Health inspection·October 22, 2025

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Practitioner and sent Resident #1 to the hospital for x-rays of the face.Record review of Resident #1's progress note dated 10/08/2025 at 12:28 PM written by LVN C indicated she received report from the hospital RN that Resident #1 did have a non-displaced fracture to his nose (also known as a hairline fracture, occurs when the bone cracks but remains aligned without shifting).Record review of an incident report dated 9/19/2025 written by LVN J indicated: CNA reported to this nurse that she was taking [Resident #1] past [Resident #3] when [Resident #3] hit [Resident #1] in the back.Record review of an incident report dated 10/08/2025 at 8:30 AM written by LVN C indicated: This [Resident #1] was sitting at the dining room table across from [Resident #2]. This [Resident #1] was moving the table when [Resident #2] asked him to stop moving the table. This [Resident #1] continued to move the table. [Resident #2] stood up and started hitting [Resident #1] with closed fists.Resident #2:Record review of a facility face sheet dated 10/20/25 for Resident #2 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior) and dementia. Face sheet also indicated a discharge date of 10/8/25 to a psychiatric hospital.Record review of a Quarterly MDS assessment dated [DATE] for Resident #2 indicated a BIMS score of 3, indicating a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He was independent with most ADLs. Record review of a comprehensive care plan dated 10/3/25 for Resident #2 indicated he was pushed by another resident on 10/3/25. Record review of an incident report dated 10/3/25 for Resident #2 indicated he was pushed by another resident and landed on the floor on his left side. Resident #2 complained of 10/10 pain to his lower back and sustained a skin tear to the left side of his neck measuring 1.2cm X 0.5cm. He was sent to the emergency room for CT scan. Record review of emergency room records dated 10/3/25 for Resident #2 indicated he received a CT of the head without contrast (a non-invasive imaging procedure used to visualize the brain's structures, including the skull and brain tissue, without the use of contrast agents) and a CT of the cervical spine without contrast. Both were negative for fractures. There was no documentation of Resident #2 receiving a CT for lumbar region.Record review of a nursing progress note dated 10/4/25 at 4:27 pm for Resident #2 read: .Resident up and about to D/R moving very slow and not straighten lower extremities when walking and assisted by staff to walk, PRN Tylenol given and is effective. Neuro's WNL will monitor. and was signed by LVN M.Record review of a nursing progress note dated 10/5/25 at 3:03 pm for Resident #2 indicated he was still experiencing pain and MD was notified. A new order was received for arthritis cream to back and to send to hospital for evaluation. Resident #2 refused to go to hospital. Progress note was signed by LVN M.Record review of a nursing progress note dated 10/6/25 at 8:36 am for Resident #2 indicated he complained of severe pain to lower back and was unable to sit up. Progress note was signed by LVN M.Record review of a nursing progress note dated 10/6/25 at 9:43 am for Resident #2 read: .Resident states he would go to Hosp. (hospital) he is hurting very bad sitting in w/c (wheelchair), [RP name] notified that residents agreed to go in to E.R. @ [hospital name] D/T increased back pain, agreed and states she's on her way she will meet him at E.R. and was signed by LVN M.Record review of a nursing progress note dated 10/6/25 at 3:00 pm for Resident #2 indicated he returned to the facility after ER visit with diagnosis of Vertebral Compression acute Fracture of L2.Record review of emergency room records dated 10/6/25 for Resident #2 indicated he received a CT scan of the lumbar spine without contrast which showed an acute compression fracture of L2. Resident #3:Record review of Resident #3's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and bipolar (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some disorder with psychotic features (hallucinations and delusions, during episodes of mania or depression).Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, which indicated Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan dated 4/03/2025 revealed Resident #3 had a mood problem related to the disease process of bipolar disorder with interventions that included: 1. Administer medications per MD order for mood management. 2. Encourage resident to express feelings and verbalize concerns during episodes of mood changes and or increased irritability. Allow adequate time to talk and actively listen in a non-judgmental manner. 3. Observe for and report to nurse any acute episode or complaints of feeling sad, loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns decreased ability to concentrate; change in ability to make purposeful move.4. Psychiatric/psychological consults as ordered by MD. Record review of incident report dated 9/19/2025 at 8:00 PM completed by LVN J indicated: CNA reported to this nurse that she was walking past [Resident #3] with [Resident #1] when [Resident #3] hit [Resident #1] in the back.Record review of Resident #1's progress note dated 9/19/2025 at 10:30 PM written by LVN J indicated: CNA reported to this nurse that this [Resident #3] had hit [Resident #1] in the back. [Resident #3] was assessed and had no sign of injury. The 2 residents were separated for the night into different rooms, both laying in their own beds, eyes closed, even respirations, no signs or symptoms of discomfort. Notified MD and Administrator of incident and separating the 2 residents for the night. Resident #4:Record review of a facility face sheet dated 10/20/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression) and Epilepsy (seizures).Record review of an MDS tab in an electronic medical record for Resident #4 indicated there had been no MDS assessment completed.Record review of a care plan tab in an electronic medical record for Resident #4 indicated there had been no comprehensive care plan completed.Record review of an assessments tab in an electronic medical record for Resident #4 indicated there had been no baseline care plan completed. Record review of an incident report dated 9/24/25 for Resident #4 indicated that Resident #4 grabbed the hand of another resident (Resident #5), pulled on her leaving red marks and a scratch mark. Resident #5:Record review of a facility face sheet dated 10/20/25 for Resident #5 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including type 2 diabetes (uncontrolled blood sugar) and dementia. Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated a BIMS score of 13, indicating intact cognition. She exhibited no behavioral symptoms directed toward others. She required set-up or clean-up assistance with most ADLs. Record review of a comprehensive care plan dated 6/4/25 for Resident #5 indicated she had cognitive impairment related to dementia. Record review of an incident report dated 9/24/25 for Resident #5 read: .Resident came to nurse and showed me her right hand having red streaks and a small scratch on the back of her hand. Resident stated, that crazy man grabbed my hand and scratched me pulling on it and he said f.u. bitch.Resident #6:Record review of a facility face sheet dated 10/20/25 for Resident #6 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder and Schizoaffective disorder, Bipolar Type (a mental health condition characterized by symptoms of both schizophrenia and mood disorders, including episodes of mania and depression).Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 3, indicating a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He required substantial/maximal assistance with most ADLs. Record review of a comprehensive care plan dated 10/3/25 indicated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some initiated aggressive behavior to another resident (pushing) on 10/3/25. Record review of an incident report dated 10/3/25 for Resident #6 indicated he pushed another resident causing the other resident to fall.Record review of a nursing progress note dated 10/3/25 at 7:30 am for Resident #6 indicated he was observed pushing another patient while in the dining room. Progress note was signed by LVN C.During an interview on 10/20/2025 at 9:40 AM the Administrator said she had 24 hours to report abuse to the state agency. She asked after further questioning am I supposed to report abuse within 2 hours? She said she did not have an excuse why she did not report the resident-to-resident altercations within the 2-hour required reporting time frame. She said she did not report the incident with Resident #1 and Resident #2 to the state because neither resident was hurt and she just didn't report it. She said she did not know Resident #1 had a non-displaced fracture to the nose. She said she did not know that she was supposed to complete a 5-day investigation and submit it to the state agency.During an interview on 10/20/25 at 10:20 am Resident # 6 did not recall any incidents where he pushed another resident.During a interview on 10/20/2025 at 10:38 AM, CNA K said on 10/08/2025 she was working on the secure unit. She said Resident #1 was in the dining room at breakfast and was moving the table. She said Resident #3 told Resident #1 to stop moving the table. She said Resident #1 continued to move the table and Resident #3 got up and went over to Resident #1 and started punching him in the face with a closed fist. She said her, the nurse and the other CNA separated Resident #1 and Resident #3, and both residents were sent out to the hospital. She said both residents returned from the hospital and both residents were sent out to the behavioral hospital the same day. She said if a resident-to-resident altercation occurred she would separate the residents and