Health inspection·December 3, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Some **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 3 of 11 residents (Resident #1, Resident #2 and Resident #3) reviewed for abuse and neglect. 1. The facility failed to protect Resident #2 from abuse from Resident #1 on 11/1/2025 when Resident #1 hit Resident #2 twice on the shoulder while cussing him. 2. The facility failed to protect Resident #2 from abuse from Resident #1 on 11/10/2025 when Resident #1 hit Resident #2 on the lower legs while cussing him. 3. The facility failed to protect Resident #3 from abuse from Resident #1 on 11/25/2025 when Resident #1 hit Resident #3 on the right thigh with his fists. The reasonable person concept was applied in determining the psychosocial outcomes. These failures could place residents at risk for severe negative psychosocial outcomes such as fear and anxiety, crying, depression, post-traumatic stress symptoms, and loss of sense of safety in their own home. Findings include: 1. Record review of Resident #1's electronic face sheet indicated Resident #1 was a [AGE] year-old male who originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #1 had diagnoses which included: cerebral infarction (stroke with right side weakness), vascular dementia (decline in cognitive function), schizophrenia (affects thinking, feelings and behaviors), schizoaffective disorder (hallucinations and delusions), conduct disorder (aggression/impulsivity/lack of remorse characteristics), and cerebral palsy (affects body movement and muscle coordination). Record review of Resident #1's quarterly MDS assessment, dated 9/28/2025, indicated a BIMS of 15, which indicated no cognitive impairment. Resident #1 used a wheelchair and was not assessed for walking 10 feet due to medical condition or safety concerns. Record review of Resident #1's care plan, dated 11/22/2023, indicated: 1. Resident #1 had traumatic brain injury and made statements at times that may be inappropriate with interventions that included: .Redirect Resident when he has inappropriate behaviors. 2. Resident #1 had aggressive behavior toward another resident dated 4/8/2024 with interventions that included: .B. Monitor resident. C. Remove resident from situation . Resident #1's care plan was updated on 11/12/2025 to include the incident that occurred on 11/10/2025. Record review of the facility incident report, dated 11/1/2025 at 3:45 PM, written by LVN E, indicated: Resident #1 rolled by Resident #2 hit him twice on his shoulder. Resident #2 had not said anything to Resident #1 and while he was hitting Resident #2 he was cursing him. Record review of the facility incident report, dated 11/10/2025 at 4:00 PM, written by LVN A, indicated: CNA reported to this nurse the [Resident #1] and [Resident #2] were in a verbal altercation, when [Resident #2] stated to [Resident #1] you want to fight. [Resident #1] hit [Resident #2] with his fist in his legs. Record review of the facility incident report, dated 11/25/2025 at 2:45 PM, written by LVN E, indicated: I heard a little loudness from [Resident #1] voice and when I turned and look out from the nurse's station [Resident #1] was rolling toward [Resident #3] and hit him on his right thigh with his fists while I tried to stop him. The Page 1 of 10 455855 455855 12/03/2025 Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904

F 0600 Level of Harm - Actual harm Residents Affected - Some only thing that I saw [Resident #3] was trying to push his fist back to keep [Resident #1] away from him. [Resident #3] appears to be astonished and didn't say anything. During an attempted interview on 12/1/2025 at 9:40 AM, Resident #1 was not able to answer questions appropriately due to cognition. Resident #1 did not have any visible injuries or bruising from the incident. 2. Record review of Resident #2's electronic face sheet indicated Resident #2 was a [AGE] year-old male who originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #2 had diagnoses which included: severe intellectual disabilities (delayed motor, language, and social accomplishments within the first 2 years of life), schizoaffective disorder (hallucinations and delusions), and cerebral palsy (affects body movement and muscle coordination). Record review of Resident #2's significant change in status MDS assessment, dated 11/10/2025, indicated a BIMS of 03, which indicated severe cognitive impairment. Resident #2 used a wheelchair and was not assessed for walking 10 feet due to medical condition or safety concerns. Record review of Resident #2's care plan, dated 9/23/2024, indicated: Resident #2 received aggressive behavior from another resident with interventions that included: A. Assess resident for injuries. B. Monitor resident. C. Remove resident from situation. During an attempted interview on 12/1/2025 at 2:30 PM, Resident #2 was not able to answer questions appropriately due to cognition. 