Health inspection·September 18, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 9/12/2023 at 11:00 AM, Resident #20 revealed that there was a CNA a month or two ago who did not want to help her go to the restroom or get her out of bed, and told her to do it herself because she used to be able to. Resident #20 stated she did not have any other incidents like this occur and was satisfied with her care before and after this incident. Interview on 9/13/2023 at 10:25 AM, the DON stated she was not aware of when to report grievances to the state. The DON stated she told the ADM of the incident and was not aware of what occurred after reporting to the ADM. Interview on 9/14/2023 at 6:05 PM, the ADM stated she was not aware the incident needed to be reported to the state and expected the DON to report any instances or allegations of abuse and/or neglect. Interview on 9/15/2023 at 3:34 PM, the DON stated she was not aware she was the ANE coordinator and had never been informed of the change. Record review of memo provided by the Administrator dated 4/8/2023 revealed Effective immediately, [DON], will take over the duties and responsibilities of Abuse Coordinator as indicated in the [Facility] Abuse Reporting Policy. This memo is signed by the ADM. There was no signature present of the DON. Record review of facility policy titled Resident Abuse, Neglect or Mistreatment, undated, revealed suspected or substantiated cases of resident abuse, neglect, misappropriation of property or mistreatment shall be thoroughly investigated and documented by the administrator, and reported to the appropriate state agencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 2 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 18 residents (Resident #3) reviewed for care plans, in that. The facility failed to develop a care plan to support Resident #3's need for a spinal cord stimulator. These failures could have placed residents at risk for not having their needs met. The findings included: A record review of Resident #3's admission record, dated 05/15/2023, revealed an admission date of 08/18/2023, with diagnoses which included post-laminectomy status [after a surgery to fuse some spinal vertebrae], chronic pain, and the presence of neurostimulator [a device which stimulates nerves]. A record review of Resident #3's admission MDS assessment, dated 08/24/2023, revealed Resident #3 was an [AGE] year-old female admitted for rehabilitation physical therapy after a surgery. Further review revealed Resident #3 was assessed without any mental cognition impairment as evidenced by a BIMS score of 15 out of 15. A record review of Resident #3's care plan dated 9/11/2023 did not reveal any support and/or interventions to meet Resident #3's needs for a spinal cord stimulator. A record review of Resident #3's Physician's progress note, dated 08/23/2023, revealed, chief complaint / reason for this visit; medically necessary visit to follow up Laminectomy, Constipation, and debility. History of Present Illness; patient is an [AGE] year-old female who resides at the facility .she is being seen today for initial nurse practitioner visit and follow up Laminectomy, Constipation, and disability . admission information relating to this stay; admit history - reason for admission for this stay, patient is an [AGE] year-old admitted to the facility for post Laminectomy. patient has a past medical history of hypertension, anemia, ulcerative colitis, chronic pain, depression, and anxiety. Patient had recent hospitalization for back pain and post Laminectomy. She underwent elective spinal cord stimulator implantation . post procedure continues to have severe pain and difficulties completing her activity. During an interview on 09/11/2023 at 1:25 PM, Resident #3 stated she was recovering from a surgery where she had a spinal cord stimulator implanted by her right hip / lower back. Resident #3 stated she had damaged spinal vertebra disks which were painful and had a surgery to fuse the disks to reduce the pain and improve her movement. Resident #3 stated she continued with the pain and had another surgery to implant a device which would send small electrical shocks to her spine to help manage the pain. Resident #3 stated she had a cell phone type of device which she would use to increase and/or decrease the amount of stimulation needed at any given time to reduce her pain. Resident #3 stated she believed she needed to always keep the stimulators remote control plugged into an electrical outlet. Resident #3 stated she had not had any interaction with the facility staff regarding the remote (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 3 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 control for the implanted stimulator and some CNAs believe it to be a cell phone. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/11/2023 at 01:30 PM, LVN F stated she was the nurse for Resident #3. However, she was not familiar with Resident #3's care plan. LVN F stated she did not have any care instructions for Resident #3's spinal cord stimulator and referred the surveyor to the MDS nurse and/or the DON. Residents Affected - Few During an interview on 09/11/2023 at 2:04 PM, RN E stated she was the nurse for Resident #3 and had assessed Resident #3 upon admission and assisted to develop the baseline care plan. RN E stated she had not assessed Resident #3 for a spinal cord stimulator and stated she had overlooked the spinal cord stimulator. RN E stated the DON was her supervisor and believed the DON was responsible for review of the baseline care plan and the comprehensive care plan. During an interview on 09/15/2023 at 03:00 PM, the DON stated she was responsible for ensuring MDS assessments were accurately completed and coordinated care plan meetings upon admission, and at a minimum quarterly. The DON stated the MDS nurse would alert her when an admission and/or quarterly MDS was completed and she [the DON] would set up a care plan meeting and then document the meeting in the Resident nursing progress notes. The DON reviewed Resident #3's care plan and recognized Resident #3 had no supports and/or nursing interventions for her spinal cord stimulator, she was not assessed with a stimulator .I will update the care plan. The DON stated she was responsible for oversight to ensure care plans were accurate, comprehensive, and timely. The DON stated residents should have a comprehensive care plan meeting with a care plan at admission, quarterly and as needed. The DON stated the failure could place residents at risk for not having their needs and or preferences met to include their need for patient educations to convey the benefits vs risk of their wishes to support their needs. During an interview on 09/15/2023 at 05:14 PM, the Administrator stated she was not involved in the residents' care plan needs. The Administrator stated the DON was responsible for the residents' care plan needs to include assessments, meetings, documentations, and reviews as needed. The Administrator stated she [the DON] did not tell me the care plans were not happening A record review of the facility's Care Plan / Comprehensive Interdisciplinary policy, dated 2005, revealed, a comprehensive care plan will be developed for each resident within seven days of completion of resident admission assessment and then quarterly thereafter. The care plan must include measurable objectives and timetables to meet a residents' medical, nursing, and psychosocial needs as identified in the comprehensive assessment . the interdisciplinary team shall develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. the interdisciplinary team shall include: the Resident [if possible], the residents' family or the power of attorney, the social worker, the dietary supervisor, and activities staff member, the director of nursing, and any other staff pertinent to residence care at the time. the comprehensive care plan will periodically be reviewed and revised by the interdisciplinary team after each resident assessment, assessment review, or significant change in condition. the care plan will be otherwise updated as warranted by changes in medication, treatment, or other changes in condition. Mandatory team members include a registered nurse with primary responsibility for the Resident . no you may also require additional assessment tools since according to federal interpretive guidelines, the physical, mental, and psychosocial rehabilitation therapist, activities personnel, medical social workers, dieticians, and other professionals such as developmental disability specialists and assessing the residents. As a result, you will still want the Residents' medical history and physical forms on admission, hospital discharge summary, etcetera, as indicated above, other tools