make sure they were safe, then she would notify the nurse and the Administrator of the incident.During an interview on 10/20/25 at 10:43 am Resident #5 did not recall any altercations with any residents where she was injured. During an interview on 10/21/2025 at 3:35 PM, CNA L said Resident #1 and Resident #2 were at the dining room table eating and Resident #1 kept moving the table. She said Resident #2 got up and started punching Resident #1 in the face. She said LVN C stepped in and stopped the altercation. She said if she witnessed a resident-to-resident altercation, she would make sure the residents were safe and then notify the charge nurse.During an interview on 10/21/2025 at 3:44 PM LVN C said on 10/08/2025 she was passing medications in the secure unit. She said Resident #1 and Resident #2 were sitting at the dining room table and Resident #1 was pushing the table. She said Resident #2 asked Resident #1 to stop moving the table and Resident #1 did not stop. She said Resident #2 started punching Resident #1 in the face. She said her and the CNA's separated Resident #1 and Resident #2, and Resident #1 had blood dripping down his face. She said she notified the DON and the Administrator and sent both residents out to the hospital. She said Resident #1 had a non-displaced nose fracture. She said both residents returned from the hospital and then both residents were sent to the behavioral hospital on the same day. She also said Resident #6 was upset because he had just finished getting a shower and was upset because he did not like to shower. She said Resident # 2 had walked past Resident #6 and Resident #6 just pushed Resident #2 down. She said there were no warning signs that indicated Resident #6 was upset. She said the DON and MDS nurse were there and came down to the secure unit. She said the Administrator was not in the facility.During an interview on 10/22/2025 at 10:45 AM, the ADON said she found out about the resident-to-resident altercation between Resident #1 and Resident #2 in the morning meeting the day after the incident occurred. She said the residents were separated and sent to the behavioral hospital. She said she knew the Administrator was supposed to report abuse to the state agency within 2 hours. She said the charges nurses do not normally notify her of resident-to-resident altercations but if they did, she would notify the DON and Administrator of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the incident.During an interview on 10/22/2025 at 3:23 PM the DON said the staff usually notified her of resident-to-resident altercations. She said she would ask staff if they had notified the Administrator and if they had not then she would notify the Administrator. She said she immediately notified the Administrator of the altercation with Resident #1 and Resident #2. She said the state agency should be notified within 2 hours of an abuse allegation.The facility Administrator was notified on 10/21/2025 at 12:35 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time.The facility's plan of removal was accepted on 10/22/2025 at 12:46 PM and included:PLAN OF REMOVAL FOR IMMEDIATE JEOPARDYAction Taken:Residents were separated from each and monitored until no further aggressive behaviors were demonstrated. Resident #5, #2 and #1 were referred to behavioral unit for impatient treatment. Resident #2 was sent to ER for evaluation and treatment. Prior to be admitted to inpatient behavior hospital #2 & #1 were sent to ER for evaluation and treatment. No other resident identified. Staff Re-Education: 10/21/2025 Regional Director of Operations educated Administrator and DON on types of abuse and policy to keep all residents free from abuse and neglect. All staff will be re-educated on the facility's Abuse/Neglect Policy by DON, Administrator, department supervisors and nurse manager including identification, prevention, and mandatory reporting requirements in services started on 10/20/25 and will continue all staff must be in serviced before starting their shift. Documentation of re-education and staff signatures were started on 10/21/25 all staff will be in serviced before starting their shift. Staff were instructed to immediately intervene and report any signs of resident-to-resident aggression or abuse to the Administrator and DON immediately. Department heads started safety survey assessments on 10/21/2025 at 1:20pm and will have all safety survey assessments completed by 4:00pm on 10/21/2025 on all residents that could give a response at north nurse's station. 10/21/2025 Secured unit charge nurse contacting family members of residents on secured unit to complete safety survey for residents that have impaired cognition. Administrator will hold Resident council meeting is scheduled for 10/22/2025 to discuss abuse/neglect for residents that would like to attend. All residents that did not attend resident council will be talked to individual by department heads and family will be contacted for residents that have impaired cognition. Medical director notified of IJ in facility on 10/21/2025.Monitoring of the Plan of Removal included the following:Record review of in-service titled Abuse/Neglect Policy-reporting/investigating/Implementing dated 10/21/2025 signed by the DON and Administrator. Record review of in-service titled Abuse and Neglect P&P dated 10/21/2025 signed by the DON and Administrator. Record review of in-service titled Resident Behaviors, De-escalation, & Prevention dated 10/22/2025 signed by 16 employees.Record review of in-service titled Abuse and Neglect Inservice which covered witness statements, and all incidents to be turned into the Administrator and DON dated 10/20/2025 signed by 57 employees.Record review of 61 resident safety surveys completed 10/21/2025 with no concerns for abuse or neglect.Record review of resident council minutes dated 10/22/2025 at 11:12 AM with 11 residents in attendance.During interviews conducted on 10/22/2025 between 3:00 PM and 4:30 PM the following staff were able to verbalize understanding of preventing abuse: Administrator, DON, ADON, SW, CNA A, CNA B, LVN C, Housekeeper D, LVN O, MDS Coordinator, MA E, CNA N, CNA F, LVN G, CNA H, and the Activity Director. On 10/21/2025 at 12:35 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/22/2025 at 4:30 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 6 of 11 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for abuse policies. 1. The facility failed to follow their policy by not reporting abuse within the 2-hour required time frame when on Resident # 3 hit Resident #1, on 9/19/25. The facility did not report the incident to the state agency until 9/22/25. 2. The facility failed to follow their policy by not reporting abuse within the 2-hour required time frame when on Resident # 4 scratched and held Resident #5's hand, on 9/24/25. The facility did not report the incident to the state agency until 9/26/25. 3. The facility failed to follow their policy by not reporting an incident of abuse on 10/8/25 when Resident #2 punched Resident #1 in the face which caused a non-displaced nose fracture. 4. The facility failed to gather written statements for incidents that occurred on 9/19/25, 9/24/25 or 10/8/25, as per facility policy. 5. The facility failed to complete the State Provider Investigation Report (5-day report) for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25 and 10/8/25, per facility policy. 6. The facility failed to review corrective actions for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25, per facility policy. 7. The facility failed to analyze the occurrence to determine what changes, if any, were needed to the policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25, as per facility policy. 8. The facility failed to refer all occurrences to the QAPI committee to be analyzed to determine what change or changes were needed, if any, to the facility's policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. An Immediate Jeopardy (IJ) situation was identified on 10/21/2025. While the IJ was removed on 10/22/2025, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse which could lead to further abuse and neglect of other residents. Findings included: 1. Record review of Resident #1's electronic face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and psychotic disorder with hallucinations (disconnect from reality, may see, hear, smell, taste or feel things that are not there). Record review of Resident #1's quarterly MDS assessment, dated 06/23/2025, indicated a BIMS score of 99, which indicated Resident #1 was unable to complete the interview. Resident #1's cognitive skills for daily decision making were severely impaired and never or rarely made decisions. Record review of Resident #1's care plan dated 9/09/2024 indicated Resident #1 had the potential to be physically aggressive with interventions which included: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. 2. Assess and address for contributing sensory deficits. 3. Assess and anticipate residents' needs: food, thirst, toileting needs, comfort level, body positioning and pain. Record review of Resident #1's progress note, dated 9/19/2025 at 10:15 PM, written by LVN J, indicated Resident #3 hit Resident #1 in the back. Record review of Resident #1's progress note, dated 10/08/2025 at 8:48 AM, written by LVN C, indicated Resident #1 was pushing the dining room table while Resident #2 was eating. Resident #2 asked Resident #1 not to push the table. Resident #1 continued to push the table. Resident #2 stood up and started punching Resident #1 in the face. Resident #1 had Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some epistaxis (bleeding from the nose). LVN C notified the DON, Administrator and the Nurse Practitioner and sent Resident #1 to the hospital for x-rays of the face. Record review of Resident #1's progress note, dated 10/08/2025 at 12:28 PM, written by LVN C, indicated she received report from the hospital RN that Resident #1 had a non-displaced fracture to his nose. Record review of an incident report, dated 9/19/2025, written by LVN J, indicated: CNA reported to this nurse that she was taking [Resident #1] past [Resident #3] when [Resident #3] hit [Resident #1] in the back. Record review of an incident report, dated 10/08/2025 at 8:30 AM, written by LVN C, indicated: This [Resident #1] was sitting at the dining room table across from [Resident #2]. This [Resident #1] was moving the table when [Resident #2] asked him to stop moving the table. This [Resident #1] continued to move the table. [Resident #2] stood up and started hitting [Resident #1] with closed fists. Resident #1 was not able to be interviewed due to Resident #1 being in the behavioral hospital. 