3. Record review of Resident #3's electronic face sheet indicated Resident #3 was a [AGE] year old male who admitted to the facility on [DATE]. Resident #3 had diagnoses which included: anxiety (feeling of fear, dread, and uneasiness), unspecified dementia (confusion or mild cognitive impairment), and cognitive communication deficit (trouble participating in conversations). Record review of Resident #3's significant change in status MDS assessment, dated 10/8/2025, indicated a BIMS of 00, which indicated severe cognitive impairment. Resident #2 used a wheelchair and was not assessed for walking 10 feet due to medical condition or safety concerns. Record review of Resident #3's care plan, dated 11/18/2025, indicated: Resident #3 had episodes of inappropriate behaviors with interventions which included: 1. Monitor for early warning signs of behavior-approach in calm manner, call by name, remove from unwanted stimuli. 2. Explain procedures, using terms, gestures resident can understand. 6. Give meds per orders, monitor labs, -report results to MD. During an attempted interview on 12/1/2025 at 2:15 PM revealed Resident #3 was not able to answer questions appropriately due to cognition. During an interview on 12/01/2025 at 9:25 AM, LVN E said Resident #1 was aggressive. She said the facility had tried to get multiple behavior hospitals to accept him due to his behaviors, but they would not accept him due to his health status. She said on 11/25/2025 Resident #1 hit Resident #3 while she was trying to hold his wheelchair back to try to separate him from Resident #3. She said all she saw Resident #3 was trying to push Resident #1's fist back to try to keep him from hitting him. She said she brought Resident #1 to the nurse's station and monitored him for a couple of hours and then Resident #1 was placed on every 15-minute monitoring. During an interview on 12/01/2025 at 11:50 AM, the Administrator said Resident #1 had aggressive behaviors. She said at times she went to the secured unit to calm Resident #1 down. She said the facility tried to get Resident #1 accepted to multiple behavior hospitals but no one in the state would accept him. She said she did find a behavior hospital out of state to accept him, but his guardian refused to let Resident #1 go anywhere out of state. The Administrator said since Resident #1's guardian refused to let Resident #1 go out of state she issued Resident #1 a 30-day discharge notice and the 30th day would be 12/12/2025. She said she finally found another nursing facility that had accepted him, and he would be discharged soon. During an interview on 12/02/2025 at 9:43 AM, LVN A said Resident #1 had aggressive behaviors towards other residents in the secured unit. She said Resident #1 at times would beat on the glass walls of the nurse's station. She said on 11/10/2025 Resident #1 and 455855 Page 2 of 10 455855 12/03/2025 Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904

F 0600 Level of Harm - Actual harm Residents Affected - Some Resident #2 got into a verbal altercation and then Resident #1 hit Resident #2 with his fist on Resident #2's leg. She said she had assessed Resident #2 with no injuries found. During an interview on 12/3/2025 at 1:00 PM, the Administrator said she had found alternate placement for Resident #1 and Resident #1 was being discharged on 12/3/2025. During an interview on 12/3/2025 at 3:05 PM, the DON said she had been employed with the facility for 3 days. She said she began the process of reviewing the facility's policies and training on abuse, neglect and exploitation. She said she expected the staff to recognize the signs of ANE and resident safety was the staff's priority. She said moving forward she expected the staff to ensure resident safety and report any abuse immediately to the administrator who was the current abuse coordinator. She stated she instructed the staff to contact her with any allegations or observations of abuse. She stated she would ensure all staff were educated on the facility's abuse policies and re-education would be done as needed. She stated it was important the residents in the facility were protected and it was all of the staff's responsibility to ensure the residents were free from ANE. Record review of the facility's abuse policy, dated 05/2017, with the last revised date of 11/24/2025, indicated: it is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. Physical abuse: Physical action within the definition of abuse, including, but