Health inspection·July 8, 2022

F 0578 no information on advanced directives. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 7/5/22 at 9:10 a.m. of Resident #6 revealed she was lying on her bed clean and well groomed, and there were two bottles of medicated eye drops sitting on her nightstand beside her bed. When asked if she gave herself the eye drops, she stated yes, that was very important to her. Residents Affected - Few Observation and interview on 7/8/22 at 10:30 a.m. of Resident #6 revealed she was lying on her bed and was watching television. Interview with Resident #6 revealed she did not recall anyone had discussed code status when she was admitted . She was not provided information about code status. Interview on 7/7/22 at 1:28 p.m. with the NC revealed that code status needed to be done when Resident #6 was admitted because staff needed to know what the resident's wishes were and the paperwork and orders needed to be completed. She stated it was important that staff knew what Resident #6 wanted for advanced directives. She stated without advanced directives residents were considered to be full code and they only had 4 residents in the facility with that preference. Interview on 7/7/22 at 2:30 p.m. with LVN C (the admitting nurse of Resident #6) revealed that when Resident #6 was admitted she did not notice she did not have an advanced directive or code status in her orders and so it was totally missed. She stated that when she admitted residents a temporary care plan was created from the assessment and that the code status was something that should be reflected. Interview on 7/8/22 at 10:35 a.m. with Resident #6 revealed she could not recall if anyone discussed code status upon admission, and she had always wanted to be a full code, but since her family member passed away in May, she was not sure anymore and may want to have DNR status. She stated she did not want to discuss the issue further, but that it was very important for her to make a decision about advanced directives. Interview on 7/8/22 at 10:16 a.m. with the ADM revealed that she went to Resident #6's family member when Resident #6 was admitted , and she said she was on her way out of town. She wanted her left as a full code, and it did not get put inside the chart. She stated if we don't have a copy of a DNR, we treat residents as a full code. The ADM stated there was nothing noted about code status in Resident #6's charts, and no one picked up on it. It would've probably got picked up in care plans and she wasn't due for a care plan meeting and the Social Worker may have caught it but we don't have a Social Worker. The nurses don't look at the code status on admission, it is up to the admissions people. We missed this on Resident #6, and it was important because staff needed to know Resident #6's wishes when it came to advanced directives. She stated she was responsible, and it was missed. Review of the facility policy and procedure titled Advanced Directive/Critical Care Choice dated 2005 revealed Procedure .1. Upon admission the social worker, DON or their designee will approach the resident, POA or legal guardian and explain the choices of Full Code or DNR. 2. During this period, the resident or significant other will be asked to document their choice on the appropriate form .4. A summary of this discussion and the names and individuals present during the discussion will be documented by social service, administration, or other participating professional in that department's section of the chart or on interdisciplinary notes. 5. Nursing administration or medical records will enter the critical care choice on the physician consolidated orders for physician's signature. 6. The category of critical care choice/DNR will be documented in the care plan. 7. The signed critical care choice form/DNR will be placed in the front of the clinical record. 8. The front of the chart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 2 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete will be flagged with a Red Dot to signify Do Not Resuscitate if permission is given. 9. Nursing staff will notify all other departments of the critical care choice. Review of the facility Advanced Care Planning Protocol dated 6/5/18 revealed Purpose .To ensure that the clinical care of individuals in long term care is consistent with each person's preferences and values, particularly when he/she is unable to participate in the decision-making process .Protocol .Provide the individual or his/her representative with a copy of the HHSC Advance Care Planning educational material, frequently asked questions about advanced care planning, the individual rights under Texas law to make decisions concerning medical care and to formulate advance directives, and facilities policies respecting the implementation of advance directives. Event ID: Facility ID: 455278 If continuation sheet Page 3 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to have an accurate assessment for 2 (Resident #1 and #21) of 10 residents reviewed for assessments in that: Residents Affected - Few 1. Resident #1 was receiving hospice services however it was not coded on the resident's MDS. 2. Resident #21 was receiving hospice services however it was not coded on the resident's MDS. This failure could affect residents who receive assessments and result in inaccurate care and treatments. The findings included: 1. Review of Resident #1's face sheet dated 7/8/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included senile degeneration of brain (an elder's decline in mental health that leads to physical changes such as a change in posture, loss of vision or hearing, weakness in strength and stiff joints), dysphagia (difficulty swallowing food or liquids), essential hypertension (abnormally high blood pressure often due to obesity, family history or an unhealthy diet) and peripheral vascular disease (a slow, progressive circulation disorder usually caused by plaque buildup inside the artery wall). Review of Resident #1's July 2022 Consolidated Physician Orders revealed an order for hospice services, with a start date of 3/23/2022. Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE], in section O, under the heading of Hospice Care revealed the MDS did not indicate the resident was on hospice services. In an interview on 7/8/2022 at 1:27 p.m. with the MDS Nurse she stated Resident #1 had an order for and was receiving hospice services. After reviewing the resident's admission MDS she stated the MDS did not indicate Resident #1 was receiving hospice services. The MDS Nurse stated Resident #1 admission MDS was completed prior to her employment as the MDS Nurse. 2. Review of Resident #21's face sheet dated 5/22/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease (a progressive neurologic disorder that causes the brain to shrink/atrophy and brain cells to die), type 2 diabetes mellitus (a chronic condition that results in too much sugar in the bloodstream and can lead to circulatory, nervous and immune system disorders), essential hypertension and dementia with behavioral disturbance. Review of Resident #21's July 2022 Consolidated Physician Orders revealed, Admit to hospice dated 4/27/2022. Review of Resident #21's admission MDS dated [DATE], in section O, under the heading of Hospice Care revealed the MDS did not indicate the resident was on hospice services. In an interview on 7/8/2022 at 11:45 a.m. with the MDS Nurse she stated Resident #21 was on hospice services. After reviewing Resident #21's Annual MDS she stated the MDS did not indicate Resident #1 was receiving hospice services. The MDS Nurse reported it was on oversight on her part. The MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 4 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse reported if the MDS was not coded correctly it could affect the resident's plan of care and/or not be addressed in the resident's plan of care. In an interview on 7/8/2022 at 11:57 a.m. with the DON she stated both Residents #1 and #21 were on hospice services. The DON reported the MDS Nurse was in training and it was a clerical error when she omitted coding hospice services for Resident #21. The DON reported if the MDS were not coded correctly it could have implications on the residents' plan of care. In an interview on 7/8/2022 at 3:36 p.m. the DON reported they cited to the Resident Assessment Instrument (RAI) manual for hospice coding of the MDS. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's [NAME], Version 1.17.1, October 2019, Section O: Special Treatments, Procedures, and Programs revealed, The intent to the items in this section is to identify any special treatments, procedures and programs that the resident received during the specified time periods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 5 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #6) of 6 residents reviewed for base line care plans in that: Resident #6's preference to self-medicate her prescribed eye drops and to keep them at bedside were not reflected on her baseline person-centered plan of care. This failure could affect residents admitted to the facility and could result in not respecting their rights or preferences of care. The findings included: Review of Resident #6's electronic face sheet dated 7/8/22 revealed she was readmitted to the facility on [DATE] with diagnoses of rheumatoid arthritis (inflammation of one or more joints), age related osteoporosis (weakening of bone strength related to age), fibromyalgia (chronic muscle pain, tenderness and fatigue), major depressive disorder (major health disorder having episodes of psychological depression), unspecified open angel glaucoma(increased pressure in the eye) and chronic pain syndrome ( ongoing pain). Review of Resident #6's quarterly MDS with an ARD of 4/7/22 revealed she scored a 15/15 on her BIMS which indicated she was cognitively intact and required minimal assistance with her ADL's. Further review in Section F-Preferences for Customary Routine and Activities revealed it was very important for her to make her own choices. Review of Resident #6's physician orders Active as of 7/6/22 revealed Latanoprost Solution 0.005 % (used to treat high pressure inside the eye) Instill 1 drop in both eyes at bedtime related to UNSPECIFIED OPEN ANGLE GLAUCOMA, STAGE UNSPECIFIED (H40.10X0) unsupervised self-administration PrescriberWritten Active 06/21/2022 2000 .Timoptic Solution 0.5 %(Timolol Maleate) (used to treat high pressure inside the eye) Instill 1 drop in right eye two times a day related to UNSPECIFIED OPEN ANGLE GLAUCOMA,STAGE UNSPECIFIED(H40.10X0) unsupervised self-administration-Start Date-06/21/2022 1600. Review of Resident #6's MAR's dated June 2022 and July 2022 revealed when she was admitted on [DATE] and she had self-administered her Timoptic Solution eye drops twice a day and her Latanoprost Solution eye drops at bedtime. Review of Resident #6's baseline care plan dated 6/21/22 revealed it did not contain any information on the resident self administering her eye drops. Review of the facility competence to self-administer medication form completed by the NC for Resident #6 was dated 7/6/22. Observation and interview on 7/5/22 at 9:10 a.m. of Resident #6 revealed she was lying on her bed clean and well groomed, and there were two bottles of medicated eye drops sitting on her nightstand beside her bed. When asked if she gave herself the eye drops she stated yes, that was very important (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 6 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0655 to her. Level of Harm - Minimal harm or potential for actual harm Interview on 7/7/22 at 1:28 p.m. with the NC revealed that Resident #6's self-medicating of eye drops needed to be on the baseline care plan because staff needed to know what her preferences were and it was in her admission physician orders. She stated she recently found out about Resident #6's self-medicating eye drops order and needed to do a self-medicating assessment on Resident #6 to ensure she used the eye drops as ordered and followed professional standards of administration. Residents Affected - Few Interview on 7/7/22 at 2:30 p.m. with LVN C (the admitting nurse of Resident #6) revealed that when