and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 4 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 disciplines may also be needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 5 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to have the interdisciplinary team, review, and revise the comprehensive care plan after each assessment and quarterly, for 2 of 18 residents (Residents #23 and #138) reviewed for care plans, in that. 1. The facility failed to revise Resident #23's refusal to wear a right foot boot while in bed. 2. The facility failed to have a quarterly care plan meeting for Resident #138. These failures could have placed residents at risk for not having their needs met. The findings included: 1. A record review of Resident #23's admission record, dated [DATE] revealed an admission date of [DATE] with diagnoses which included type II diabetes [a condition where the body does not make enough insulin, or it does not respond to it effectively. Insulin is a hormone that helps the cells use glucose (sugar) for energy. Symptoms include feeling tired, hungry, or thirsty, and passing more urine] and atherosclerosis of native arteries of right leg ulceration of ankle [a condition where the arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall]. A record review of Resident #23's quarterly MDS, dated [DATE], revealed Resident #23 was an [AGE] year-old male admitted for long term care with a right leg ankle ulcer. Further review revealed Resident #23 was assessed without any mental cognition impairment as evidenced by a BIMS score of 15 out of 15. A record review of Resident #23's care plan dated [DATE] revealed, Resident #23 has an open wound to the right lateral ankle r/t Diabetes Date Initiated: [DATE] Revision on: [DATE] .Multipodus Boot to be on the right foot while in bed A record review of Resident #23's physician order dated [DATE], revealed Resident #23 was to have his legs raised above his heart when seated and wear a protective boot that corrects foot misalignments and minimizes the chance of skin breakdown, make sure resident wears multi-podis boot anytime he is in bed with the kickstand out so his foot doesn't roll laterally. During an interview on [DATE] at 12:50 PM Resident #23 stated he was supposed to wear a splint type boot on his right foot at night, but he refused to wear the boot due to comfort. Resident #23 stated he could not recall how long he had not worn the boot and stated it had been months. During an interview on [DATE] at 04:30 PM, CNA G stated she was the CNA for Resident #23. CNA G stated Resident #23 did not wear his boot while in bed. CNA G stated she was not aware Resident #23 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 6 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some supposed to wear the boot while in bed. CNA G stated it had been some time since Resident #23 wore the boot, He refused to wear it. CNA G stated she believed the nurses were aware of his refusals but could not be specific to which nurse, date, and time. During an interview on [DATE] at 04:30 PM, LVN H stated Resident #23 did not wear a boot at night and had not for some time. LVN H stated she had not documented the refusals and had not reported the refusals to the DON but believed Resident #23's refusals were widely known. LVN H stated she was not familiar with Resident #23's care plan and did not participate with the care plan meetings. 2. A record review of Resident #138's admission record, dated [DATE], revealed an admission date of [DATE] with diagnoses which included major depressive disorder single episode, hemiplegia hemiparesis [partial paralysis on one side of the body that can affect the arms, legs, and facial muscles] following cerebral infarction [a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off], and acquired absence of left leg below the knee [an amputation]. A record review of Resident #138's entry MDS dated [DATE] revealed Resident #138 was a [AGE] year-old female admitted for long term care. A record review of Resident #138's BIMS Evaluation dated [DATE], revealed no mental cognition impairment as evidenced by a BIMS score of 15 out of 15. A record review of Resident #138's physician's orders summary, dated [DATE] revealed Resident #138 was ordered by her physician, on [DATE] to not receive CPR, DNR (Do Not Resuscitate). A record review of Resident #138's nursing progress notes revealed the DON documented a care plan meeting on [DATE]. A record review of Resident #138's medical record did not evidence any further care plan meeting beyond [DATE]. A record review of Resident #23's care plan did not evidence any review beyond [DATE]. During an interview on [DATE] at 11:15 AM, Resident #138 stated she could not specifically recall when she last attended a care plan meeting, maybe spring sometime. The surveyor asked Resident #138 if she had formulated an advance directive to detail if she wished to receive CPR if she was without breaths and a pulse; Resident #138 stated she wished to receive resuscitation measures, CPR, if she was without a pulse and not breathing. Resident #138 stated she once wanted to not receive CPR but has since changed her mind. Resident #138 stated no care plan meeting has occurred recently and stated if it had she would certainly request to receive CPR if needed. During an interview on [DATE] at 02:30 PM, the MDS nurse stated the facility process for care plan development was to have the admission LVN's assess residents for the baseline care plan, then the MDS nurse [herself] would assess the Resident per the RAI [Resident Assessment Instrument] and develop the MDS. The MDS nurse stated upon development of the MDS, the MDS nurse would report to the interdisciplinary team to include the DON. The MDS nurse stated the DON would review and sign the MDS and then would coordinate a care plan meeting. The MDS nurse received a report from the surveyor that a record review of Resident #138's Care plan meetings did not reveal any care plans after the [DATE] care plan meetings however there were several MDS assessments during the time from [DATE] to [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 7 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The MDS nurse stated it was her error she did not alert the DON to the need for a care plan meeting. The MDS nurse stated the DON was responsible for oversight to ensure care plan meetings occurred at a minimum every quarter. During an interview on [DATE] at 03:00 PM, the DON stated she was responsible for ensuring MDS assessments were accurately completed and coordinated care plan meetings upon admission, and at a minimum quarterly. The DON stated the MDS nurse would alert her when an admission and/or quarterly MDS was completed and she [the DON] would set up a care plan meeting and then document the meeting in the Resident nursing progress notes. The DON received a report from the surveyor that Resident #23 had an order for a splint boot for his right foot while in bed, but the resident had been refusing to wear the boot for months. The DON stated staff had not reported the refusals and or documented the refusals and the refusals were not reviewed in the care plan meeting. The DON received a report from the surveyor that Resident #138 had not had a care plan meeting since [DATE]. The DON stated she was not aware and would schedule a care plan meeting for Resident #138. The DON stated she was responsible for oversight to ensure care plans were accurate, comprehensive, and timely. The DON stated residents should have a comprehensive care plan meeting with a care plan at admission, quarterly and as needed. The DON stated the failure could place residents at risk for not having their needs and or preferences met to include their need for patient educations to convey the benefits vs risk of their wishes to support their needs. During an interview on [DATE] at 05:14 PM, the Administrator stated she was not involved in the residents' care plan needs. The Administrator stated the DON was responsible for the residents' care plan needs to include assessments, meetings, documentations, and reviews as needed. The Administrator stated she [the DON] did not tell me the care plans were not happening A record review of the facility's Care Plan / Comprehensive Interdisciplinary policy, dated 2005, revealed, a comprehensive care plan will be developed for each resident within seven days of completion of resident admission assessment and then quarterly thereafter. The care plan must include measurable objectives and timetables to meet a residents' medical, nursing, and psychosocial needs as identified in the comprehensive assessment . the interdisciplinary team shall develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. the interdisciplinary team shall include: the Resident [if possible], the