not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Record review of the facility's resident to resident abuse policy, dated 05/2017, with the last revised date of 11/24/2025, indicated: .Will seek proper placement at another home if the physician, responsible party, and/or interdisciplinary care plan team feel that a resident will be a danger to other residents and/or self. 455855 Page 3 of 10 455855 12/03/2025 Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 11 (Resident #1) residents reviewed for supervision. The facility failed to ensure the secured unit, 800 hall, door alarm and door lock was functioning properly. On 10/30/2025 Resident #1 eloped from the facility and was found in the parking lot. An Immediate Jeopardy (IJ) situation was identified on 12/02/2025. While the IJ was removed on 12/03/2025, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm, serious injuries, and death due to lack of supervision and failure to follow protocols.Findings include: Record review of Resident #1's electronic face sheet indicated Resident #1 originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #1 had diagnoses included: cerebral infarction (stroke with right sided weakness), vascular dementia (decline in cognitive function), schizophrenia (affects thinking, feelings and behaviors), schizoaffective disorder (hallucinations and delusions), and cerebral palsy (affects body movement and muscle coordination). Record review of Resident #1's quarterly MDS assessment, dated 9/28/2025, indicated a BIMS of 15, which indicated no cognitive impairment. Resident #1 used a wheelchair and was not assessed for walking 10 feet due to medical condition or safety concerns. Record review of Resident #1's care plan, dated 8/7/2023, indicated: The resident is an elopement risk. 8/6/2023 resident exited the facility and left premises. Resident was found on highway. 10/30/2025 Resident was found outside by shower tech of facility near an entrance door. interventions included: .5. Monitor resident 1:1. Document wandering behavior and attempted diversional interventions in behavior log. 6. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Every 15-minute monitoring for 72 hours. Record review of Resident #1's elopement risk assessment, dated 9/7/2025, indicated a elopement score of 16 which was high risk to wander. Record review of Resident #1's elopement risk assessment, dated 10/30/2025, indicated a elopement score of 11 which was high risk to wander. Record review of the facility incident report for Resident #1, dated 10/30/2025 at 12:00 PM, completed by LVN A indicated: 2 CNAs reported to this nurse patient was found outside in the facility parking lot. During an observation and interview on 12/01/2025 at 9:20 AM, CNA F pushed the secured unit 800 hall back door and the door opened, and the alarm sounded. She said the nurse had to check all the secured unit doors every day to ensure all the doors were locked and the alarms were functioning properly. She said she did not know why the secured unit 800 hall door was not locked. During an interview on 12/01/2025 at 9:25 AM, LVN E said she was the nurse for the secured unit. She said the nurses on the secured unit were supposed to check all the secured unit doors every shift to ensure they were locked, and all door alarms were functioning properly. She said she checked the secured unit 800 hall door on 12/1/2025 when she got to work at 6:00 AM and it was locked, and the alarm was functioning properly. She said she did not know why the door was unlocked on 12/1/2025 during the state surveyor observation at 9:20 AM. During an interview on 12/1/2025 at 9:35 AM, CNA G said the secured unit 800 hall door was supposed to be locked, with the alarm functioning at all times. She said she did not know why the door was unlocked on 12/1/2025 at 9:20am. During an attempted interview on 12/1/2025 at 9:40 AM, Resident #1 was not able to answer questions appropriately due to cognitive communication deficit. During an interview on 12/1/2025 at 11:30 AM, the DON said 12/1/2025 was her first day working at 455855 Page 4 of 10 455855 12/03/2025 Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the facility and did not know anything about the elopement on 10/30/2025 prior to her employment. During an interview on 12/1/2025 at 11:41 AM, the Maintenance Director said she did not know why the secured unit 800 hall door was not locked on 12/1/25 at 9:20 AM, but it was not supposed to be unlocked. She said she checked the secured unit 800 hall door when she got to work on 12/1/2025 and the door was locked. She said she checked all facility doors daily to ensure all door locks and door alarms were functioning properly. She said the secured unit 800 hall door