Resident #6 was admitted she self-medicated and that information needed to be in her baseline care plan so that others knew what her care needs and preferences were. She stated she missed putting that information on self-medicating of eye drops into Resident #6's person-centered baseline plan of care, and she did not know why it was missed. Review of the facility policy and procedure titled Care Plan/Comprehensive Interdisciplinary dated 2005 revealed A temporary care plan will be completed by the admitting nurse for every new patient to the facility. Review of the facility form titled Temporary Care Plan (undated) revealed it did not include under SELF-HELP an area for self-medicating. Review of the facility policy and procedure titled Self-Administration of Medications (undated) revealed Upon admission the resident or their legal representative documents the acceptance/refusal of self-administration of medication on the appropriate sheet .If the resident wishes to self-administer medications, they will be assessed by the facilities interdisciplinary Care Plan Committee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 7 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a medical, nursing, and mental and psychological needs, that are identified in the comprehensive assessment for 6 (#9, #11, #18, #19, #21 and #27) of 20 residents reviewed for comprehensive person-centered care plans in that: 1. Resident #9's PASRR comprehensive person-centered care plan did not address detailed information about the specialized services being provided. 2. Resident #11's comprehensive person-centered care plan did not reflect her indwelling urinary catheter leg strap. 3. Resident #18's comprehensive person-centered care plan did not reflect she was always incontinent of bladder and bowel. 4. Resident #19's comprehensive person-centered care plan did not reflect her indwelling urinary catheter leg strap. 5. Resident #21's comprehensive person-centered care plan did not reflect the resident was receiving hospice services. 6. Resident #27's PASRR comprehensive person-centered care plan did not reflect any specialized services being provided. These failures could affect residents who require specific care and could result in missed or inadequate care. The findings included: 1. Review of Resident #9's face sheet dated 5/4/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included scoliosis (a sideways curvature of the spine that most often is diagnosed in adolescents), trisomy 18 (a genetic condition when a person has an extra copy of chromosome 18 that causes physical growth delays during fetal development) and cerebral palsy (abnormal brain development or damage that affect a persons ability to maintain balance and posture). Review of Resident #9's Annual MDS dated [DATE] revealed the resident did not speak, had severely impaired cognitive status and required extensive to total care with activities of daily living. Review of Resident #9's comprehensive person-centered care plan dated 7/07/2022 revealed the resident was positive for PASRR services (Preadmission Screening and Resident Review-eligible for specialized services due to mental illness or intellectual and developmental disability regardless of funding source or age). Further review of the care plan revealed PT/OT to work with resident 3 X a week and provided no information on the local authority, that the local authority would be contacted for changes or that they would meet quarterly for an interdisciplinary team meeting (IDT) with the local (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 8 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0656 authority. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #11's electronic face sheet dated 7/8/22 revealed she was admitted to the facility on [DATE] with diagnoses of diabetes (inability to regulate glucose in the blood), retention of urine (holds urine), dementia (cognitive loss) and rhabdomyolysis (a breakdown of skeletal muscle due to direct or indirect muscle damage which could lead to kidney damage). Residents Affected - Some Review of her Quarterly MDS with an ARD of 3/29/22 revealed she was coded a 9 under bladder which indicated she had an indwelling urinary catheter. She was coded a 3 on bowel which indicated she was always incontinent of bowel. She scored an 8/15 on her BIMS which indicated she was moderately cognitively impaired and required extensive assistance with her care. Review of Resident #11's comprehensive person-centered care plan dated 7/7/22 did not reflect she needed to have a leg-strap with her indwelling urinary catheter. Review of Resident #11's Order Summary Active As Of 7/8/22 revealed Check for placement and function of leg strap every shift every shift related to RETENTION OF URINE, UNSPECIFIED (R33.9) Prescriber Written Active 06/11/2022. Review of Resident #11's MAR for June 2022 and July 2022 revealed nurses initialed off on check for placement and function of leg strap every shift. Observation on 7/5/22 at 09:10 revealed Resident #11 lying in bed, she had an indwelling urinary catheter with a drainage bag. She did not want to talk. Interviews of MDS nurse and NC combined see below. 3. Review of Resident #18's electronic face sheet dated 7/8/22 revealed she was admitted to the facility on [DATE] with diagnoses of senile degeneration (cognitive and memory loss), chronic pain), (ongoing discomfort, anemia (low iron in blood) and weight loss. Review of Resident #18's quarterly MDS assessment with an ARD of 5/7/22 revealed she was not a candidate for a BIMS which indicated she was severely cognitively impaired. She required extensive assistance with ADL's and was coded 3 on bladder and bowel which indicated always incontinent. Review of Resident #18's comprehensive person centered care plan dated 5/12/22 did not reflect she was always incontinent of bowel and bladder. Observation on 7/7/22 at 4:20 p.m. of Resident #18 revealed she received incontinent care from CNA D. Resident #11 was incontinent of bladder and bowel. Interviews of MDS nurse and NC combined see below. 