November 17, 2025

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for one (Resident #1) of one resident reviewed. The facility failed to provide basic life support measures including CPR to Resident #1 on [DATE] when Resident #1, who was full code, was found unresponsive. On date [DATE] at 9:13 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 3:10 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and at a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of injury, harm, impairment, or death to a resident receiving care in this facility.Findings included: Review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old female. admitted [DATE], with diagnoses including unspecified dementia (group of symptoms that affect memory, thinking, and other cognitive functions, significantly impacting daily life), polyneuropathy (nerve damage), anxiety disorder (mental health condition with excessive worry or fear and can interfere with daily life), chronic kidney disease(kidneys are not filtering correctly), dysphagia(difficulty swallowing), muscle wasting of both legs (loss of muscle tissue and strength, and schizophrenia(a brain disorder that affects how a person thinks, feels or acts). Review of Resident #1 quarterly MDS, dated [DATE], reflected a BIMS score of 03, indicating severe cognitive impairment. Further review of the MDS reflected Resident #1 could sometimes make self-understood and could respond to simple, direct communication only. Review of Resident #1's care plan, dated [DATE], reflected the focus area was: (Resident #1) request code status of FULL CODE. Review of Resident #1's Progress Notes, dated [DATE] at 9:46 p.m.by LVN A, reflected, (Resident #1) resting at long intervals. VS wnl. Skin cool to the touch. The resident is arousable with touch. Provided incontinent care to the resident as needed. Review of Resident #1's Progress Notes, dated [DATE] at 2:31 p.m.by LVN A, reflected, Resident continues to rest. Vs obtained. Skin is cool to touch with skin color discoloration. Incont. Of B.B. resp, even but shallow, pulse is weak and thready (weak, thin, and barely perceptible). Will continue to check on resident this shift. Review of Resident #1's Progress Notes dated [DATE] at 6:26 p.m.by LVN A, reflected, Resident is Page 1 of 4 676355 676355 11/17/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0678 Level of Harm - Immediate jeopardy to resident health or safety nonresponsive. No vitals are able to be detected. Notified Hospice. They are sending someone out to pronounce resident. During an interview on [DATE] at 5:30 p.m. the Administrator told me that agency nurses are trained with their company (The agency) The nursing home in serviced them on documentation, abuse and neglect, and change in condition. Residents Affected - Few During an interview on [DATE] at 6:08 p.m. the Administrator stated she was called by LVN A about Resident #1's. She stated she asked if CPR was performed and LVN A stated it was not. The Administrator stated LVN A told her she (LVN A) was an experienced nurse and Resident #1 was already dead. The Administrator stated she told LVN A that even though Resident #1 was on Hospice, she was a full code, and it was expected that CPR be performed. The administrator stated that LVN A had repeated to the ADM that she was very experienced and Resident #1 was dead. The administrator stated, after the incident, staff were in serviced on Code Status Identification, Hospice Care, and Full Code Status Nursing Home Residents. During an interview on [DATE] at 7:00 p.m., LVN A stated this was her first time working with Resident #1. She stated she did not know anything about any of the residents, but she relied on what the CNA told her. LVN A stated Resident #1 was on Hospice, so she assumed Resident #1 was a DNR. During an interview with CNA B on [DATE] at 1:00 p.m., she said she had no concerns with the resident. She stated she checked, changed, and turned every two hours. CNA B stated Resident#1 moaned when she was turned but was not in distress. CNA B said when she left the facility at 4:45 a.m. the resident was alive. Review of facility policy, undated, entitled Hospice Care and Full Code Status in Nursing Home Residents revealed the following policy statement, Hospice enrollment does not automatically change a resident's code status. Life savings measures must be initiated immediately for any resident designated as Full Code, regardless of hospice status. Staff must verify code status before initiating emergency interventions. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 9:13 p.m. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 9:13 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 8:09 a.m. Nursing staff and agency personnel received immediate re-education from the DON on the proper procedure for locating a resident's code status within the electronic medical record. Retention of training and comprehension evidenced by the employee's signature, indicating understanding of the material presented. All nursing staff and agency personnel will receive in-service training prior to the start of their shift. The Chief Executive Officer in-serviced the DON on the proper procedure for locating a resident's code status within the electronic medical record. Retention of training and comprehension evidenced by the employee's signature, indicating understanding of the material presented. The DON in-serviced the ADON on locating residents code status on electronic medical record specifically. Retention of training and comprehension evidenced by the employee's signature, indicating understanding of the material presented. 