had to be locked from the outside and the key stayed in the lock on the outside of the door. She said she did not know why they kept the key in the lock on the door on the outside, but it had always been kept there since she worked at the facility. She said after Resident #1 eloped, on 10/30/2025, she added another alarm to the fire doors that were on the secured unit 800 hall as an intervention for the elopement. During an interview on 12/1/2025 at 11:50 AM, the Administrator said on 10/30/2025 the nurse for the secured unit was assisting another resident and Resident #1 exited the door on the secured unit 800 hall. She said staff told her they did not hear the alarm on the door going off. She said on the secure unit she had never known staff to turn off the alarms, she said on the other end of the building she had found the other doors alarms were turned off in the past. During an observation and interview on 12/2/2025 at 9:15 AM the State Surveyor walked to the secure unit to enter the code on the keypad to enter the secured unit and there was no light on the keypad indicating that the keypad was working. The secured unit doors were not locked and there was no staff in sight. The nurse for the secured unit was not at the nurse's station. Multiple residents were observed standing by the doors on the inside of the secured unit. At 9:18 AM, CNA B was observed entering the last room on the left of the secured unit 900 hall. At 9:22 AM, Housekeeper H approached the secure unit and attempted to put the code in the keypad. Housekeeper H then went to notify the Maintenance Director the secured unit doors were not working and not locked. Housekeeper H left the secured unit doors unmonitored to go and tell the maintenance director the doors were not functioning. At 9:24 AM, CNA C returned from outside of the facility and entered the secured unit and stood at the door to monitor. LVN A then returned to the nurse's station from outside at 9:43 AM and CNA C told her no one was missing from the secured unit. When the State Surveyor asked CNA C how she knew none of the residents were missing from the unit, since she had not left the doors since returning from outside and CNA C did not answer. Upon further questioning of LVN A, she said she had not been told anyone was going to be working on the secured unit, and the doors would not be functioning properly. LVN A said she asked the Maintenance Director what they were working on and the Maintenance Director just said stuff. LVN A said this had never happened to her before and she was not sure what she was supposed to do but said she could print a census and go and do a head count to make sure all residents were in the secured unit. During an interview on 12/2/2025 at 9:27 AM, CNA B said on 10/30/2025 she did not hear the door alarm when Resident #1 eloped. She said she did not know Resident #1 had eloped until CNA J returned Resident #1 to the secured unit. During an interview on 12/2/2025 at 9:30 AM, CNA C said on the day Resident #1 eloped she did not hear an alarm and did not know how the resident was able to get out of the secured unit 800 hall door. She said she would have been able to hear the alarm if it went off because she was in the secured unit dining room with residents when Resident #1 was returned to the secured unit, by CNA J. During an interview on 12/2/2025 at 9:43 AM, LVN A said on 10/30/2025 she received a call that she had a resident who returned from a behavior facility and was in the parking lot refusing to come into the facility. She said she was outside with the resident for approximately 15 minutes after she was able to get the resident to come into the facility, she was readmitting the resident when 2 CNA's brought Resident #1 down the hall and back to the secured unit and told her they had 455855 Page 5 of 10 455855 12/03/2025 Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few found him in the parking lot. She said she had 2 CNAs on the secured unit that day and no one had heard the alarm going off that morning. She said the Morning prior to Resident #1 eloping, she and the Maintenance Director both checked the secured unit 800 hall door and it was locked, and the alarm was functioning. She said some mornings she found the secured unit 800 hall door unlocked and the alarm not working when she did her daily check and said she would have to lock the door and reset the alarm. She said it made her wonder if there was a short in the wiring due to her finding the door not functioning properly. During an interview on 12/2/2025 at 10:00 AM, LVN K said on 10/30/2025 she was on her break, and she had gone and got something to eat and came back to the facility to eat in her car in the parking