4. Review of Resident #19's electronic face sheet dated 7/8/22 revealed she was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease (hardening and occlusion of the arteries), anxiety (nervousness), diabetes mellitus (inability to regulate blood sugar in the blood), chronic pain (ongoing pain), bladder disorder and urine retention (bladder holding urine). Review of Resident #19's admission MDS assessment with an ARD of 5/8/22 revealed she scored an 8/15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 9 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0656 Level of Harm - Minimal harm or potential for actual harm on her BIMS which indicated she was moderately cognitively impaired. She required extensive assistance with ADL's. She was coded to have a urinary catheter. Review of Resident #19's comprehensive person-centered care plan dated 5/16/22 revealed her care plan did not reflect her indwelling urinary catheter leg strap. Residents Affected - Some Review of Resident #19's Active Orders As Of 7/8/22 revealed Check for placement and function of leg strap every shift every shift Prescriber Written Active 04/26/2022. Review of Resident #19's MAR for April 2022, May 2022, June 2022 and July 2022 revealed nurses initialed off on check for placement and function of leg strap every shift. Interviews of MDS nurse and NC combines see below. 5. Review of Resident #21's face sheet dated 5/22/2022 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease (a progressive neurologic disorder that causes the brain to shrink/atrophy and brain cells to die), type 2 diabetes mellitus (a chronic condition that results in too much sugar in the bloodstream and can lead to circulatory, nervous and immune system disorders), essential hypertension and dementia with behavioral disturbance. Review of Resident #21's July 2022 Consolidated Physician Orders revealed, Admit to hospice dated 4/27/2022. Review of Resident #21's admission MDS dated [DATE], in section O, under the heading of Hospice Care revealed the MDS did not indicate the resident was on hospice services. Review of Resident #21's comprehensive person-centered care plans dated 7/8/2022 revealed the resident did not have a care plan for hospice services. 6. Review of Resident #27's face sheet dated 12/8/2021 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included essential hypertension (abnormally high blood pressure often due to obesity, family history or an unhealthy diet), mild cognitive impairment and chronic pain. Review of Resident #27's Annual MDS dated [DATE] revealed the resident was eligible for PASRR services due to other related conditions and had a Brief Interview for Mental Status (BIMS) score of 15, cognitively intact. Review of Resident #27's comprehensive person-centered care plans with a start date of 6/13/2022 revealed the resident was PASRR positive and with only one intervention to Maintain communication with PASRR services quarterly, with no information on the local authority or the specialized services being provided by the facility. Review of Resident #27's PASRR IDT meeting notes dated 6/10/2021 revealed the facility was providing rehabilitation services to include physical and occupational therapy. Review of Resident #27's July 2022 Consolidated Physician Orders revealed the resident was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 10 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0656 receiving physical, occupational and speech therapy. Level of Harm - Minimal harm or potential for actual harm In an interview on 7/7/2022 at 12:02 p.m. with Resident #27 the resident stated she was receiving rehabilitation services 3 times a week. Interview on 7/8/22 at 2:48 pm. with the MDS nurse revealed that she had only been at the facility for a few months and that she was also over other programs She stated she was also working at the sister facility in town. She stated that she tried to keep up with the care plans but that the MDS accuracy was her focus. She stated she had the NC as a resource and she helped her when she could. She stated that it was important for Residents #9's, #11's, #18, #19, #21's and #27's care plans to be person-centered and to reflect their needs, services, care requirements, physician orders and preferences. She said the care plans are important because it communicated to other staff what care requirements are needed for each resident. Residents Affected - Some Interview on 7/8/22 at 3:00 p.m. with the NC revealed that the MDS's were her priority, to check them and make sure they were accurate, so the care plans were not a priority. She stated she and the MDS nurse needed to work on them. She stated that it was important for Residents #9's, #11's, #18, #19, #21's and #27's care plans to be person-centered and to reflect their needs, services, care requirements, physician orders and preferences. She said the care plans are important because it communicated to other staff what care requirements are needed for each resident. She stated that she was ultimately accountable for the residents care. Review of the facility policy and procedure titled Care Plan/Comprehensive Interdisciplinary dated 2005 revealed A comprehensive care plan will be developed for each resident within (7) days of completion of resident admission assessment and then quarterly thereafter. The care plan must include measurable objectives and timetables to meet a resident's medical, nursing and psychosocial needs as identified in the comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 11 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to review and revise the person-centered comprehensive care plan after each assessment for 2 (residents #12 and #30) of 12 residents reviewed for care plan revisions in that: 1. Resident #12's comprehensive person-centered care plan was not revised to address his high risk for skin breakdown, new skin breakdown areas, and preventive measures and treatments ordered. 