2. Record review of Resident #2's facility face sheet, dated 10/20/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Alzheimer's disease and dementia (decline in cognitive abilities such as memory, thinking, and problem solving). Resident #2 was discharges to a psychiatric hospital on [DATE]. Record review of Resident #2's Quarterly MDS assessment, dated 5/27/25, indicated a BIMS score of 3, which indicated a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He was independent with most ADLs. Record review of Resident #2's comprehensive care plan, dated 10/3/25, indicated he received aggression on 10/3/25 when he was pushed by another resident. Record review of Resident #2's incident report, dated 10/3/25, indicated he was pushed by another resident and landed on the floor on his left side. Resident #2 complained of 10/10 pain to his lower back and sustained a skin tear to the left side of his neck measuring 1.2cm X 0.5cm. He was sent to the emergency room for CT scan. Record review of Resident #2's emergency room records, dated 10/3/25, indicated he received a CT of the head without contrast and a CT of the cervical spine without contrast. Both were negative for fractures. There was no documentation of Resident #2 receiving a CT for the lumbar region. Record review of Resident #2's nursing progress note, dated 10/4/25 at 4:27 PM, for indicated: .Resident up and about to D/R moving very slow and not straighten lower extremities when walking and assisted by staff to walk, PRN Tylenol given and was effective. Neuro's WNL will monitor. signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/5/25 at 3:03 PM, indicated Resident #2 was still experiencing pain and the MD was notified. New order was received for arthritis cream to back and to send to hospital for evaluation. Resident #2 refused to go to the hospital. Progress note was signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/6/25 at 8:36 AM, indicated he complained of severe pain to the lower back and was unable to sit up. The progress note was signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/6/25 at 9:43 AM, indicated: .Resident states he would go to Hospital. he is hurting very bad sitting in w/c [family member] notified that residents agreed to go into E.R. at [hospital name] D/T increased back pain, [family member] agreed and states she's on her way she will meet him at E.R. signed by LVN M. Record review of Resident #2's nursing progress note, dated 10/6/25 at 3:00 PM, indicated he returned to the facility after ER visit with diagnosis of Vertebral Compression acute Fracture of L2. Record review of Resident #2's emergency room records, dated 10/6/25, indicated he received a CT scan of the lumbar spine without contrast which showed an acute compression fracture of L2. Resident #2 was not able to be interviewed due to Resident #2 currently in the behavioral hospital. 3. Record review of Resident #3's electronic face sheet indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some behavior), anxiety (excessive worry, fear, and nervousness), and bipolar disorder with psychotic features (hallucinations and delusions, during episodes of mania or depression). Record review of Resident #3's quarterly MDS assessment, dated 07/02/2025, indicated a BIMS score of 09, which indicated Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan, dated 4/03/2025, indicated Resident #3 had a mood problem related to the disease process of bipolar disorder with interventions which included: 1. Administer medications per MD order for mood management. 2. Encourage resident to express feelings and verbalize concerns during episodes of mood changes and or increased irritability. Allow adequate time to talk and actively listen in a non-judgmental manner. 3. Observe for and report to nurse any acute episode or complaints of feeling sad, loss of pleasure and interest in activities; feelings or worthlessness or guilt; change in appetite/eating habits; change in sleep patterns decreased ability to concentrate; change in ability to make purposeful move.4. Psychiatric/psychological consults as ordered by MD. Record review of Resident #1's progress note, dated 9/19/2025 at 10:30 PM, written by LVN J, indicated: CNA reported to this nurse that this [Resident #3] had hit [Resident #1] in the back. [Resident #3] was assessed and had no sign of injury. The 2 residents were separated for the night into different rooms, both laying in their own beds, eyes closed, even respirations, no signs or symptoms of discomfort. Notified MD and Administrator of incident and separating the 2 residents for the night. Record review of incident report for Resident #3 dated 9/19/2025 at 8:00 PM, completed by LVN J, indicated: CNA reported to this nurse that she was walking past [Resident #3] with [Resident #1] when [Resident #3] hit [Resident #1] in the back. Record review of the state agency reporting system website https://txhhs.my.salesforce.com indicated the facility Administrator reported the resident-to-resident altercation on 9/22/2025 at 2:48 PM which occurred on 9/19/2025 at 8:00 PM. Record review of the state agency reporting system website https://txhhs.my.salesforce.com indicated the facility Administrator did not report the resident-to-resident altercation which occurred on 10/08/2025 at 8:48 AM. During an interview on 10/20/2025 at 10:15 AM, Resident #3 said he never had an altercation with anyone at the facility. 4. Record review of Resident #4's facility face sheet, dated 10/20/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included bipolar disorder (extreme mood swings between mania and depression) and Epilepsy (seizures). Record review of Resident #4's MDS tab in the electronic medical record indicated there had been no MDS assessment completed. Record review of Resident #4's care plan tab in the electronic medical record indicated there had been no comprehensive care plan completed. Record review of Resident #4's assessments tab in an electronic medical record indicated there had been no baseline care plan completed with 48 hours of admission. Record review of Resident #4's incident report, dated 9/24/25, indicated Resident #4 grabbed the hand of another resident and pulled on her, leaving red marks and a scratch mark. 5. Record review of Resident #5's facility face sheet, dated 10/20/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes (high blood sugar) and dementia (loss of memory, language, problem solving and other thinking abilities). Record review of Resident #5's Quarterly MDS assessment, dated 9/26/25, indicated a BIMS score of 13, which indicated intact cognition. She exhibited no behavioral symptoms directed toward others. She required set-up or clean-up assistance with most ADLs. Record review of Resident #5's comprehensive care plan, dated 6/4/25, indicated she had cognitive impairment related to dementia. Record review of Resident #5's incident report, dated 9/24/25, indicated: .Resident came to nurse and showed me her right hand having red streaks and a small scratch on the back of her hand. Resident stated, ‘that crazy man grabbed my hand and scratched me pulling on it and he said f.u. bitch.' During an interview on 10/20/25 at 10:43 AM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Resident #5 denied any altercations with any residents where she was injured. 6. Record review of Resident #6's facility face sheet, dated 10/20/25, indicated he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #6 had diagnoses which included Major Depressive (feelings of sadness, hopelessness) Disorder, and schizoaffective disorder (combines symptoms of schizophrenia and mood disorders such as depression or mania), Bipolar Type (extreme mood swings between mania and depression). Record review of Resident #6's Quarterly MDS assessment, dated 8/18/25, indicated a BIMS score of 3, which indicated a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He required substantial/maximal assistance with most ADLs. Record review of Resident #6's comprehensive care plan, dated 10/3/25, indicated he initiated aggressive behavior to another resident (pushing) on 10/3/25. Record review of Resident #6's incident report, dated 10/3/25, indicated he pushed another resident causing the other resident to fall. Record review of Resident #6's nursing progress note, dated 10/3/25 at 7:30 AM, indicated he was observed pushing another resident while in the dining room. The progress note was signed by LVN C. During an interview on 10/20/25 at 10:20 AM Resident # 6 did not recall any incidents where he pushed another resident. During a interview on 10/20/2025 at 10:38 AM, CNA K said on 10/08/2025 she was working on the secure unit. She said Resident #1 was in the dining room at breakfast and was moving the table. She said Resident #3 told Resident #1 to stop moving the table. She said Resident #1 continued to move the table and Resident #3 got up and went over to Resident #1 and started punching him in the face with a closed fist. She said her, the nurse and the other CNA separated Resident #1 and Resident #3, and both residents were sent out to the hospital. She said