residents' family or the power of attorney, the social worker, the dietary supervisor, and activities staff member, the director of nursing, and any other staff pertinent to residence care at the time. the comprehensive care plan will periodically be reviewed and revised by the interdisciplinary team after each resident assessment, assessment review, or significant change in condition. the care plan will be otherwise updated as warranted by changes in medication, treatment, or other changes in condition. Mandatory team members include a registered nurse with primary responsibility for the Resident . no you may also require additional assessment tools since according to federal interpretive guidelines, the physical, mental, and psychosocial rehabilitation therapist, activities personnel, medical social workers, dieticians, and other professionals such as developmental disability specialists and assessing the residents. As a result, you will still want the Residents' medical history and physical forms on admission, hospital discharge summary, etcetera, as indicated above, other tools and disciplines may also be needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 8 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interviews and record reviews, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 1 day (08/20/2023) of 90 days reviewed for nursing services, in that: The facility failed to have a registered nurse working on Sunday 08/20/2023. This failure could place residents at risk for harm by denying residents the advanced nursing skill level a registered nurse is supposed to provide. The findings included: A record review of the facility's Facility Assessment Tool dated 08/08/2023 revealed the facility's average daily census was projected to be 30-50, with an average of residents who have specialized care needs: 14 who need oxygen therapy, 1-3 residents who need a BiPaP / CPaP [BiPAP and CPAP machines have a lot in common. They both deliver positive air pressure (PAP) via a tabletop device connected to a tube and a mask], 1-7 residents who have behavioral health needs, 2-5 residents who need injectable medications, and an average of 7 residents who have hospice care needs. A record review of the facility census dated 09/11/2023 revealed 38 residents . A record review of the facility's RN Payroll report for the months of June 2023, July 2023, and August 2023 revealed on 08/20/2023 there was no RN scheduled for any shift during the 24-hour day. A record review of the facility's August 2023 nursing schedule revealed no RN scheduled for 08/20/2023. During an interview on 09/15/2023 at 03:00 PM, the DON stated she was responsible for making the RN coverage schedule and at a minimum she had an RN on the schedule for a minimum of 8 hours daily. The DON reviewed the August 2023 schedule and recognized there was no RN scheduled for 08/20/2023. The DON stated she could not explain the error and she and the Administrator were responsible for oversight of the schedule. The DON stated potential harm to the residents was possible . When asked what specific potential harm the DON stated that was difficult to speculate. During an interview on 09/15/2023 at 05:14 PM, the Administrator stated she was not involved in the development and oversight of the nursing schedules and the task was solely the DON's. The Administrator stated she was unaware the facility lacked an RN on 08/20/2023. The Administrator stated she believed she currently had sufficient nursing coverage. A record review of the facility's undated RN Coverage Requirements and Staffing Policy revealed, at a minimum, the facility must maintain a ratio (for every 24-hour period) of a registered nurse must be on site 8 consecutive hours a day, seven days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 9 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 19 of 38 residents (Residents #2, #6, #10, #12, #15, #16, #17, #19, #21, #25, #26, #27, #28, #29, #30, #35, #39, #40, and #138) reviewed for pharmacy services, in that; 1. Resident #2 was administered a diabetic medication 24 minutes late by RN E on 09/13/2023. 2. Resident #6 was administered injectable insulin 1 hour and 23 minutes late by LVN D on 09/13/2023. 3. Resident #10 was administered 3 drugs, a blood thinner medication, a probiotic, and breathing treatment medication, 32 minutes late, by RN E on 09/13/2023. 4. Resident #12 was administered a stool softener medication 47 minutes late, by LVN D on 09/13/2023. 5. Resident #15 was administered 6 medications, a gastro-esophageal reflux medication, a vitamin, 2 pain relief medications, an antibiotic medication, and a mood-altering drug 58 minutes late by LVN D on 09/13/2023. 6. Resident #16 was administered a stool softener medication 25 minutes late by RN E on 09/13/2023. 7. Resident #17 was administered 2 drugs, an antihypertensive [high blood pressure] and an anti-psychotic [mood altering] medication 20 minutes late, by LVN D on 09/13/2023. 8. Resident #19 was administered 4 medications, 2 anti-depressant medications, a high blood pressure medication, and a breathing treatment medication 25 minutes late, by RN E on 09/13/2023. 9. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 10 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #21 was administered 3 drugs, an eye vitamin, glaucoma eye drops, and an anti-hypertensive 33 minutes late, by RN E on 09/13/2023. 10. Resident #25 was administered 2 drugs, a dementia drug and a pain relief medication 11 minutes late, by LVN D on 09/13/2023. 11. Resident #26 was administered 3 medications, a high blood pressure medication, a pain medication, and a stool softener 40 minutes late, by LVN D on 09/13/2023. 12. Resident #27 was administered 3 drugs, 2 cardiac medications and a high blood pressure medication 1 hour late on 09/13/2023. 13. Resident #28 was administered 2 drugs, a pain medication, and a high blood pressure medication 1 hour and 44 minutes late, by LVN D on 09/13/2023. 14. Resident #29 was administered 2 drugs, a cardiac medication, and a stool softener medication 37 minutes late, by RN E on 09/13/2023. 15. Resident #30 was administered an insulin medication 29 minutes late, by RN E on 09/13/2023. 16. Resident #35 was administered 3 drugs, a blood thinner medication, a cardiac medication, and a stool softener medication 2 hours and 40 minutes late minutes late, by LVN D on 09/13/2023. 17. Resident #39 was administered 2 drugs, a cerebral palsy medication and a seizure medication 2 hours and 29 minutes late, by LVN D on 09/13/2023. 18. Resident #40 was administered 2 drugs, a cardiac medication and a pain relief medication 20 minutes late, by RN E on 09/13/2023. 19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 11 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Resident #138 was administered 4 drugs, a nausea medication, an allergy medication, a blood thinner medication and a muscle pain relief medication 42 minutes late, by RN E on 09/13/2023. These failures could place residents at risk for not receiving the therapeutic effects of the medications prescribed. Residents Affected - Some The findings included: 1. A record review of Resident #2's admission record, dated 09/15/2023, revealed an admission date of 12/02/2013 with diagnoses which included diabetes mellitus II [a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel]. A record review of Resident #2's quarterly MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old male admitted for long term care. Resident #2 was assessed with a BIMS score of 09 out of 15 which indicated moderate cognitive impairment. A record review of Resident #2's physician orders summary dated 09/13/2023 revealed Resident #2 was to receive metformin [a drug to help body cells use sugar from the blood] tablet, 1000 mg, give 1 tablet by mouth two times a day related to type 2 diabetes at 0800 and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #2 on 09/13/2023, 1 metformin tablet 1000 mg at 09:24 AM, 24 minutes late. 2. A record review of Resident #6's admission record, dated 09/15/2023, revealed an admission date of 08/09/2023 with diagnoses which included diabetes mellitus II [a disease in which the body has difficulty using excess sugar in the blood]. A record review of Resident #6's admission MDS dated [DATE] revealed Resident #6 was an [AGE] year-old male assessed with a BIMS score of 14 out of 15 indicating no mental cognition impairment. A record review of Resident #6's physicians order summary dated 09/13/2023 revealed Resident #6 was to receive novolog flexpen subcutaneous solution pen injector 100 unit/ml (insulin aspart) inject as per sliding scale: if 110 - 129 = 2 units; 130 - 149 = 4 units; 150 - 169 = 6 units; 170 - 200 = 8 units, subcutaneously two times a day related to type 2 diabetes mellitus twice a day