676355 Page 2 of 4 676355 11/17/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0678 Level of Harm - Immediate jeopardy to resident health or safety A comprehensive audit of each resident's code status was completed to ensure accuracy and compliance with facility policy. Nursing staff and agency personnel were re-educated on emergency response procedures and initiating CPR immediately for any Full Code resident without signs of life. Retention of training and comprehension evidenced by the employee's signature, indicating understanding of the material presented. Residents Affected - Few Staff and agency personnel received education regarding the meaning of the red and green markers on each resident's door to indicate code status. Retention of training and comprehension evidenced by the employee's signature, indicating understanding of the material presented. A Performance Improvement Plan was put in place for trend analysis and system improvement. Monitoring: Record review on [DATE] of DON in-service training revealed the DON covered Locating code status in then electronic medical record, code status Identification and the red and green dots on resident's doors. Record review revealed that 8 of 15 regular nursing staff signed the in-service training there were also 12 agency staff that had signed the in-service training. During an interview on [DATE] at 12:06 p.m. with the facility owner, he stated in- serviced the DON on the policy and procedures of full code and CPR. He said he checked for understanding by asking her if she understood and had her repeat what he had said. He also said that she signed off saying she understood. Record review on [DATE] revealed that the DON in-serviced the ADON on Basic Life Support/CPR policy, what DNR means, what the green and red dots mean, and locating a code status on the crash cart if power outage. During an interview on [DATE] at 12:41 p.m., the ADON stated she was in-serviced on code status, the policy and procedures, what the stars on the doors mean, and where to find the code status. She said the code status was found in the binder on the crash cart, in the resident's profile, MDS and on the stars on the doors. She said the red star meant stop and the green meant CPR. During an interview on [DATE] at 1:40 p.m. CNA C stated she had been trained on change of condition, code status and what the green and red dots on the door mean. During an interview on [DATE] at 2:15 p.m. CNA D stated she was trained and in-service on change of condition, code status and what green and red dots on the door mean. During an interview on [DATE] at 2:32 p.m. LVN E stated she trained and in-service on change of condition, code status and what green and red dots on the door mean. A comprehensive audit of each resident's code status was completed to ensure accuracy and compliance with facility policy. Record review on [DATE] of DON and MDS Code Status Auditing, dated [DATE], revealed all residents were audited for code status. 676355 Page 3 of 4 676355 11/17/2025 Brenham Healthcare Center 1303 Hwy 290 E Brenham, TX 77833

F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review on [DATE] of residents Code Status Binder on the crash cart revealed 7/35 were DNR status. Record review on [DATE] of 7/7 DNR residents revealed all seven residents had a signed DNR. The DNR status was indicated on their face sheet, care plan, and physician orders. Record review on [DATE] of 28/28 residents code status of Full Code revealed all 28 had full code on their face sheet, orders, and care plans. Record review on [DATE] revealed the DON in-serviced staff on Hospice Care and Full code status in Nursing Home Residents, verification of code status, emergency response for full code residents and reporting. Record review on [DATE] revealed 8 of 15 nursing staff signed the in-service training there were also 12 agency staff signed the in-service training. Observation on [DATE] at 10:26 a.m., revealed all residents who were in the facility had a red or green star that matched their code status. Record review on [DATE] revealed that 8 of 15 regular nursing staff signed the in-service training there were also 12 agency staff that had signed the in-service training that covered the training for the red and green dots on the residents' doors. Record review on [DATE] of Implementation of Performance Improvement Plan: Code Status Documentation and Compliance, dated [DATE], revealed the facility designed a plan of action for the code status documentation and compliance in long term care. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 3:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 676355 Page 4 of 4