2. Resident #30's comprehensive person-centered care plan was not revised to address his recent fall and preventive measures placed. These failures could affect residents with MDS assessments and could result in additional care needs being missed. The findings included: 1. Review of Resident #12's electronic face sheet dated 7/8/22 revealed he was admitted to the facility on [DATE] with diagnoses of diabetes mellitus (inability to regulate blood sugar), dementia (cognitive impairment), hemiplegia and hemiparesis (paralysis to one side and half of body), cerebral infarction (stroke in the brain), and pressure ulcer (skin breakdown resulting from pressure) of unspecified site, unspecified stage. Review of Resident #12's quarterly MDS assessment with an ARD of 4/15/22 revealed he scored a 13/15 on his BIMS which indicated he was cognitively intact. He required extensive assistance with his ADL's. He was coded to be at risk of developing pressure ulcers, had a pressure reducing device in bed, and application of dressings to feet. Review of Resident #12's comprehensive person-centered care plan dated 4/29/22 revealed under Focus .I have a ulcer to the left heel .interventions .dietary to D/C liquid protein and start juven tid on meal trays .will be provided cottage cheese with breakfast. No other skin issues, interventions or treatments were noted. Review of Resident #12's Active Orders as Of: 7/8/22 revealed CHANGE DRESSING TO BILATERAL HEELS EVERY TUESDAY AND FRIDAY BEGINNING 07-01-2022 AND AS NEEDED WITH DRESSING FAILURE OR COMPROMISE. REMOVE DRESSINGS AND CLEANSE RIGHT HEEL WOUND WITH WOUND CLEANSER. APPLY PURACOL PLUS AG (Collagen Gel) TO WOUND AND COVER WITH MEPILEX HEEL DRESSING. APPLY MEPILEX BORDER HEEL DRESSING TO LEFT HEEL FOR PROTECTION every 8 hours as needed for wound care prn Prescriber Written Active 06/29/2022 .PREVALON BOOTS ON WHEN IN BED every shift for DECREASE PRESSURE IN BED Prescriber Written Active 05/17/2022. Review of Resident #12's MAR dated July 2022 revealed nurses signed that he received the treatment ordered above to his bilateral heels every Tuesday and Friday. Review of facility incident reports revealed Resident #12 had an incident on 2/24/22, where he bumped his toe, had a blood blister/bruise to the top of his third toe on his left foot. and on 4/18/22, Resident #12 had a toenail come off on right fifth toenail and on 5/2/22, Resident #12 had a toenail come off left third toe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 12 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #12's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] revealed he scored a 12 which indicated he was at high risk for skin breakdown. Review of Resident #12's progress note dated 5/11/22 revealed: Has superficial open area left heel 1.8 cm length by 2 cm width by 0.2 cm depth. Pink tissue in wound bed noted right outer heel with superficial open area 0.8 cm width by 1 cm width by 0.1 cm depth. Pink tissue in wound bed, cleansed both open areas with wound cleanser and protective dressing applied. DH2 shoe on left foot. Bilateral tubigrip to lower legs from toes to bend of knee. Encouraged resident not to use heels to propel self in wheelchair. Float heels in bed. Observation on 7/5/22 at 09:20 a.m. of Resident #12 revealed he was sitting in his room in a wheelchair, he had mutipodus boots on both his feet. A set of prevalon boots could be seen near his bed. His toes were exposed and had scabbed areas on them. Interview on 7/5/22 at 09:30 a.m. with Resident #12 revealed he had problems with his feet and he had areas on his heels that needed treatments. He stated his treatments were usually done at the wound care clinic, but that now they were being done also at the facility. 2. Review of Resident #30's electronic face sheet dated 7/8/22 revealed he was admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (cognitive impairment and dysfunction), vascular dementia (cognitive impairment), macular degeneration (loss of vision), depressive disorders (decreased mood), Parkinson's disease (a disease affecting movement) and insomnia (difficulty sleeping). Review of Resident #30's quarterly MDS assessment with an ARD of 6/10/22 revealed he was not a candidate for a BIMS which indicated he was severely cognitively impaired. He required extensive assistance with his ADL's. He was always incontinent of bladder and frequently incontinent of bowel. He was coded to have had a fall since admission or the prior assessment. Review of Resident #30's comprehensive person-centered care plan dated 6/9/22 did not reflect he was at moderate risk for falls, had a fall and had interventions in place such as a mat on the floor by the bed. Review of Resident #30's fall risk assessment dated [DATE] revealed he scored a 14 which indicated he was at moderate risk for falls. Review of the facility incident report for Resident #30 dated 4/30/22 revealed he had an unwitnessed fall which resulted in a bruise to the top of his scalp. Review of Resident #30's orders Active as Of July 8, 2022 revealed written above in the heading space FLOOR MAT AT BEDSIDE WHEN IN BED. Has physician's orders for 1/2 bedrail at top of bed, fall mat at bedside when in bed DX: Frequent falls, dated 8/31/21. Observation on 7/6/22 at 9:30 a.m. of Resident #30 revealed he was lying in bed with a floor mat by the side of the bed. He was not interviewable. Interview on 7/8/22 at 2:48 pm. with the MDS nurse revealed that she had only been at the facility for a few months and that she was also over other programs She stated she was also working at the sister facility in town. She stated that she tried to keep up with the care plans but that the MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 13 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0657 Level of Harm - Minimal harm or potential for actual harm accuracy was her focus. She stated she had the NC as a resource, and she helped her when she could. She stated that it was important for Resident #12's and #30's care plans to be revised after each assessment and updated with changes so that it is person-centered and that it reflected their needs, services, care requirements, physician orders and preferences. She said the care plans were important because it communicated to other staff what care requirements are needed for each resident. Residents Affected - Few