at 07:30 AM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #6 on 09/13/2023, NovoLog flex pen subcutaneous solution pen injector at 08:53 AM, 1 hour and 20 minutes late. 3. A record review of Resident # 10's admission record dated 09/15/2023 revealed an admission date of 07/17/2023 with diagnoses which included hypertension [high blood pressure], cholecystitis [swelling of the gallbladder], and allergies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 12 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #10's admission MDS dated [DATE] revealed Resident #10 was a [AGE] year-old female assessed with a BIMS score of 13 out of 15 which indicated intact mental cognition. A record review of Resident #10s physician order summary, dated 09/13/2023 revealed resident #10 was to receive, florastor capsule 250mg, give at 08:00 and 08:00 PM; fluticasone nasal spray, at 08:00 AM and at 08:00 PM; and Eliquis 5mg 1 tablet, give at 08:00 AM and at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #10 on 09/13/2023, fluticasone nasal spray, florastor capsule, and Eliquis 5mg at 09:32 AM, 32 minutes late. An observation and interview on 09/13/23 at 09:18 AM, revealed RN E prepared and administered to Resident #10 the following medications: Eliquis oral tablet 5 mg (apixaban); Florastor oral capsule; and Fluticasone Propionate nasal suspension. RN E stated she was late administering the medications due to her increased workload of having to observe the breakfast dining room for resident safety, and was responsible for all medication pass, wound care, and treatments for her residents. RN E stated the medications were ordered to be administered at 08:00 AM and she had until 09:00 AM to administer the medications per professional standards. RN E stated she had not reported her potential late medication administration for her halfof the facility census residents and still required more medication administrations for residents. RN E stated the potential risk for residents was they may not receive the therapeutic effects of their medications. 4. A record review of Resident #12's admission record dated 09/13/2023 revealed an admission date of 04/05/2021 with diagnoses which included constipation. A record review of Resident #12's annual MDS dated [DATE], revealed Resident #12 was an [AGE] year-old female assessed with a BIMS score of 10 out of 15 which indicated moderate mental cognition impairment. A record review of Resident #12's physician order summary, dated 09/13/2023 revealed Resident #12 was to receive senna plus 1 tablet two times a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #12 on 09/13/2023, senna plus capsule at 09:47 AM, 47 minutes late. 5. A record review of Resident #15's admission record dated 09/15/2023, revealed an admission date of 05/22/2023 with diagnoses which included gastro-esophageal reflux, chronic pain syndrome, kidney failure, and dementia. A record review of Resident #15's quarterly MDS dated [DATE] revealed Resident #15 was a [AGE] year-old female admitted for long term care. A record review of Resident #15's physician order summary dated 09/13/2023 revealed Resident #15 was to receive pantoprazole [a drug to reduce stomach acid] 40mg capsule twice a day at 08:00 AM and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 13 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some again at 08:00 PM; vitamin d twice a day at 08:00 Am and again at 08:00 PM; pregabalin [a drug to reduce nerve pain] twice a day at 08:00 AM and again at 08:00 PM; hydrocodone acetaminophen 7.5mg - 325mg 1 tablet twice a day at 08:00 AM and again at 08:00 PM; nitrofurantoin [an antibiotic] 1 - 100mg capsule, twice a day at 08:00 Am and again at 08:00 PM; Seroquel [a mood altering dementia drug] 1 - 50mg tablet twice a day at 08:00 AM and again at 08:00 PM; atenolol [a blood pressure medication] give 1 - 100mg tablet twice a day at 08:00 AM and again at 08:00 PM; and potassium give 1 -10mEq twice a day at 08:00 AM and Again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #15 on 09/13/2023, pantoprazole, vitamin D, pregabalin, hydrocodone acetaminophen, nitrofurantoin, Seroquel, atenolol, and potassium at 09:58 AM, 58 minutes late. 6. A record review of Resident #16's admission record, dated 09/15/2023, revealed an admission date of 07/12/2023 with diagnoses which included constipation, atrial flutter [an irregular heartbeat], and a urinary tract infection. A record review of Resident #16's admission MDS, dated [DATE], revealed Resident #16 was an [AGE] year-old female admitted for hospice services care. A record review of Resident #16's physician orders summary, dated 09/13/2023, revealed Resident #16 was to receive senna plus [a stool softener] 1 tablet twice a day at 08:00 AM and again at 08:00 PM; eliquist [a blood thinner] 5mg 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and nitrofurantoin [an antibiotic] 100mg 1 capsule twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #16 on 09/13/2023, senna plus capsule, a nitrofurantoin capsule, and an eliquist tablet at 09:25 AM, 25 minutes late. 7. A record review of Resident #17's admission record, dated 09/15/2023, revealed an admission date of 10/12/2022 with diagnoses which included hypertension [high blood pressure] and anxiety. A record review of Resident #17's quarterly MDS, dated [DATE], revealed Resident #17 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 06 out of 15 which indicated severe mental cognition impairment. A record review of Resident #17's physician's order summary, dated 09/13/2023, revealed Resident #17 was to receive metoprolol [a high blood pressure medication] 50mg twice a day at 08:00AM and again at 08:00 PM and Depakote [a medication to reduce anxiety] 125mg twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #17 on 09/13/2023, metoprolol and Depakote at 09:21 AM, 21 minutes late. 8. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 14 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #19's admission record, dated 09/15/2023, revealed an admission date of 03/09/2021 with diagnoses which included chronic obstructive pulmonary disease [a group of diseases that cause airflow blockage and breathing-related problems], depression, and hypertension [high blood pressure]. A record review of Resident #19's physician orders summary, dated 09/13/2023, revealed Resident #19 was to receive Symbicort [a steroid breathing treatment] aerosol 80-4.5mcg/act 2 puffs inhale orally twice a day at 08:00 AM and again at 08:00 PM; quetiapine [a mood altering medication] 50mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; bupropion [an antidepressant] 50mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and metoprolol [a drug to reduce blood pressure] 50mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #19 on 09/13/2023, Symbicort 2 puffs, quetiapine 50mg, buprion 50mg, and metoprolol 50mg at 09:25 AM, 25 minutes late. 9. A record review of Resident #21's admission record revealed an admission date of 01/09/2023 with diagnoses which included glaucoma [a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve] and hypertension [high blood pressure]. A record review of Resident #21's quarterly MDS, dated [DATE], revealed Resident #21 was a [AGE] year-old female admitted for long term care with a BIMS of 11 which indicated mild cognitive impairment. A record review of Resident #21's physician orders summary dated 09/13/2023 revealed Resident #21 was to receive [NAME] vision multivitamins twice a day at 08:00 AM and again at 08:00 PM; dorzolamide optic solution 1 drop in both eyes, twice a day at 08:00 AM and again at 08:00 PM; and metoprolol [a high blood pressure medication] 100mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #21 on 09/13/2023, pressor vision multivitamins, dorzolamide eye drops, and metoprolol at 09:33 AM, 33 minutes late. 10. A record review of Resident #25's admission record, dated 09/15/2023, revealed an admission date of 07/19/2023 with diagnoses which included dementia, and aftercare following joint replacement surgery. A record review of Resident #25's admission MDS dated [DATE], revealed Resident #25 was a [AGE] year-old female admitted for post rehab therapy. A record review of Resident #25's physician order summary, dated 09/13/2023, revealed Resident #25 was to receive Namenda [a drug used for memory loss] 10mg give 1 ablet by mouth two times a day related to dementia, at 08:00 AM and again at 08:00 PM; and Tylenol 8 Hour Tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 15 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm extended release 650mg give 1 tablet by mouth three times a day related to aftercare following joint replacement surgery at 08:00 AM, at 01:00 PM, and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #25 on 09/13/2023, Namenda