both residents returned from the hospital and both residents were sent out to the behavioral hospital the same day. She said if a resident-to-resident altercation occurred she would separate the residents and make sure they were safe, then she would notify the nurse and the Administrator of the incident. During an interview on 10/20/2025 at 11:00 AM, the Administrator said she had 24 hours to report abuse to the state agency. She asked after further questioning am I supposed to report abuse within 2 hours? She said she did not have an excuse why she did not report the resident-to-resident altercations within the 2-hour required reporting time frame. She said she did not report the incident with Resident #1 and Resident #2 to the state survey agency because neither resident was hurt and she just didn't report it. She said she did not know Resident #1 had a non-displaced fracture on the nose. She said she did not know she was supposed to complete a 5-day investigation and submit it to the state agency. The Administrator said she did not know what the 3613A was. She said she had not completed them nor sent in any 5-day investigations to the state agency's reporting website. When asked what the reporting time frame was for abuse, she stated 24 hours. When surveyor further questioned administrator, she asked if it was 2 hours. During an interview on 10/21/2025 at 3:35 PM, CNA L said Resident #1 and Resident #2 were at the dining room table eating and Resident #1 kept moving the table. She said Resident #2 got up and started punching Resident #1 in the face. She said LVN C stepped in and stopped the altercation. She said if she witnessed a resident-to-resident altercation, she would make sure the residents were safe and then notify the charge nurse. During an interview on 10/21/2025 at 3:44 PM, LVN C said on 10/08/2025 she was passing medications in the secure unit. She said Resident #1 and Resident #2 were sitting at the dining room table and Resident #1 was pushing the table. She said Resident #2 asked Resident #1 to stop moving the table and Resident #1 did not stop. She said Resident #2 started punching Resident #1 in the face. She said her and the CNA's separated Resident #1 and Resident #2, and Resident #1 had blood dripping down his face. She said she notified the DON and the Administrator and sent both residents out to the hospital. She said Resident #1 had a non-displaced nose fracture. She said both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some residents returned from the hospital and then both residents were sent to the behavioral hospital on the same day. LVN C said Resident #6 was upset because he had just finished getting a shower and was upset because he did not like to shower. She said Resident # 2 walked past Resident #6 and Resident #6 and pushed Resident #2 down. She said there were no warning signs that indicated Resident #6 was upset. She said the DON and MDS nurse were there and came down to the secure unit. She said the Administrator was not in the facility. She said if there was a resident-to-resident altercation she would make sure the residents were safe then she would notify the DON and the Administrator. During an interview on 10/22/2025 at 10:45 AM, the ADON said she found out about the resident-to-resident altercation between Resident #1 and Resident #2 in the morning meeting the day after the incident occurred. She said the residents were separated and sent to the behavioral hospital. She said she knew the Administrator was supposed to report abuse to the state agency within 2 hours. She said the charges nurses do not normally notify her of resident-to-resident altercations but if they did, she would notify the DON and Administrator of the incident. During an interview on 10/22/2025 at 3:23 PM, the DON said the staff usually notified her of resident-to-resident altercations. She said she would ask staff if they notified the Administrator and if they had not then she would notify the Administrator. She said she immediately notified the Administrator of the altercation with Resident #1 and Resident #2. She said the state agency should be notified within 2 hours of an abuse allegation. Record review of the facility's policy titled Resident to Resident Abuse, dated May 2017, indicated: .2. The Administrator will: 1. Notify state agency as required. 2. Notify local law enforcement as required . This was determined to be an Immediate Jeopardy (IJ) on 10/21/2025 at 12:35 PM. The facility Administrator was notified. The Administrator was provided with the IJ template on 10/21/2025 at 12:35 PM. The following plan of removal submitted by the facility was accepted on 10/22/2025 at 2:54 PM: Summary of Details which lead to outcomes:On 10/20/2025 a complaint survey was initiated at the facility. On 10/21/2025 a surveyor provided an IJ Template notification that it has been determined that conditions at the facility constitute an immediate jeopardy to the health and safety of the residents. The notification of the immediate jeopardy state as follows: Tag #Tag: F607 - Development/Implementation of Abuse Policy FAILURE: The failure to keep residents free from abuse or neglect related to not developing or implementing the abuse policy and this puts residents at risk for serious injury, harm, impairment, or death from abuse allegations and delays in reporting abuse allegations and delays in reporting abuse allegations to the abuse coordinator to implement preventative measures. Identify residents who could be affected:All residents Problem 1: The facility failed to develop and implement policies to investigate, prevent and report incidents for resident abuse. The facility failed to develop and implement policies to investigate, prevent, and report incidents of staff to resident abuse. The facility failed to follow their policy by not reporting abuse within the 2 hour required time frame when on 9/19/25 Resident [TF36] # 3 hit Res #1. The facility did not report the incident to the state agency until 9/22/25.The facility failed to follow their policy by not reporting abuse within the 2 hour required time frame when on 9/24/25 Res # 4 scratched and held Res #5's hand. The facility did not report the incident to the state agency until 9/26/25.The facility failed to follow their policy by not reporting an incident of abuse on 10/8/25 when Res #2 punched Res #1 in the face causing a non-displaced nose fracture.The facility failed to gather written statements for incidents that occurred on 9/19/25, 9/24/25, or 10/8/25 as per facility policy.The facility failed to complete the State Provider Investigation Report (5-day report) for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. The facility failed to review corrective actions for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some and 10/8/25 as per facility policy.The facility failed to analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy.The facility failed to refer all occurrences to QAPI committee to be analyzed to determine what change or changes are needed, if any, to the facilities policies and procedures to prevent further occurrences for incidents of resident-lo-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. Action Taken: Residents had interventions put in place including separation from other residents when resident to resident altercations occurred. Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4 resident admitted to behavioral inpatient on 9/25/2025. Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behavior were noted. Resident #2 & Resident #1 were separated from one another and both sent to ER, while in ER staff made referral to impatient behavioral hospital. Both Residents #2 & #1 were admitted to inpatient behavioral hospital.Abuse reportable events policy was reviewed and revised on 10/21/2025 to include steps for reporting, documentation required and time to report events. Abuse/neglect in services were started with all staff on 10/21/2025 by the Administrator, the DON, nurse managers and department supervisors, all employees must be educated before working their scheduled shift. Social Services in serviced Administer on 10/20/2025 to complete safety surveys with each incident especially any allegations of abuse/neglect to ensure residents feel safe in the facility and they have not experienced any negative events. The DON and Nurse manager assigned to educate nurse on documentation related to incidents, including incident reports, witness statements, progress notes, monitoring logs and head to toe skin assessments. Per facility policy charge nurse will be the staff member that begins taking written statements after the allegation is reported to the Administrator and DON. 10/20/2025 safety surveys started by department heads for residents that could answer survey questions, secured unit charge nurse contacting family members for residents on the secured unit with impaired cognition. Resident council meeting scheduled for residents on 10/22/2025. 