lot. She said she saw Resident #1 sitting in his wheelchair at the end of the secured unit 800 hall on the sidewalk. She said Resident #1 was sitting there for about 15 minutes and she thought a staff member was with him when suddenly Resident #1 unlocked his wheelchair and started rolling across the parking lot. She said CNA J was walking across the parking lot and saw Resident #1 and started running across the parking lot and caught Resident #1 and returned him into the facility. During an interview on 12/2/2025 at 10:10 AM, CNA J said she was taking her trash out and when she was coming back around the side of the building, she saw Resident #1 sitting outside on the sidewalk. She said Resident #1 unlocked the wheels of his wheelchair and started rolling down in the parking lot. She said she intercepted Resident #1 and assisted Resident #1 back into the building near the entrance opposite the secured unit and returned Resident #1 to the secured unit. She said she did not know how long Resident #1 had been outside alone and did not see any injuries on Resident #1. Record review of the facility's secured unit door monitoring log, dated 10/30/2025, indicated the secured unit 800 hall door and alarm were functioning properly. Record review of the facility's policy Elopement, dated 05/2017, indicated: it is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or home grounds. Establish a monitoring system for resident until flight risk is resolved. Determine what measures can be taken to prevent it from happening again. This was determined to be an Immediate Jeopardy (IJ) on 12/2/2025 at 1:24 p.m. The facility Administrator and DON were notified. The Administrator was provided with the IJ template on 12/2/2025 at 1:24 p.m. The following plan of removal submitted by the facility was accepted on 12/3/2025 at 12:01 p.m.: Summary of Details which lead to outcomes:On 12/02/2025, an abbreviated survey was initiated at [facility]. On 12/02/2025, a surveyor provided an IJ Template notification that it has been determined that conditions at the facility constitute immediate jeopardy to the health and safety of the residents. Identify residents who could be affected:19 residents Problem 1: The facility failed to provide adequate supervision to prevent Resident #1 from eloping from the secured unit. On 10/30/2025 at approximately 11:56 AM Resident #1 left the facility through the back door of the secured unit and was unattended for approximately 15 minutes before being assisted back in the facility by CNA. On 12/02/2025 at 9:15am, the secured unit doors were observed to be unlocked and not monitored by staff for approximately 7 minutes. Action Taken: After elopement on 10/30/2025 Resident #1 was returned to unit by CNA and assessed for injury by nurse working shift. Resident #1 was placed on monitoring every 15 minutes until risk resolved. After fire contractor was on secured unit working on wires the doors became unsecure and staff not aware.On 12/02/2025 after being made aware of doors being unlocked on secured unit by secured unit nurse, maintenance supervisor checked all doors on the secured unit for alarms and proper functioning. The nurse completed head count to ensure all residents were safe on the unit. In-services started with secured unit staff and other departments to ensure unit remains secure, and residents remain safe. Inservice was started on 12/02/2025 by Administrator. Administrator or designee will in services all employees that work or will 455855 Page 6 of 10 455855 12/03/2025 Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few work on secured unit will have training prior to starting their shift so they are made aware of changes. Inservice consist of nursing making walking rounds to check the alarms doors for proper functioning at the beginning and end of each shift. Secured unit staff is to always have 2 staff members, CNA must report to nurse when taking break and nurse must inform other nurse on duty when she is on break and inform CNA staff when nurse is taking break and who to contact in cause any issues occur. Administrator in-serviced environmental supervisor on 12/02/2025- laundry staff should be making rounds on secured unit and collecting soiled linen. This allows secured unit staff to remain on secured unit to provide supervision and care to residents. Laundry Staff were in serviced on 12/02/2025 by environmental supervisor. In-services completed by Administrator on 12/2/2025 with maintenance supervisor that she must remain on secured unit any time that maintenance is being done on secured unit and inform staff when maintenance is being done. Check the doors to make sure they remain locked. On 12/02/2025 Administrator started in