and Tylenol at 09:14 AM, 14 minutes late. Residents Affected - Some 11. A record review of Resident #26's admission record, dated 09/15/2023, revealed an admission date of 07/20/2023 with diagnoses which included hypertension [high blood pressure], and polyneuropathy [nerve pain] and constipation. A record review of Resident #26's admission MDS, dated [DATE], revealed Resident #26 was an [AGE] year-old male assessed with a BIMS of 11 which indicated mild cognitive impairment. A record review of resident #26's physician order summary dated 09/13/2023 revealed Resident #26 was to receive atenolol [ahigh blood pressure medication] 50mg give 1 tablet twice a day at 08:00 Am and again at 08:00 PM; acetaminophen [Tylenol] 325mg give 1 tablet twice a day at 08:00 Am and again at 08:00 PM; timoptic ophthalmic solution 0.5 % (Timolol Maleate) Instill 1 drop in both eyes two times a day related to glaucoma, and senna plus [a stool softener] 8.6-50mg give 1 tablet twice a day at 08:00 Am and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #26 on 09/13/2023, Tylenol, senna, and atenolol at 09:40 AM, 40 minutes late. An observation and interview on 09/13/23 at 09:30 AM revealed LVN D prepared and administered to Resident #26 the following medications: Senna Plus oral tablet 8.6-50 mg, timoptic ophthalmic solution 0.5 %, acetaminophen oral tablet 325 mg, and atenolol oral tablet 50. LVN D stated she was late administering the medications due to her increased workload of having to observe the breakfast dining room for Resident safety. LVN D stated the medications were ordered to be administered at 08:00 AM and she had until 09:00 AM to administer the medications per professional standards. LVN D stated she had not reported her potential late medication administration for her half of the facility census residents and still required more medication administrations for residents. LVN D stated the potential risk for residents was they may not receive the therapeutic effects of their medications. 12. A record review of Resident # 27's admission record, dated 09/15/2023, revealed an admission date of 10/07/2022 with diagnoses which included atrial fibrillation [an irregular heartbeat] and hypertension [high blood pressure]. A record review of Resident #27's quarterly MDS dated [DATE], revealed Resident #27 was an [AGE] year-old female assessed with a BIMS of 04 out of 15 which indicated severe mental cognition impairment. A record review of Resident #27's physician order summary, dated 09/13/2023, revealed Resident #27 was to receive diltiazem [a drug for an irregular heartbeat] 180mg give 1 capsule twice a day at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 16 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 08:00 AM and again at 08:00 PM; lisinopril [a drug to lower blood pressure] 20mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and Eliquis [a blood thinner] 2.5mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #25 on 09/13/2023, diltiazem 180mg, lisinopril 20mg, and Eliquis 2.5mg at 09:29 AM, 29 minutes late. 13. A record review of Resident #28's admission record, dated 09/15/2023, revealed an admission date of 02/21/2023 with diagnoses which included hypertension [high blood pressure] and anxiety. A record review of Resident #28's quarterly MDS, dated [DATE], revealed Resident #28 was a [AGE] year-old female admitted for long term hospice care. A record review of Resident #28's physician order summary, dated 09/13/2023 revealed Resident #28 was to receive gabapentin [a drug used for nerve pain relief] 100mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and metoprolol [a drug to lower blood pressure] 50mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #28 on 09/13/2023, gabapentin 100mg, and metoprolol 50mg at 10:43 AM, 1 hour and 43 minutes late. 14. A record review of Resident #29's admission record, dated 09/15/2023, revealed an admission date of 04/25/2023, with diagnoses which included constipation and hypertension [high blood pressure]. A record review of Resident #29's quarterly MDS, dated [DATE], revealed Resident #29 was a [AGE] year-old male assessed with a BIMS score of 14 which indicated no cognitive mental impairment. A record review of Resident #29's physician order summary dated 09/13/2023 revealed Resident #29 was to receive Colace [a stool softener] 100mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and carvedilol [a blood pressure medication] 25mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #29 on 09/13/2023, Colace 100mg and carvedilol 25mg at 09:37 AM, 37 minutes late. 15. A record review of Resident #30's admission record dated 09/15/2023 revealed an admission date of 12/14/2022 with diagnoses which included diabetes type II [a group of diseases that affect how the body uses blood sugar (glucose). Glucose is an important source of energy for the cells]. A record review of Resident #30's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 17 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Quarterly MDS dated [DATE] revealed Resident #30 was an [AGE] year-old female admitted for long term care. A record review of Resident #30's physician order summary dated 09/13/2023 revealed Resident #30 was to receive Lantus [a slow long-lasting medication to absorb high blood sugars] 100units/ml inject 15 units in the morning. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #29 on 09/13/2023, Lantus 15units at 09:29 AM, 29 minutes late. 16. A record review of Resident #35's admission record, dated 09/15/2023, revealed an admission date of 08/29/2023 with diagnoses which included cerebral infarct [a brain bleed stroke], atrial fibrillation [an irregular heartbeat], and constipation. A record review of Resident #35's admission MDS, dated [DATE], revealed Resident #35 was an [AGE] year-old female assessed with a BIMS score of 14 out of 15 indicating no mental cognition impairment. A record review of Resident #35's physician order summary dated 09/13/2023 revealed Resident #35 was to receive Eliquis [a blood thinner] 5mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; carvedilol [a drug to slow your heartbeat] 25mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; baclofen [a drug to treat muscle stiffness] 10mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and docusate sodium [a stool softener] 100mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #35 on 09/13/2023, Eliquis 5mg, carvedilol 25mg, baclofen 10mg, and docusate 100mg at 11:41 AM, 2 hours and 41 minutes late. 17. A record review of Resident #39's admission record, dated 09/15/2023, revealed an admission date of 09/08/2023 with diagnoses which included cerebral palsy [cerebral means having to do with the brain. Palsy means weakness or problems with using the muscles] and epilepsy [seizures]. A record review of Resident #39's admission MDS, dated [DATE], revealed Resident #39 was a [AGE] year-old female admitted for long term care. A record review of Resident #39's physician order summary, dated 09/13/2023, revealed Resident #39 was to receive gabapentin [a drug used for nerve pain relief] 250mg/ml give 15ml three times a day at 08:00 AM, at 01:00 PM, and at 08:00 PM and levetiracetam 100mg/ml give 10ml two times a day at 08:00 Am and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed LVN D administered to Resident #39 on 09/13/2023, gabapentin 100mg/ml 15ml and levetiracetam 100mg/ml 10 ml at 10:29 AM, 1 hour and 29 minutes late. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 18 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 18. Level of Harm - Minimal harm or potential for actual harm A record review of Resident #40's admission record dated 09/15/2023, revealed an admission date of 09/07/2023 with diagnoses which included hypertension [ high blood pressure] and neuropathy [nerve pain]. Residents Affected - Some A record review of Resident #40's admission MDS dated [DATE] revealed Resident #40 was an [AGE] year-old male admitted for long term care. A record review of Resident #40's physician order summary, dated 09/13/2023 revealed Resident #40 was to receive carvedilol [a medication which slows the heartbeat] 3.125mg give twice a day at 08:00 AM and again at 08:00 PM and gabapentin [a drug for nerve pain relief] 100mg give twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #40 on 09/13/2023, gabapentin 100mg and carvedilol 3.125mg at 09:20 AM, 20 minutes late. 19. A record review of Resident #138's admission record, dated 09/15/2023, revealed an admission date of 06/29/2023 with diagnoses which included nausea, allergies, peripheral vascular disease [is the reduced circulation of blood to a body part other than the brain or heart], and constipation. A record review of Resident #138's quarterly MDS dated [DATE] revealed Resident #23 was an [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 15 out of 15 indicating no cognitive mental impairment. A record review of Resident #138's physician order summary, dated 09/13/2023 revealed Resident #138 was to receive ondansetron [a drug for nausea] 4mg give 1 tablet by mouth before meals; Zyrtec allergy tablet 10mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; apixaban [a blood thinner] 5mg tablet give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; Colace 100mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM; and baclofen [a drug to relive muscle stiffness] 10mg give 1 tablet twice a day at 08:00 AM and again at 08:00 PM. A record review of the facility's medication administration audit report, dated 09/14/2023, revealed RN E administered to Resident #138 on 09/13/2023, ondansetron 4mg, Zyrtec 10mg, apixaban 5mg, Colace 100mg, and baclofen 10mg at 09:42 AM, 42 minutes late. During an interview on 09/15/2023 at 03:00 PM, the DON stated residents' medications were to be administered at the time the prescriber ordered the medications and could be administered 1 hour prior or 1 hour past the prescribed time per professional standards. The DON stated she was not alerted to the potential late medication pass on 09/12/2023 by any of the nurses. The DON stated the risk to residents was they may not receive the therapeutic effects of their medications as prescribed. A record review of the facility's undated Medication Error policy revealed, it is the policy of the facility to be free of significant medication errors an error rate. A medication error report will be filled out for each medication for treatment error . federal regulations state a medication error is a discrepancy between what the physician ordered and what is actually administered. Significant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 19 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm medication error causes the resident discomfort or jeopardizes his or her health . examples are listed below: omissions; unauthorized drugs; wrong dose; wrong route of administration; wrong dosage form; wrong time, including before and after meals or drugs administered 60 minutes earlier or later then the scheduled time. Any medication error must immediately be reported to the resident's attending physician, a medication error form completed, and the immediate supervisor notified. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 20 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and what, if any, action has been taken to address them, for 34 of 38 residents (Residents #1, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 28, 30, 31, 33, 36, 41, 43, 44, 45, 46, 47, 48, 49) whose records were reviewed for pharmacy services. The facility failed to present the pharmacist's recommendations to the residents' physician for medication regimen review This failure could place residents at risk for significant health status declines. The findings included: Record review of Resident #1 Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: paraplegia, unspecified (paralysis of the legs and lower body), epilepsy, unspecified, not intractable, without status epilepticus (disorder characterized by recurrent seizures), and radiculopathy, lumbosacral region (pain syndrome caused by compression or irritation of nerve roots in the lower back). Record review of Resident #1 MDS assessment dated [DATE] reflected a BIMS Score of 13, reflecting intact cognition. Record review of Resident #4 Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: Parkinson's disease (disorder of the central nervous system that affects movement), heart failure, and hypothyroidism (a condition in which the thyroid does not produce enough thyroid hormone). Record review of Resident #4 MDS, dated [DATE] reflected a BIMS of 12, reflecting moderately impaired cognition. Record review of Resident #5 Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Presence of Cardiac Pacemaker (small electrical device used to treat when a heart is not beating regularly), Unspecified Diastolic Heart Failure (Congestive) and Dementia (the loss of cognitive functioning). Record review of Resident #5 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #6's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Dementia, Diabetes (a group of diseases that result in too much sugar in the blood). Record review of Resident #6 MDS, dated [DATE] reflected a BIMS of 14, reflecting intact cognition. Record review of Resident #7's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 21 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm admitted to the facility on [DATE] with diagnosis that included: Acute respiratory failure (inability to breathe properly), congestive heart failure, and atrial fibrillation (an abnormal heartbeat), and long-term use of anticoagulants (blood thinners). Record review of Resident #7 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Residents Affected - Many Record review of Resident #9's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: dementia and chronic anemia (low concentration of iron in blood). Record review of Resident #9 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #11's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Alzheimer's (progressive disease that destroys memory and other important mental functions), Diabetes, and heart disease. Record review of Resident #11 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #12's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart disease, heart failure, and kidney disease. Record review of Resident #12 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #13's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease, Alzheimer's disease, and diabetes. Record review of Resident #13 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #14's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Alzheimer's disease, and lymphedema (swelling in the arms or legs). Record review of Resident #14 MDS, dated [DATE] reflected a BIMS of 14, reflecting intact cognition. Record review of Resident #15's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Dementia, diabetes, and kidney failure. Record review of Resident #15 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #16's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, COPD (a group of lung diseases that block airflow and make it difficult to breathe), and myocardial infarction (blockage of blood to the heart). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 22 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #16 MDS, dated [DATE] reflected a BIMS of 9, reflecting moderately impaired cognition. Record review of Resident #17's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: atrial fibrillation (an abnormal heartbeat), COPD, and diabetes. Residents Affected - Many Record review of Resident #17 MDS, dated [DATE] reflected a BIMS of 6, reflecting severely impaired cognition. Record review of Resident #19's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: chronic kidney disease, COPD, and dementia. Record review of Resident #19 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #20's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: cerebral palsy (permanent neuromuscular disorder causing limitation on all four limbs following a lesion on the developing brain), hyperlipidemia (abnormally high concentration of fats in the blood), and essential (primary) hypertension (abnormally high blood pressure). Record review of Resident #20 MDS, dated [DATE] reflected a BIMS of 13, reflecting intact cognition. Record review of Resident #21's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: atrial fibrillation. Record review of Resident #21 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #22's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease and dementia. Record review of Resident #22 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #23's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: diabetes. Record review of Resident #23 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #24's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: paraplegia, calculus of kidney (small hard deposit that forms in the kidneys). Record review of Resident #24 MDS, dated [DATE] reflected a BIMS of 12, reflecting moderately impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 23 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of Resident #25's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: dementia. Record review of Resident #25 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #26's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: hydrocephalus (buildup of fluid deep within the brain), hypertension (high blood pressure), and polyneuropathy (malfunction of peripheral nerves). Record