10/22/2025 to discuss revision to policy including the steps to reporting and the required documentation that was needed for completing an investigation related to an incident that occurred and was a reportable event. Department heads would speak to resident's individually that did not attend the meeting and call family members with residents that have impaired cognition. The Administrator would be completing the meeting with residents. The Regional director of operations in serviced the DON and Administrator on revision to policy on abuse/neglect allegations. Policy only stated notify state agency as required. The revision now has specific contact information with multiple methods of notification including email, phone, and TULIP. Multiple methods on how to submit 3613 investigation report including email, TULIP, and fax. No other incidents were found at this time. Regional Director of operations visited the facility on a monthly basis and would follow up with the Administrator/DON with each self-report to ensure the investigation of self-reports were completed in timely manner and 3613 was submitted to state with all the documentation gathered with investigation. All communication between monthly visits were to be sent through email. The Nurse manager started Inservice with nurses to 10/21/2025 to discuss Documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that was required for investigation. Inservice was related to having more thorough assessment and appropriate documentation in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete In-services would be completed before staff worked the next shift. Monitoring: The facility's Abuse Reportable events Policy was reviewed and revised on 10/21/25 to clarify timelines for internal/external reporting and investigation steps.The revised policy was approved by the Governing Body and redistributed to all departments. Future new hires will receive abuse prevention and reporting training during orientation before working any shift.The DON or designee will initiate and complete all abuse investigations within five days using the state-approved Form 3613-A process.All investigations will be reviewed and signed by the Administrator for accuracy and timeliness before submission.The Administrator or DON will audit all incident reports weekly for 90 days to ensure proper reporting, investigation, and documentation.Results will be presented to the QA Committee monthly for review and any needed corrective actions.The QA Committee will evaluate compliance and determine if further education or policy revisions are needed. Monitoring of the POR included the following: Record review of inservice, dated 10/20/2025, titled Safety Surveys after abuse/neglect allegation which indicated random safety surveys must be completed after each abuse/neglect allegation signed by the SW . Record review of inservice, dated 10/21/2025, titled Documentation requirements for incidents which indicated all incident reports require the following documentation: head to toe assessments, progress notes, witness statements, monitoring log for behaviors, treatment orders for injuries, completed incident reports, and requested hospital documentation signed by 24 employees. Record review of 61 resident safety surveys completed 10/21/2025 documented no concerns for abuse or neglect. Record review of resident council minutes, dated 10/22/2025 at 11:12 AM, with 11 residents in attendance. Record review of inservice titled Form 3613 Quick Reference & Staff Training Guide, dated 10/21/2025, signed by the DON and Administrator. Record review of inservice titled Abuse and Neglect P&P, dated 10/21/2025, signed by the DON and Administrator. Record review of inservice titled Abuse/Neglect Policy-reporting/investigating/Implementing, dated 10/21/2025, signed by the DON and Administrator. During interviews conducted on 10/22/2025 between 3:00 PM and 4:30 PM the following staff were able to verbalize understanding of developing and implementing the facilities abuse policy: Administrator, DON, ADON, SW, CNA A, CNA B, LVN C, Housekeeper D, LVN O, MDS Coordinator, MA E, CNA N, CNA F, LVN G, CNA H, and the Activity Director. The Administrator was informed the Immediate Jeopardy was removed on 10/22/2025 at 4:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 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, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility had evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 6 of 11 residents (Residents #1, Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6) reviewed for abuse/neglect. 1.The facility failed to investigate abuse when Resident # 3 hit Resident #1, on 9/19/25. 2. The facility failed to investigate abuse when Resident # 4 grabbed, pulled, and scratched Resident #5's hand, on 9/24/25. 3. The facility failed to investigate abuse when Resident #6 pushed Resident #2 to the ground, on 10/3/25. 4. The facility failed to investigate abuse when Resident #2 punched Resident #1 in the face which caused a non-displaced nose fracture, on 10/8/25. 5. The facility failed to gather written statements for incidents that occurred on 9/19/25, 9/24/25, or 10/8/25 as per facility policy. 6. The facility failed to complete the State Provider Investigation Report (5-day report) for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. 7. The facility failed to review corrective actions for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. 8. The facility failed to analyze the occurrence to determine what changes, if any, are needed to the policies and procedures to prevent further occurrences for incidents of resident-to-resident abuse on 9/19/25, 9/24/25, 10/3/25, and 10/8/25 as per facility policy. An Immediate Jeopardy (IJ) situation was identified on 10/21/2025. While the IJ was removed on 10/22/2025, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for abuse, physical harm, psychosocial harm, trauma, unrecognized abuse and emotional distress.Findings Included: 1.Record review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included alzheimers disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and psychotic disorder with hallucinations (disconnect from reality, may see, hear, smell, taste or feel things that are not there). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated Resident #1 was unable to complete the interview. Resident #1's cognitive skills for daily decision making were severely impaired and never or rarely made decisions. Record review of Resident #1's care plan dated 9/09/2024 revealed Resident #1 had the potential to be physically aggressive with interventions that included: 1. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. 2. Assess and address for contributing sensory deficits. 3. Assess and anticipate residents' needs: food, thirst, toileting needs, comfort level, body positioning, and pain. Record review of Resident #1's progress note dated 9/19/2025 at 10:15 PM written by LVN J indicated Resident #3 hit Resident #1 in the back. Record review of Resident #1's progress note dated 10/08/2025 at 8:48 AM written by LVN C indicated Resident #1 was pushing the dining room table while Resident #2 was eating. Resident #2 asked Resident #1 not to push the table. Resident #1 continued to push the table. Resident #2 stood up and started punching Resident #1 in the face. Resident #1 had epistaxis (bleeding from the nose). LVN C notified the DON, Administrator and the Nurse Practitioner and sent Resident #1 to the hospital for xrays of the face. Record review of Resident #1's progress note dated 10/08/2025 at 12:28 PM written by LVN C indicated she received report from the hospital RN that Resident #1 did have a non-displaced fracture to his nose. Record review of an incident report dated 9/19/2025 written by LVN J indicated: CNA Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some reported to this nurse that she was taking [Resident #1] past [Resident #3] when [Resident #3] hit [Resident #1] in the back. Record review of an incident report dated 10/08/2025 at 8:30 AM written by LVN C indicated: This [Resident #1] was sitting at the dining room table across from [Resident #2]. This [Resident #1] was moving the table when [Resident #2] asked him to stop moving the table. This [Resident #1] continued to move the table. [Resident #2] stood up and started hitting [Resident #1] with closed fists. Resident #1 was not able to be interviewed due to Resident #1 currently in the behavioral hospital. 2. 2. Record review of Resident #2's facility face sheet, dated 10/20/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Alzheimer's disease and dementia (decline in cognitive abilities such as memory, thinking, and problem solving). Resident #2 was discharges to a psychiatric hospital on [DATE]. Record review of a Quarterly MDS assessment dated [DATE] for Resident #2 indicated a BIMS score of 3, indicating a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He was independent with most ADLs. Record review of a comprehensive care plan dated 10/3/25 for Resident #2 indicated he received aggression on 10/3/25 when he was pushed by another resident. Record review of an incident report dated 10/3/25 for Resident #2 indicated he was pushed by another resident and landed in the floor on his left side. Resident #2 complained of 10/10 pain to his lower back and sustained a skin tear to the left side of his neck measuring 1.2cm X 0.5cm. He was sent to the emergency room for CT scan. Record review of emergency room records dated 10/3/25 for Resident #2 indicated he received a CT of the head without contrast and a CT of the cervical spine without contrast. Both were negative for fractures. There was no documentation of Resident #2 receiving a CT for the lumbar region. Record review of a nursing progress note dated 10/4/25 at 4:27 pm for Resident #2 read: .Resident up and about to D/R moving very slow and not straighten lower extremities when walking and assisted by staff to walk, PRN Tylenol given and is effective. Neuro's WNL will monitor. and was signed by LVN M. Record review of a nursing progress note dated 10/5/25 at 3:03 pm for Resident #2 indicated he was still experiencing pain and MD was notified. A new order was received for arthritis cream to back and to send to hospital for evaluation. Resident #2 refused to go to hospital. Progress note was signed by LVN M. Record review of a nursing progress note dated 10/6/25 at 8:36 am for Resident #2 indicated he complained of severe pain to lower back and was unable to sit up. Progress note was signed by LVN M. Record review of a nursing progress note dated 10/6/25 at 9:43 am for Resident #2 read: .Resident states he would go to Hosp. he is hurting very bad sitting in w/c, notified that residents agreed to go in to E.R. @ [hospital name] D/T increased back pain, wife agreed and states she's on her way she will meet him at E.R. and was signed by LVN M. Record review of a nursing progress note dated 10/6/25 at 3:00 pm for Resident #2 indicated he returned to the facility after ER visit with diagnosis of Vertebral Compression acute Fracture of L2. Record review of emergency room records dated 10/6/25 for Resident #2 indicated he received a CT scan of the lumbar spine without contrast which showed an acute compression fracture of L2. 