services with secured unit staff so they are aware the secured unit must always have 2 employees on the secured unit for resident safety. CNAs must report to nurse when taking a break to ensure appropriate staffing is on the secured unit. Nurses must inform other nurses on shift when they are taking their break and make sure the CNAs are aware, so they know who to contact If there are any issues while nurse is on break. In-services will be completed with staff prior to working shift on secured unit. On 12/02/2025 Administrator started in services with secured unit nurses to ensure they are doing walking rounds at the beginning and the end of each shift to check the functioning of alarms and doors. Completing a head count at the beginning and end of each shift and report any issues found immediately. In-services will be completed prior to working shift on secured unit. On 12/02/2025 Administrator and other department managers started Inservice on elopement. Facility must follow policy and procedure regarding elopement. Establish a monitoring system until risk has resolved and assign staff to sit one on one with resident until risk resolved. All nurses will be in serviced over changes to elopement policy and monitoring system prior to working shift. Elopement policy and procedure were revised on 12/02/2025, to state a staff will sit one on one with resident until the risk of elopement has resolved. One on one form has been created, and staff must follow guidelines on monitoring form. Guidelines include staff must always remain within arm's reach, resident must remain in line of sight continuously, document observations every 15 minutes, report any changes in behavior to charge nurse. Administrator started in services with all staff on 12/02/2025 and make sure staff is in serviced prior to starting shift. Monitoring of the POR included the following: During an observation on 12/3/2025 at 1:00 PM all secured unit doors were locked, and alarms were functioning properly. LVN A was observed at the nurse's station outside of the secured unit and CNA B, and CNA C were observed inside of the secured unit. During interviews on 12/3/2025 between 2:15 PM and 3:45 PM the following staff said they had received in services and were able to verbalize understanding that secured unit nurses must do walking rounds, check door locks and alarms, a head count, linen barrels were to be collected by laundry staff, there must be 2 staff members on the secured unit at all times , and the revised elopement policy: HSK/Laundry Supervisor, HSK M, HSK L, CNA C, HSK H, LVN A, Cook, HSK N, DM, CNA O, Dishwasher, RN P, CNA Q, Activity Director, MDS, LVN K, CNA S, DON, ADON, MA T, HSK U, LVN V, CNA B, Maintenance Director, and MA W. Record review of the facility's in-service, dated 12/2/2025, titled Secured unit nurses must do walking rounds checking the alarms and doors to ensure they are functioning properly. 2 nurses must sign off at the beginning and end of each shift with oncoming nurse. Nurses must do a head count at this time as well. Any issues found must be reported immediately. With 14 employee signatures. Record review of the facility's in-service, dated 12/2/2025, titled Laundry-Collecting linen barrels off of secured unit 455855 Page 7 of 10 455855 12/03/2025 Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few with 5 housekeeping and laundry employee's signatures. Record review of the facility's in-service, dated 12/2/2025, titled Security of secured unit signed by the Maintenance Director. Record review of the facility's in-service, dated 12/2/2025, titled Secured Unit Staff signed by 6 secured unit employees. Record review of the facility's in-service, dated 12/2/2025, titled Elopement signed by 28 facility employees. Record review of the facility's Elopement Policy, dated 05/2017, with the following revision added: Establish a monitoring system for resident until flight risk is resolved- Residents that elope must be placed one on one and staff must sit with this resident until the risk has resolved. While monitoring staff will report any issues to charge nurse. One on One monitoring form must be completed. Resident must remain within arm's reach of staff at all times. Resident must remain in line of sight continuously. Document observations every 15 minutes. The Administrator and DON were informed the Immediate Jeopardy was removed on 12/2/2025 at 1:24 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 455855 Page 8 of 10 455855 12/03/2025 Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 3 entrances (south lobby entrance) and for the dining room chairs in 1 of 2 dining areas reviewed for environmental concerns. 1. 