Interview on 7/8/22 at 3:00 p.m. with the NC revealed that the MDS's were her priority, to check them and make sure they were accurate, so the care plans were not a priority. She stated she and the MDS nurse needed to work on them. She stated that it was important for Residents #12's and #30's care plans to be revised after an MDS assessment or with changes in care so that it was person-centered and reflected their needs, services, care requirements, physician orders and preferences. She said the care plans were important because it communicated to other staff what care requirements were needed for each resident. She stated that she was ultimately accountable for the resident's care. Review of the facility policy and procedure titled Care Plan/Comprehensive Interdisciplinary dated 2005 revealed A comprehensive care plan will be developed for each resident within (7) days of completion of resident admission assessment and then quarterly thereafter. The care plan must include measurable objectives and timetables to meet a resident's medical, nursing and psychosocial needs as identified in the comprehensive assessment .The care plan will periodically be reviewed and revised by the interdisciplinary team after each resident assessment, assessment review, or significant change in condition. the care plan will be otherwise updated as warranted by changes in medication, treatment or other changes in condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 14 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week from March 19th through, April 2022, May 2022, June 2022, and July 2022. The facility failed to maintain RN coverage 8 hours a day for over 3 months. This failure could affect all residents of the facility and could result in missed resident nursing assessments, interventions, care, and treatment. The findings included: Record review of the time sheets of RN A and the DON's (who was an RN) from 3/18/2022 to 7/8/2022 revealed there was no RN coverage for 8 hours a day from 3/19/22 to 7/6/22. In an interview on 7/06/22 at 2:58 p.m., the Administrator stated the facility did not have an RN in the facility for 8 hours a day from 3/18/22 to 7/6/22. The Administrator said the facility tried hiring RN's, but with the gas prices so high no one wanted to travel, and that the hospital offered the RN's more money, so they had no one who wanted to apply. She stated she knew they needed an RN, and they would continue to try to hire one. The ADM stated If we need an RN to come in and assess something we reach out to our other facility. In an interview on 7/7/22 at 9:07 a.m. with the DON Consultant, revealed that the facility advertised, and they even have used the website. She stated that the facility had been without RN coverage for 8 hours a day since March 2022. She stated The cost of living here is very high, rent is about $3000. Nobody can afford to live here. The hospital hires contract staff, and we can't afford them. The implication of not having RN coverage could be a lack of quality care for high skilled care residents. At present I do not take residents who require high skilled nursing care. I am on call 24 hours a day, and I live 2 blocks away. Further interview on 7/8/22 at 2:00 p.m. the Administrator revealed the facility did not have a policy on RN coverage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 15 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Residents Affected - Few 1. There was a hard-boiled egg in a plastic container that was passed the use by date. 2. There was a 5-pound container of cottage cheese that was passed its use by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 7/7/2022 at 10:39 a.m. in the facility kitchen revealed a facility refrigerator located near the main entrance into the kitchen. Observation inside the refrigerator revealed a plastic container holding one hard boiled egg. Located on the lid of the container revealed hand-written dates, 5/16/22 and 6/24/22. Interview on 7/7/2022 at 10:39 a.m. with the Food Service Supervisor (FSS) revealed she did not know why there were 2 different dates on the container lid. The FSS revealed they ordered hard boiled eggs that come in a large plastic bag that was dated. The FSS reported that must have been the last egg from their most recent order of hard-boiled eggs but was uncertain why there were 2 different dates. The FSS stated the egg should have been thrown out because of the conflicting dates. 2. Observation and interview on 7/7/2022 at10:41 a.m. in the kitchen refrigerator revealed an unopened 5-pound container of cottage cheese with a use by date of 6/24/22. The FSS reported the cottage cheese should have been thrown out because it was passed the used by date. In an interview on 7/8/2022 at 9:30 a.m. with the FSS revealed she found out from her staff why the container with the egg had 2 dates. She reported the first date for 5/16/2022 was the date that was on the bag the eggs came in and the second date for 6/24/2022 was the date the egg was placed in the plastic container. The FSS stated she checked the kitchen refrigerators 2 times a week on Mondays and Fridays for any expired food items. The FSS reported any food that was served beyond its use by date or beyond the time limit they could store open food items, which she thought was 7 days, placed the residents at risk for food born illnesses. Review of information provided by the FSS titled, Refrigerated Foods, not dated, revealed, 2. Hard cheese keeps well at room temperature, but soft cheeses (cottage cheese) spoil quickly. Eggs will keep several days, depending on freshness. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 16 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (#18, #19 and #30) of 4 residents reviewed for incontinent or catheter care and for the improper handling of dirty linen in 1 out of 1 shower room observed for infection control, in that: Residents Affected - Few 1. CNA D put dirty wipes and dirty gloves onto Resident #18's clean bedspread during incontinent care for the resident. 2. CNA A took off her dirty gloves during incontinent and catheter care for Resident #19 and put them onto the top of Resident #19's clean bedspread. 