3. Record review of Resident #3's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior), anxiety (excessive worry, fear, and nervousness), and bipolar disorder with psychotic features (hallucinations and delusions, during episodes of mania or depression). Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09, which indicated Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan dated 4/03/2025 revealed Resident #3 had a mood problem related to the disease process of bipolar disorder with interventions that included: 1. Administer medications per MD order for mood management. 2. Encourage resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some to express feelings and verbalize concerns during episodes of mood changes and or increased irritability. Allow adequate time to talk and actively listen in a non-judgmental manner. 3. Observe for and report to nurse any acute episode or complaints of feeling sad, loss of pleasure and interest in activities; feelings or worthlessness or guilt; change in appetite/eating habits; change in sleep patterns decreased ability to concentrate; change in ability to make purposeful move.4. Psychiatric/psychological consults as ordered by MD. Record review of Resident #1's progress note dated 9/19/2025 at 10:30 PM written by LVN J indicated: CNA reported to this nurse that this [Resident #3] had hit [Resident #1] in the back. [Resident #3] was assessed and had no sign of injury. The 2 residents were separated for the night into different rooms, both laying in their own beds, eyes closed, even respirations, no signs or symptoms of discomfort. Notified MD and Administrator of incident and separating th 2 residents for the night. Record review of incident report dated 9/19/2025 at 8:00 PM completed by LVN J indicated: CNA reported to this nurse that she was walking past [Resident #3] with [Resident #1] when [Resident #3] hit [Resident #1] in the back. Record review of the state agency reporting system website https://txhhs.my.salesforce.com indicated the facility Administrator reported the resident-to-resident altercation on 9/22/2025 at 2:48 PM that occurred on 9/19/2025 at 8:00 PM. Record review of the state agency reporting system website https://txhhs.my.salesforce.com indicated the facility Administrator did not report the resident-to-resident altercation that occurred on 10/08/2025 at 8:48 AM. During an interview on 10/20/2025 at 10:15 AM Resident #3 said he had never had an altercation with anyone at the facility. 4. Record review of a facility face sheet dated 10/20/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including bipolar disorder (extreme mood swings between mania and depression) and Epilepsy (seizures). Record review of an MDS tab in an electronic medical record for Resident #4 indicated there had been no MDS assessment completed. Record review of a care plan tab in an electronic medical record for Resident #4 indicated there had been no comprehensive care plan completed. Record review of an assessments tab in an electronic medical record for Resident #4 indicated there had been no baseline care plan completed with 48 hours of admission. Record review of an incident report dated 9/24/25 for Resident #4 indicated that Resident #4 grabbed the hand of another resident, pulled on her leaving red marks and a scratch mark.5. Record review of a facility face sheet dated 10/20/25 for Resident #5 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including type 2 diabetes (high blood sugar) and dementia (loss of memory. Language, problem solving and other thinking abilities). Record review of a Quarterly MDS assessment dated [DATE] for Resident #5 indicated a BIMS score of 13, indicating intact cognition. She exhibited no behavioral symptoms directed toward others. She required set-up or clean-up assistance with most ADLs. Record review of a comprehensive care plan dated 6/4/25 for Resident #5 indicated she had cognitive impairment related to dementia. Record review of an incident report dated 9/24/25 for Resident #5 read: .Resident came to nurse and showed me her right hand having red streaks and a small scratch on the back of her hand. Resident stated, that crazy man grabbed my hand and scratched me pulling on it and he said f.u. bitch.During an interview on 10/20/25 at 10:43 am Resident #5 denied any altercations with any residents where she was injured. 6. Record review of a facility face sheet dated 10/20/25 for Resident #6 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder (feelings of sadness, hopelessness) and Schizoaffective disorder, Bipolar Type (hallucinations, delusions, disorganized thinking). Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated a BIMS score of 3, indicating a severe cognitive impairment. He exhibited no behavioral symptoms directed toward others. He required substantial/maximal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some assistance with most ADLs. Record review of a comprehensive care plan dated 10/3/25 indicated he initiated aggressive behavior to another resident (pushing) on 10/3/25. Record review of an incident report dated 10/3/25 for Resident #6 indicated he pushed another resident causing the other resident to fall. Record review of a nursing progress note dated 10/3/25 at 7:30 am for Resident #6 indicated he was observed pushing another patient while in the dining room. Progress note was signed by LVN C. During an interview on 10/20/25 at 10:20 am Resident # 6 did not recall any incidents where he pushed another resident. During an interview on 10/20/2025 at 9:40 AM, the Administrator Said she had 24 hours to report abuse to the state agency. She asked after further questioning am I supposed to report abuse within 2 hours? She said she did not have an excuse why she did not report the resident-to-resident altercations within the 2-hour required reporting time frame. She said she did not report the incident with Resident #1 and Resident #2 to the state because neither resident was hurt and she just didn't report it. She said she did not know Resident #1 had a non-displaced fracture to the nose. She said she did not know that she was supposed to complete a 5-day investigation and submit it to the state agency. During an interview on 10/20/2025 at 10:38 AM, CNA K said on 10/08/2025 she was working on the secure unit. She said Resident #1 was in the dining room at breakfast and was moving the table. She said Resident #3 told Resident #1 to stop moving the table. She said Resident #1 continued to move the table and Resident #3 got up and went over to Resident #1 and started punching him in the face with a closed fist. She said her, the nurse and the other CNA separated Resident #1 and Resident #3, and both residents were sent out to the hospital. She said both residents returned from the hospital and both residents were sent out to the behavioral hospital the same day. During an interview on 10/20/25 at 11:00 AM, the Administrator said she did not know what the 3613A was. She said she had not completed them nor sent in any 5-day investigations to the state agency's reporting website. When asked what the reporting time frame was for abuse, she stated 24 hours. When surveyor further questioned administrator, she asked if it was 2 hours. The Administrator said she did not know she was supposed to complete an investigation and did not know what an investigation consisted of. During an interview on 10/21/2025 at 3:35 PM, CNA L said Resident #1 and Resident #2 were at the dining room table eating and Resident #1 kept moving the table. She said Resident #2 got up and started punching Resident #1 in the face. She said LVN C stepped in and stopped the altercation. During an interview on 10/21/2025 at 3:44 PM, LVN C said on 10/08/2025 she was passing medications in the secure unit. She said Resident #1 and Resident #2 were sitting at the dining room table and Resident #1 was pushing the table. She said Resident #2 asked Resident #1 to stop moving the table and Resident #1 did not stop. She said Resident #2 started punching Resident #1 in the face. She said her and the CNA's separated Resident #1 and Resident #2, and Resident #1 had blood dripping down his face. She said she notified the DON and the Administrator and sent both residents out to the hospital. She said Resident #1 had a non-displaced nose fracture. She said she completed an incident report and began reaching out to the behavioral hospital to have residents placed. She said both residents returned from the hospital and then both residents were sent to the behavioral hospital on the same day. During an interview on 10/22/2025 at 10:45 AM, the ADON said she found out about the resident-to-resident altercation between Resident #1 and Resident #2 in the morning meeting the day after the incident occurred. She said the residents were separated and sent to the behavioral hospital. She said she knew the Administrator was supposed to report abuse to the state agency within 2 hours. During an interview on 10/22/2025 at 3:23 PM the DON said the staff usually notified her of resident-to-resident altercations. She said she would ask staff if they had notified the Administrator and if they had not then she would notify the Administrator. She said she immediately notified the Administrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some of the altercation with Resident #1 and Resident #2. She said the state agency should be notified within 2 hours of an abuse allegation. Record review of the facility's policy titled Resident to Resident Abuse, dated May 2017, indicated: .3. Begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family, and/or residents. In certain situations, the person writing the information, along with the person making the statement, if at all possible, and a witness to the dictated statement should sign the completed form. 4. Ask any witness to wait for the Administrator of the person on-call to arrive at the home. If an employee is involved, the employee will be detained and removed from their assigned duties until they are interviewed by the Administrator or person on-call or other appropriate staff. C.The Abuse Coordinator will: 1. Review all aspects of the investigation as soon as possible. 