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 12/01/25, 12/02/25 and 12/03/25. 2. The facility failed to ensure the dining room chairs in Hall 900 (secured unit) were in good repair and without damage to the cushions. 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 include: During multiple observations on 12/01/25, 12/02/25 and 12/03/25 between 8:00 AM to 4:30 PM the ceiling at the south lobby entrance was leaking water and there were towels and buckets under the leaks catching the water. During an observation on 12/01/2025 at 8:00 AM revealed a section of pink insulation approximately 1 feet by 2 feet was noted hanging from the ceiling. During an observation on 12/01/2025 at 10:00 AM, the insulation had been removed and the hole repaired. The area of repair continued to leak water with a bucket and towel located under the area of the leak . During multiple observations on 12/01/25, 12/02/2025 and 12/03/2025 between 8:30 AM and 4:00 PM, the chairs located in the dining room of the secured unit, hall 900, were noted to have rips, tears and holes in 14 chairs observed. 6 chairs were noted to have inner cushion exposed. Residents observed sitting in chairs during observations. During an interview on 12/01/2025 at 9:30 AM, the Maintenance Supervisor said the roof was an ongoing problem and when it rained it leaked. She said she sealed the roof twice, but it was not working. She said the corporate maintenance personnel was actively evaluating and working on the issue. She said a ceiling that leaked and was in disrepair could cause falls, changes in resident condition and overall affect their health and dignity. During an interview on 12/02/25 at 8:15 AM, CNA C said she routinely worked on hall 900 and the ceiling in the lobby entrances leaked anytime it rained. She said she was unable to recall how long there had been a hole in the south entrance ceiling. She said the staff knew to place towels and buckets to catch the water. She said the maintenance supervisor worked on the roof regularly to remove the water, but nothing had fixed the problem. She said the housekeepers also regularly emptied the buckets as needed and cleaned daily. She said the leaking could cause falls and injuries. She stated the chairs located in the dining room for hall 900 were in poor condition for a long period of time, she was unable to give an approximate time. She stated housekeeping staff cleaned the chairs daily. She said the residents deserved to have chairs that were in nice condition and not torn up. During an interview on 12/03/25 at 2:00 PM, LVN A said she routinely worked on hall 900 and the ceiling in the lobby entrances leaked anytime it rained. She said she was not sure how long there had been a hole in the south entrance ceiling. She said the maintenance supervisor worked on the roof regularly. She said the residents and visitors were at risk for falls and injuries. She stated the chairs located in the dining room for hall 900 were in poor condition for many months, she was unable to provide an approximate timeline. She stated housekeeping staff cleaned the chairs daily. She said the residents should have a nice environment as well as any visitors and chairs should not have rips or tears. During an interview on 12/03/25 at 2:00 PM, the Administrator said maintenance was responsible for the repairs of the facility and assessed the roof, applied sealant but despite the repair the roof continued to leak. She said a local contractor was scheduled to evaluate the roof next week and provide an estimate for repairs needed. She stated she communicated with corporate management on multiple occasions regarding the roof leaking and sent photos of the current leaks. She stated the insulation that was 455855 Page 9 of 10 455855 12/03/2025 Kennedy Health & Rehab 504 N John Redditt Dr Lufkin, TX 75904

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some observed on 12/01/25, was a recent occurrence and the night shift staff notified her the night before of the insulation exposed. She said she notified corporate management of the ceilings condition. 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 that repairs were completed. The administrator stated she was aware of the conditions of the chairs located in the dining room of hall 900. She said the chairs had been in the facility for over 5 years. She said the materials used on the chairs peeled and became worn very quickly. She said the chairs could present a cleaning and disinfecting problem due to cloth and foam materials being exposed. She stated the residents had a right to a clean environment and furniture that was without holes and tears. Record review of the facility's 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 455855 Page 10 of 10