3. CNA A did not change her dirty gloves after she cleaned Resident #30's bottom after he had a bowel movement and did not sanitize her hands after she completed Resident #30's incontinent care. 4. CNA B brought dirty linen out of a shower room unbagged and carried the soiled linen with her bare hands. These failures could affect residents who receive incontinent or catheter care and showers and could result in the spread of bacteria and infections. The findings included: 1. Review of Resident #18's electronic face sheet dated 7/8/22 revealed she was admitted to the facility on [DATE] with diagnoses of senile degeneration (cognitive and memory loss), chronic pain), (ongoing discomfort, anemia (low iron in blood) and weight loss. Review of Resident #18's quarterly MDS assessment with an ARD of 5/7/22 revealed she was not a candidate for a BIMS which indicated she was severely cognitively impaired. She required extensive assistance with ADL's and was coded 3 on bladder and bowel which indicated always incontinent. Review of Resident #18's comprehensive person-centered care plan dated 5/12/22 did not reflect she was always incontinent of bowel and bladder. Observation and interview on 7/7/22 at 4:20 p.m. of Resident #18 revealed she received incontinent care from CNA D. Resident #18 was incontinent of bladder and bowel. CNA D cleaned the resident and placed the dirty wipes in the plastic bag on the resident's bed. The last three wipes and her dirty gloves were tossed toward the bag, missed and landed on the top of Resident #18's clean bed spread. Interview at the same time with CNA D revealed she should have taken more time and placed the dirty wipes and gloves into the bag to prevent cross contamination. Interview on 7/8/22 at 2:00 p.m. with the NC revealed that CNA D should have been more careful and placed the dirty items in the bag and not on Resident #18's clean bed. She stated that CNAs had training on infection control and incontinent care. She stated that not following proper procedures could lead to an increase in infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 17 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 Review of CNA D's Nurse Aide Skills Performance Checklist dated 9/20/21 revealed she was signed off on provide male perineal care and provide female perineal care. Review of CNA D's Certificate of Completion dated 5/24/22 revealed she completed the Infection and Infection Control module provided by Texas Health and Human Services. Residents Affected - Few Review of the facility policy and procedure titled Perineal Care/Incontinent Care dated 2005 revealed Female Perineal Care .If resident is soiled with feces .discard each wipe after use .change gloves. 2. Review of Resident #19's electronic face sheet dated 7/8/22 revealed she was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease (hardening and occlusion of the arteries), anxiety (nervousness), diabetes mellitus (inability to regulate blood sugar in the blood), chronic pain (ongoing pain), bladder disorder and urine retention (bladder holding urine). Review of Resident #19's admission MDS assessment with an ARD of 5/8/22 revealed she scored an 8/15 on her BIMS which indicated she was moderately cognitively impaired. She required extensive assistance with ADL's. She was coded to have a urinary catheter. Review of Resident #19's comprehensive person-centered care plan dated 5/16/22 revealed she had an indwelling urinary catheter. Review of Resident #19's Active Orders As of 7/8/22 revealed Foley catheter to be changed only under .Hospice direction. Foley catheter to be left in place: DX: Urine retention/bladder prolapse .start date: 5/5/22. Observation on 7/7/22 at 4:15 p.m. of CNA A as she performed catheter and incontinent care for Resident #19 revealed CNA A took off her dirty gloves after doing incontinent care and put them on Resident #19's clean bedspread. Interview on 7/7/22 at 4:20 p.m. with CNA A she stated she knew better and had been trained on how to do peri care and that the dirty gloves she took off needed to go in the plastic bag which was sitting atop of Resident #19's bed. Interview on 7/8/22 at 2:00 p.m. with the NC revealed that CNA A should have been more careful and placed the dirty items in the bag and not on Resident #19's clean bed. She stated that CNAs had training on infection control and incontinent care. She stated that not following proper procedures could lead to an increase in infections. She stated that CNA A was an agency CNA and she did not have any paperwork to support her training, but she did get in-serviced while at the facility on infection control. Review of the facility policy and procedure titled Catheter Care, Indwelling Catheter, dated 2005 revealed .remove gloves and discard in appropriate container. 3. Review of Resident #30's electronic face sheet dated 7/8/22 revealed he was admitted to the facility on [DATE] with diagnoses of senile degeneration of brain (cognitive impairment and dysfunction), vascular dementia (cognitive impairment), macular degeneration (loss of vision), depressive disorders (decreased mood), Parkinson's disease (a disease affecting movement) and insomnia (difficulty sleeping). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 18 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 Review of Resident #30's quarterly MDS assessment with an ARD of 6/10/22 revealed he was not a candidate for a BIMS which indicated he was severely cognitively impaired. He required extensive assistance with his ADL's. He was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #30's comprehensive person-centered care plan dated 6/9/22 revealed Focus .resident has mixed bladder incontinence r/t disease process of dementia .clean peri-area with each incontinent episode. Observation on 7/7/22 at 10:00 a.m. of CNA A who performed incontinent care for Resident #30 in the shower room where he was being lifted with a standing lift revealed she did not change gloves after she cleaned Resident #30's bottom after he had a bowel movement and did not sanitize her hands after she completed his incontinent care and removed her gloves. She then continued to get his chair and continue with his transfer. Interview on 7/7/21 at 10:20 a.m. with CNA A, she stated she knew better, and she did not know why she didn't change gloves after cleaning Resident #30 and she stated she should have sanitized her hands after taking off her gloves when she was finished. Interview on 7/8/22 at 2:00 p.m. with the NC revealed that CNA A should have changed her gloves after cleaning Resident #30 and sanitized her hands when she had finished the care. She stated that CNAs had training on infection control and incontinent care. She stated that not following proper procedures could lead to an increase in infections. She stated that CNA A was an agency CNA and she did not have any paperwork to support her training, but she did get in-serviced while at the facility on infection control. Review of the facility policy and procedure titled Perineal Care/Incontinent Care dated 2005 revealed Male Perineal Care .If resident is soiled with feces .discard each wipe after use .change gloves. 4. Observation on 7/5/22 at 9:30 a.m. of CNA B revealed she came out of a shower room and carried unbagged dirty linen with her bare hands. Interview on 7/5/22 at 09:35 a.m. with CNA B she stated that she had gloves in her pockets and did not know why she brought the dirty linen out without putting it in a bag and wearing gloves. She stated she could spread bacteria that way, and that she was trained on how to properly handle dirty linen. Interview on 7/8/22 at 2:00 p.m. with the NC revealed that CNA B needed to have the soiled linen bagged and she needed to have worn gloves when she removed the soiled linen from the shower room. She stated that CNAs had training on infection control and incontinent care. She stated that not following proper procedures could lead to an increase in infections. She stated that CNA A was an agency CNA and she did not have any paperwork to support her training, but she did get in-serviced while at the facility on infection control. Review of CNA B's Nurse Aide Skills Performance Checklist dated 5/18/22 revealed she was checked off on hand washing and handling soiled linens. Review of the facility policy and procedure titled Hand Washing/Hygiene dated 2005 revealed Purpose .to prevent the spread of infection .Indications for Performing Hand Hygiene (Including Alcohol Gels) revealed .after contact with soiled objects .after removing gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 19 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 Review of facility staff in-service training titled PPE, dated 5/23/22, Universal Precautions dated 2/22/22, Infection Control dated 1/7/22 and Infection Control: Breaking the Chain. dated 1/21/22 revealed CNA's A and B were in attendance. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 20 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 2 of 16 resident rooms (room [ROOM NUMBER] and #48) reviewed for physical environment, in that: 1. There were 4 nails sticking out of the wall directly above the bed in room [ROOM NUMBER] bed A. 2. There was a large area of sheetrock that was ripped down to the gypsum plaster in room [ROOM NUMBER] next to bed A. These failures could affect all residents as well as staff and the public by causing them to live, work, and visit a facility with an environment that is not safe, functional, sanitary, and/or comfortable. The findings included: 1. Observation on 7/6/2022 at 9:46 a.m. revealed in room [ROOM NUMBER] the side of bed A was pushed against the wall. Further observation revealed directly above the bed there were 4 nails sticking out of the wall. Located above the 4 nails were family pictures placed above on the wall. In an interview on 7/6/2022 at 4:37 p.m. with the Maintenance Supervisor, after observing the nails sticking out of the wall, reported the resident likely removed the pictures from the wall that was hanging from the nails and placed the pictures elsewhere. The Maintenance Supervisor reported no one had notified him the nails were sticking out of the wall. The Maintenance Supervisor reported the potential outcome with the nails sticking out of the wall was the resident could get a skin tear or injury if the resident was trying to reach for the pictures above the nails. In an interview on 7/6/2022 at 4:48 p.m. with the Administrator reported the family placed the pictures directly above the bed for the resident in room [ROOM NUMBER]A and the resident would remove the pictures from the wall while she was lying in bed. 2. Observation on 7/5/2022 at 4:56 p.m. in room [ROOM NUMBER] revealed the side of bed A was pushed against the wall. Closer observation of the wall revealed a large area measuring about 7 inches wide and 12 inches long where the top paper covering on the sheet rock was ripped off and exposed the gypsum plaster underneath. In an interview on 7/62022 at 4:38 p.m. with the Maintenance Supervisor, after he observed the wall, revealed it was likely caused by the resident's electric bed rubbing the wall when being raised and lowered, causing the paper covering of the sheet rock to tear. The Maintenance Supervisor revealed he was not aware of the damage on the wall. The Maintenance Supervisor reported all the staff were aware where the Maintenance Log, which staff document repairs that need to be done, was kept at the nurses' station. Review of the Maintenance Supervisor Log reveal there was no information regarding the nails sticking out of the wall in room [ROOM NUMBER]A and the damage on the wall in room [ROOM NUMBER]A. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 21 of 22 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 455278 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Healthcare and Rehab Center Inc 1208 N Llano Fredericksburg, TX 78624 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 0921 In an interview on 7/8/2022 at 3:36 p.m. the DON reported they did not have a policy regarding required repairs needed in residents' rooms. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455278 If continuation sheet Page 22 of 22