2. Ensure that all reports are complete and appropriate authorities have been notified, including the notification of the local law enforcement related to any crimes against a resident. 3. Complete the investigation and direct any disciplinary action required. 4. Complete the State Provider Investigation Report (5-day report). 5. Review corrective action(s). 7. Refer all occurrences to QAPI Committee to be analyzed to determine what change or changes are needed, if any, to the facilities policies and procedures to prevent further occurrences. This was determined to be an Immediate Jeopardy (IJ) on 10/21/2025 at 12:35 PM. The facility Administrator was notified. The Administrator was provided with the IJ template on 10/21/2025 at 12:35 PM. The following plan of removal submitted by the facility was accepted on 10/22/2025 at 2:54 PM: Summary of Details which lead to outcomes:On 10/20/2025 a complaint survey was initiated at [The Facility]. On 10/21/2025 a surveyor provided an IJ Template notification that it has been determined that conditions at the facility constitute an immediate jeopardy to the health and safety of the residents. The notification of the immediate jeopardy state as follows: Tag #F610 Investigate/prevent/correct alleged violation. FAILURE: The failure of keeping residents free from abuse or neglect related to failure to investigate/prevent/correct alleged violation puts residents at risk for continued injury, harm, impairment from perpetrators having continued access a risk resident. Identify residents who could be affected:All residents Problem 1: The facility failed to investigate the following incidents of alleged abuse:On 9/19/25, Resident #3 hit Resident #1.On 9/24/25, Resident #4 grabbed, pulled, and scratched Resident #5's hand.On 10/3/25, Resident #6 pushed Resident #2 to the ground.On 10/8/25, Resident #2 punched Resident #1 in the face, resulting in a non-displaced nose fracture. The facility also failed to obtain written statements, analyze the circumstances, and complete required State Provider Investigation Reports (Form 3613) for these incidents. This lack of investigation and corrective follow-up placed residents at risk of serious harm, injury, or death from further abuse. Action Taken: Residents had interventions put in place including separation from other residents when resident to resident altercations occurred. Resident #4 was separated from Resident #5, referral sent to behavioral inpatient for Resident #4, resident admitted to behavioral inpatient on 9/25/2025. Resident #6 and Resident #2 were separated from one another. Both Resident #6 & Resident #2 were sent to the ER for evaluation and treatment. Once returned both were placed on monitoring until no signs of behaviors were noted. Resident #2 & Resident #1 were separated from one another and both sent to the ER, while in the ER staff made referral to impatient behavioral hospital. Both Resident #2 & #1 were admitted to inpatient behavioral hospital. Care plans reviewed and updated as needed for incidents reported. Staff separated residents and monitored for any additional behaviors or until placement occurred for residents. When no additional behaviors occurred, residents were removed from monitoring. In house psych iatric services are contacted with behavioral incidents for evaluation and additional treatment if needed. -All staff will be re-educated on the Abuse/Neglect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Policy and the procedures for reporting, documenting, and investigating all allegations of abuse or neglectin services started on 10/20/2025 by the Administrator, the DON, nurse manager, and department managers and will continue until all staff were in serviced and no staff will work their scheduled shift until in serviced. Inservice's started by DON on 10/22/2025 to discuss resident behaviors, how to de-escalate and prevention all staff must be in-serviced before working their scheduled shift. In addition to in-services started on 10/22/2025, the facility has asked contact from local behavioral hospital to conduct training with staff during mandatory Inservice. -Inservice's started on 10/20/2025 related to reporting allegations of abuse to Administrator and DON immediately. Re-education was started on 10/20/25 and will continue no staff is to work their scheduled shift until in services are completed for them. RDO trained Administrator and DON on 10/21/2025 at 2:00 PM on investigating, prevention, and report abuse/neglect allegations. RDO in serviced Administrator/DON on 10/21/2025 with this information. Staff in services were started with staff over completing witness statements, abuse and neglect (timely reporting and types of abuse), safety surveys when state surveyors mentioned these issues. Revision of policy and procedure was loaded into staff communication system on 10/21/2025 at 2:53 PM so everyone who has already signed in services was made aware of revision to policy. -Regional Director of operations visits the facility on monthly basis and will follow up with the Administrator/DON with each self-report to ensure investigation of self-reports are completed in timely manner and 3613 is submitted to state with all the documentation gathered with investigation. All communication between monthly visits is to be sent through email. The in services for documentation including witness statements and monitoring was started on 10/20/2025 for required documentation that is needed with incidents, including witness statements and monitoring, all staff will be in services prior to start of shift. Nurse manager started Inservice on 10-21-2025 for all Documentation including incident reports, witness statements, skin assessments, treatments for injuries, interventions that were put in place to protect the residents, in services to help prevent incident from further occurring, monitoring documentation, any hospital records, safety surveys and any additional information that is required for investigation. This information was also included in facility communication for all nurses on 10-21-2025.-On 10/21/2025 department heads started safety survey rounds for residents. Charge nurse on secured unit contacting family members for residents that reside on the secured unit to complete safety survey for residents that have impaired cognition started on 10/21/2025 facility is awaiting phone calls from 4 family members where facility left voicemail. -Resident counsel scheduled with residents on 10/22/2025 to discuss changes to policy and what is required when these types of allegations are reported. Department heads will speak to each resident that did not attend resident council meeting individual and for those that have impaired cognition family members will be contacted. Monitoring -The Administrator and DON will personally review all incident reports and abuse allegations within 2 hours of occurrence to ensure timely reporting, investigation, and documentation.-The Social Services Director and Unit Managers will monitor daily for any new behavioral incidents and report immediately to administration.-The DON or Designee will complete a daily audit of all incident logs for the next 30 days, then weekly for 90 days.-Audit results will be documented and discussed in QA meeting for review and corrective follow-up. Any staff member who fails to report, investigate, or document an allegation of abuse appropriately will be subject to disciplinary action up to and including termination.The QA Committee will review all incident reports and abuse allegations monthly for 90 days to ensure that each incident is investigated, documented, and reported according to policy. Monitoring of the POR included the following: Record review of inservice titled Abuse and Neglect P&P, dated 10/21/2025, completed by the DON and Administrator. Record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete review of inservice titled Abuse/Neglect Policy-reporting/investigating/Implementing, dated 10/21/2025, completed by the DON and Administrator. Record review of inservice titled Resident Behaviors, De-escalation, & Prevention, dated 10/22/2025, completed by 16 employees. Record review of inservice titled Abuse & Neglect In-Service Timely Reporting, dated 10/20/2025, completed by 74 employees. Record review of inservice titled Abuse and Neglect P&P, dated 10/21/2025, completed by the DON and Administrator. Record review of inservice titled Abuse and Neglect Inservice which covered witness statements, and all incidents to be turned into the Administrator and DON, dated 10/20/2025, completed by 57 employees. Record review of inservice, dated 10/21/2025, titled Documentation requirements for incidents completed by 24 employees. Record review of 61 resident safety surveys completed 10/21/2025 documented no concerns for abuse or neglect. Record review of resident council minutes dated 10/22/2025 at 11:12 AM with 11 residents in attendance. During interviews conducted on 10/22/2025 between 3:00 PM and 4:30 PM the following staff were able to verbalize understanding of developing and implementing the facilities abuse policy: Administrator, DON, ADON, SW, CNA A, CNA B, LVN C, Housekeeper D, LVN O, MDS Coordinator, MA E, CNA N, CNA F, LVN G, CNA H, and the Activity Director. The Administrator was informed the Immediate Jeopardy was removed on 10/22/2025 at 4:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 1 (Resident #4) of 6 residents reviewed for MDS transmission, in that: The facility failed to complete and transmit an Entry and Discharge MDS assessment for Resident #4 within 14 days of completion.These failures could place residents at risk of not having their assessment and care plan completed timely, which could result in denial of services and/or payment for services.Findings include: Record review of a facility face sheet dated 10/20/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression) and Epilepsy (seizures). Face sheet indicated also indicated a discharge date of 9/25/25 to a psychiatric hospital. Record review of an MDS tab in Resident #4's electronic medical record indicated there had been no MDS assessments completed. MDS tracking tab in PCC indicated an entry MDS was due with an ARD of 9/9/25, a discharge MDS was due with an ARD of 9/11/25, an entry MDS was due with an ARD of 9/23/25, and a discharge MDS was due with an ARD of 9/23/25. None had been completed, nor transmitted. During an interview on 10/21/25 at 2:43 pm MDS nurse said she started as the MDS nurse on 9/29/25 and she had no prior experience with MDS assessments. She said she had had a little bit of training with the previous MDS nurse where she would show her regulations in RAI, but she had received no formal training. She said all residents should have an entry MDS on admission and a discharge assessment with discharged . She said she did remember reading that in the RAI manual. She said she was not doing MDSs when Residents #2 and #4 were admitted and discharged . She said the Administrator did tell her yesterday (10/20/25) that there were a lot of MDSs that had not been done, completed, or transmitted. She said she was trying to get them completed now and able to submit. She said if MDSs are not completed timely, accurately and not submitted as required, the facility would not receive payments. She said care plans may not be completed accurately, and staff would not know how to take care of the residents. During an interview on 10/22/25 at 3:23 pm DON said the MDS coordinator was responsible for completing and transmitting MDS assessments. She said the care plans may not be up to date if MDSs are not completed timely. She said going forward she would be responsible for monitoring and ensuring timely completion and submissions. During an interview on 10/22/25 at 4:19 pm the Administrator said she would be responsible for MDS being completed and transmitted going forward. She said care plans could be missed if MDSs were not completed timely and transmitted as required and residents could be at risk of harm. Record review of a facility policy titled Electronic Transmission of the MDS dated September 2010 read: .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed for 1 of 6 residents (Resident #4)reviewed for care plans . The facility failed to complete baseline care plans within 48 hours of admission for Residents #4. This failure could place residents at risk of not receiving care and services to meet their needs.Findings included:Record review of a facility face sheet dated 10/20/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression) and Epilepsy (seizures).Record review of an MDS tab in an electronic medical record for Resident #4 indicated there had been no MDS assessment completed.Record review of a care plan tab in an electronic medical record for Resident #4 indicated there had been no comprehensive care plan completed.Record review of an assessments tab in an electronic medical record for Resident #4 indicated there had been no baseline care plan completed.During an interview on 10/21/25 at 2:43 pm MDS Coordinator said she had started doing MDSs on 9/29/25 and had no prior experience. She said the floor nurses should be responsible for completing the baseline care plan, but she said she did not know how long the facility had to complete the baseline care plan. She said if they were not completed the staff may not know how to take care of the residents. During an interview and observation on 10/21/25 at 3:15 pm LVN J said she was a floor nurse but said she did not complete the baseline care plans. She said she thought the ADON did them. She said she thought they must be done by an RN. She gave me a checklist from a book at the nurses' station that she said the floor nurses use to complete admissions. Baseline care plan was not included on the checklist. During an interview on 10/21/25 at 3:50 pm LVN J brought another list that she said came out with the checklist in July or August and baseline care plans were included on that list. She said she was not aware that they were to be completing them.During an interview on 10/22/25 at 10:45 am ADON said she had worked at the facility since July 2024, but she had been ADON since 10/1/25. She said she did not know baseline care plans were supposed to be done on admission until yesterday (10/21/25). She said she did not know how long the facility had to do a baseline care plan. She said moving forward her and the DON would be checking over new admissions to make sure baseline care plans were done. She said staff would not know how to take care of the residents without the baseline care plan.During an interview on 10/22/25 at 3:23pm DON said the admission nurse would be responsible for baseline careplans going forward. She said going forward her and the ADON would be responsible for making sure those are being completed. She said residents potentially would not be cared for properly without a baseline care plans.During an interview on 10/22/25 at 4:19pm Administrator said the MDS coordinator would be responsible for baseline care plans. She said care could be missed if baseline care plans were not completed and residents could be at risk of harm. Record review of a facility policy titled Care Plans - Baseline dated December 2016 read: .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. and .To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. Event ID: Facility ID: 455855 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 455855 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904 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 FORM CMS-2567 (02/99) Previous Versions Obsolete Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 9 resident hallways (Hallway 900 secured unit) and 2 of 3 entrances (north and south lobby entrance) reviewed for environmental concerns, in that:1. The facility failed to ensure the ceiling on the 900 hall was in good repair and did not leak water on 10/20/25, 10/21/25 and 10/22/25.2. The facility failed to ensure the lobby ceiling located at the south entrance (near the secured unit) was in good repair and did not leak water on 10/20/25, 10/21/25 and 10/22/25.3. The facility failed to ensure the lobby ceiling located at the north entrance was in good repair and did not have a hole and missing sheet rock exposing the frame and insulation on 10/20/25, 10/21/25 and 10/22/25.These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.Findings included: During multiple observations on 10/20/25, 10/21/25 and 10/22/25 between 9:00 am to 4:00 pm the ceiling on 900 hall and the ceiling at the south lobby entrance were leaking water and there were towels and buckets under the leaks catching water. The north entrance lobby ceiling had missing sheet rock exposing the frame and insulation. During an interview on 10/22/25 at 9:15 am CNA A said she had worked at the facility almost 2 1/2 years and the ceiling on 900 hall and the ceiling in the lobby entrances leak anytime it rains. She said she was not sure how long there had been a hole in the north entrance ceiling. She said the staff know to place towels and buckets to catch the water. She said the maintenance supervisor works on the roof regularly to remove the water, but nothing has fixed the problem. She said the housekeepers also regularly empty the buckets as needed and clean daily. She said the residents deserved better and the leaking could cause falls and injuries. During an interview on 10/22/2025 at 10:50 am the Maintenance Supervisor said that the roof was the problem and when it rains it leaks. She said she had sealed the roof twice already, but it was not working. She said she had been in contact with her corporate maintenance personnel, and he instructed her to continue to seal the roof. She said the area at the north entrance was better and was now dry and she was going to replace the sheet rock in the next week or so. She said the area on 900 hall and the south lobby continued to leak despite repairs. She said a ceiling that leaks and was in disrepair could cause falls, changes in resident condition and overall affect their health and dignity. During an interview on 10/22/25 at 11:00 am the Administrator said maintenance was responsible for the repairs of the facility and had been on the roof, applied sealant but despite the repair the roof continued to leak. She said they had reached out to corporate and was instructed to seal the roof as needed. She said a leaking ceiling and ceiling in disrepair could affect the residents overall health, safety and dignity. She said she expected the environment to be free of hazards and would continue to work to see the repairs were completed. Record review of a facility policy titled Quality of Life - Homelike Environment dated June 2024 indicated, .Residents are provided with a safe, clean, comfortable and homelike environment. 2. the facility staff and management shall maximize to the extent possible the characteristics of the facility that reflect a personalized setting; a. clean, sanitary, and orderly environment; daily cleaning and monthly deep cleaning . Event ID: Facility ID: 455855 If continuation sheet Page 22 of 22