review of Resident #26 MDS, dated [DATE] reflected a BIMS of 11, reflecting moderately impaired cognition. Record review of Resident #28's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: senile degeneration of the brain, and Sjogren's syndrome (immune system disorder). Record review of Resident #28 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #30's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart disease, kidney failure, and diabetes. Record review of Resident #30 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #31's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease. Record review of Resident #31 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #33's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Bacteremia (the presence of bacteria in the blood stream), and a urinary tract infection. Record review of Resident #33 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #36's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease, kidney disease, and heart disease. Record review of Resident #36 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #43's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, and atrial fibrillation. Record review of Resident #43 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #44's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: recent joint replacement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 24 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Record review of Resident #44 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #45's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Sjogren's syndrome, heart failure, and installed pacemaker. Residents Affected - Many Record review of Resident #45 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #46's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: diabetes, and an acquired absence of left leg below knee. Record review of Resident #47's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), and diabetes. Record review of Resident #47 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #48's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, atrial fibrillation, and chronic kidney disease. Record review of Resident #49's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, COPD, diabetes, and kidney disease. Record review of Resident #49 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of documents titled Consultant Pharmacist's Monthly Report for [Facility], dated June 18 & 19, 2023; July 23 & 24, 2023; and August 20 & 21, 2023 reflected the pharmacist had made medication regimen review recommendations for the residents' physician to review. The record review of pharmacy medication regimen review Note To Attending Physician/Perscriber revealed 33 residents had no interventions to support the pharmacist recommendations. Interview on 9/14/2023 at 10:30 AM, the DON stated that pharmacist recommendations were sent to the physician by the pharmacist at the end of the day after the pharmacist had finished their review of medications. The DON stated it was regular for the facility to not hear back from the physicians regarding the pharmacy medication regimen reviews. Interview on 9/14/2023 at 3:07 PM, the DON stated that ensuring pharmacy medication regimen review were sent to physicians and sent back to the facility was the shared responsibility between the DON, the MDS Nurse, and the Social Worker. The DON stated that since there is not an ADON present, the MDS Nurse and Social Worker assisted the DON in processing pharmacy medication regimen reviews. Interview on 9/14/2023 at 4:13 PM, the Pharmacist stated he was contracted to review the facility's residents for medication regimen review and to attend QAPI meetings. The pharmacist stated he had made monthly pharmacy reviews to include recommendations for the residents' physicians to review. The pharmacist stated he did not provide the physicians with the pharmacy medication regimen review paperwork, and that it was the responsibility of the facility to provide the pharmacy medication regimen recommendations to the residents' physicians. The pharmacist stated he had attended QAPI meetings (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 25 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and could not say if the QAPI meeting produced any quality improvement interventions to ensure residents physicians were addressing his recommendations. Interview on 9/14/2023 at 5:00 PM, the Medical Director stated he openly discussed the difficulties that have been occurring with the primary care physicians of residents not signing or reviewing the pharmacy recommendations during QAPI approximately 6 months ago. The Medical Director stated that the difficulties discussed during the QAPI meeting had continued and he believed there needed to be a system put in place where he can assist with pharmacy review. The Medical Director stated the risks associated with not reviewing or implementing pharmacy recommendations to include gradual dose reductions can vary but can include medications building up in the residents' bodies to toxic levels. Interview on 9/14/2023 at 5:50 PM, the Administrator stated she could not recall exactly what date, but at QAPI meetings, the difficulty of having residents' physicians review the pharmacists' recommendations was addressed. The Administrator could not identify what quality improvement measures were decided upon to address the failure of the resident's physician's lack of reviewing the pharmacist's recommendations. The Administrator stated she was not aware the failure was not corrected. The Administrator stated she believed the failure was addressed by the DON and the Medical Director. The Administrator stated the DON had not reported the continued failure to have resident's physician's review the pharmacist's recommendations. The ADM stated the responsibility for ensuring QAPI interventions were decided and implemented was upon the medical director, the DON, and the pharmacist. Interview on 9/15/2023 at 4:30 PM, the DON stated there was a long-term breakdown to have residents' physicians review the pharmacist's medication regimen review. The DON stated she had been the DON since May 2023 and has had difficulty having resident's physician's sign and document rationales for the resident's pharmacist medication regimen review. The DON stated that they were not aware of any adverse outcomes related to the pharmacy medication regimen reviews not being provided to the physicians. The DON stated she had reported the lack of physician reviews to the Administrator and the medical director on multiple occasions and at QAPI monthly meetings. The DON stated there had been no quality improvement measures decided at the June, July, or August 2023 QAPI meetings. The DON stated she believed the pharmacist drug regimen recommendations were not submitted to the residents' physicians because the pharmacist understood the recommendations were sent by the facility, whereas the facility understood the pharmacist was responsible for sending the pharmacy medication regimen reviews. The DON later stated the facility is ultimately responsible for sending the pharmacy medication regimen reviews to the residents' physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 26 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 32 medication administration opportunities with 7 errors resulting in a 21.88% medication error rate, for 2 of 5 residents (Resident #10 and #26) and 2 of 2 staff Nurses (LVN D and RN E) reviewed for medication pharmacy services, in that: Residents Affected - Some 1. LVN D administered 4 late medications to Resident #26. 2. RN E administered 3 late medications to Resident #10. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings include: 1. A record review of Resident #26's admission record dated 09/15/2023 revealed an admission date of 07/20/2023 with diagnoses which included hypertension [high blood pressure], constipation, glaucoma [a serious eye disease that can damage the optic nerve and cause vision loss or blindness], and polyneuropathy [a condition in which multiple peripheral nerves are damaged]. A record review of Resident #26's admission MDS assessment dated [DATE] revealed Resident #26 was an [AGE] year-old male admitted from the community for long term hospice care. A record review of Resident #26's care plan dated 09/15/2023 revealed, The resident has a terminal prognosis r/t polyneuropathy . Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain . Resident #26 has impaired visual function r/t Glaucoma . A record review of Resident #26's physician order summary, dated 09/12/2023, revealed Resident #26 was to receive on 09/12/2023 at 08:00 AM the following medications: Senna Plus oral tablet 8.6-50 mg (Sennosides-Docusate Sodium) give 2 tablet by mouth two times a day related to constipation; Timoptic ophthalmic solution 0.5 % (Timolol Maleate) Instill 1 drop in both eyes two times a day related to glaucoma; Acetaminophen oral tablet 325 mg give 2 tablet by mouth three times a day related to polyneuropathy; and Atenolol oral tablet 50 mg give 1 tablet by mouth two times a day related to hypertension. During an observation and interview on 09/13/23 at 09:30 AM revealed LVN D prepared and administered to Resident #26 the following medications: Senna Plus oral tablet 8.6-50 mg (sennosides-docusate sodium) Give 2 tablet by mouth two times a day related to constipation . timoptic ophthalmic solution 0.5 % (Timolol Maleate) Instill 1 drop in both eyes two times a day related to glaucoma .acetaminophen oral tablet 325 mg give 2 tablet by mouth three times a day related to polyneuropathy . [and] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 27 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some atenolol oral tablet 50 mg give 1 tablet by mouth two times a day related to hypertension. LVN D stated she was late administering the medications due to her increased workload of having to observe the breakfast dining room for Resident safety. LVN D stated the medications were ordered to be administered at 08:00 AM and had until 09:00 AM to administer the medications per professional standards. LVN D stated she had not reported her potential late medication administration for her ½ of the facility census residents and still required more medication administrations for residents. LVN D stated the potential risk for residents was they may not receive the therapeutic effects of their medications. 2. A record review of Resident #10's admission record dated 09/13/2023, revealed an admission date of 07/17/2023 with diagnoses which included allergies, hypertension [high blood pressure], and cholecystitis [a painful condition that inflames your gallbladder, a small organ that stores bile, a digestive fluid]. A record review of Resident #10's admission MDS dated [DATE], revealed Resident #10 was a [AGE] year-old female assessed with a BIMS score of 13 out of 15 which indicated Resident #10 was cognitively intact. A record review of Resident #10's physician order summary, dated 09/12/2023, revealed Resident #26 was to receive on 09/12/2023 at 08:00 AM the following medications: Eliquis oral tablet 5 mg (apixaban) give 5 mg by mouth every morning and at bedtime related to essential (primary) hypertension; Florastor oral capsule (saccharomyces boulardii) give 250 mg by mouth every morning and at bedtime related to acute cholecystitis; and Fluticasone Propionate nasal suspension (Fluticasone Propionate) 2 spray in each nostril every 12 hours for allergies. During an observation and interview on 09/13/23 at 09:18 AM RN E revealed RN E prepared and administered to Resident #10 the following medications: Eliquis oral tablet 5 mg (apixaban) give 5 mg by mouth every morning and at bedtime related to essential (primary) hypertension; Florastor oral capsule (saccharomyces boulardii) give 250 mg by mouth every morning and at bedtime related to acute cholecystitis; and Fluticasone Propionate nasal suspension (Fluticasone Propionate) 2 spray in each nostril every 12 hours for allergies. RN E stated she was late administering the medications due to her increased workload of having to observe the breakfast dining room for Resident safety, and was responsible for all medication pass, wound care, and treatments for her residents. RN E stated the medications were ordered to be administered at 08:00 AM and had until 09:00 AM to administer the medications per professional standards. RN E stated she had not reported her potential late medication administration for her ½ of the facility census residents and still required more medication administrations for residents. RN E stated the potential risk for residents was they may not receive the therapeutic effects of their medications. During an interview on 09/15/2023 at 03:00 PM, the DON stated residents' medications were to be administered at the time the prescriber ordered the medications and can be administered 1 hour prior or 1 hour past the prescribed time per professional standards. The DON stated she was not alerted to the potential late medication pass on 09/12/2023 by any of the nurses. The DON stated the risk to residents was they may not receive the therapeutic effects of their medications as prescribed. A record review of the facility's undated Medication Error policy revealed, it is the policy of the facility to be free of significant medication errors an error rate. A medication error report will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 28 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete be filled out for each medication for treatment error . federal regulations state a medication error is a discrepancy between what the physician ordered and what is actually administered. Significant medication error causes the resident discomfort or jeopardizes his or her health . examples are listed below: omissions; unauthorized drugs; wrong dose; wrong route of administration; wrong dosage form; wrong time, including before and after meals or drugs administered 60 minutes earlier or later then the scheduled time. Any medication error must immediately be reported to the resident's attending physician, a medication error form completed, and the immediate supervisor notified. Event ID: Facility ID: 675740 If continuation sheet Page 29 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 1 medication rooms and 1 of 38 residents (Resident #40) reviewed for medication storage, in that: 1. LVN F failed to store unadministered medications for Resident #40. 2. The facility failed to secure the medication storage room. These failures could place residents at risk for misappropriation of property and harm by not receiving the therapeutic effects of the medications prescribed by the physician. The findings included: 1. During an observation on 09/11/2023 at 09:03 AM revealed the facility sole medication storage room door was ajar and unsecured. Further observations revealed the room to be unsupervised and unattended. During an observation and interview on 09/11/2023 at 09:15 AM LVN D stated she and LVN F were the nurses on duty and the only staff with keys to the medication storage room. LVN D stated the room was unlocked and proceeded to close and lock the medication storage room door. LVN D stated the room should have been locked. LVN D stated the risk was someone could have had access to the medications. 2. A record review of Resident #40's admission record, dated 09/11/2023, revealed an admission date of 09/07/2023 with diagnoses which included depression, hypertension [high blood pressure], surgical aftercare following surgery on the digestive system, and polyneuropathy [a condition in which multiple peripheral nerves are damaged]. A record review of Resident #40's admission MDS dated [DATE], revealed Resident #40 was an [AGE] year-old male admitted from an acute care hospital for post-surgery care. A record review of Resident #40's September 2023 physician order summary revealed Resident #40, on the morning of 09/11/2023 at 08:00 AM, was to receive 4 drugs and 1 dietary supplement. The medications and supplement were, Escitalopram Oxalate Oral Tablet 20 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day related to DEPRESSION . Lisinopril Oral Tablet 2.5MG (Lisinopril) Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Manuka Honey Give 1 Tbsp by mouth one time a day for Supplement . Carvedilol Oral Tablet 3.125 MG Carvedilol) Give 1 tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 30 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION .Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth three times a day related to POLYNEUROPATHY. During an observation on 09/11/2023 at 11:18 AM of Resident #40's uninhabited unsupervised room revealed a bed side table with multiple pill cups atop of the table. 1 cup was empty aside from a sticky brown residue and another pill cup presented with 3 pills and 1 capsule inside, 1 oval white capsule and 3 round white pills, 1 small, 1 medium, and 1 larger than the rest. The cups were written upon with a marker [Resident #40]. During an observation and interview on 09/11/2023 at 11:50 AM LVN F stated she was Resident #40's nurse and had administered medications that morning around 08:00 AM - 09:00 AM. LVN F entered Resident #40 unoccupied unsupervised room and recognized the medications upon the bedside table. LVN F stated she was surprised because she recalled Resident #40 taking his medications. LVN F stated she must have made an oversight error and did not administer Resident #40's medications due to being distracted with Resident #40 hygiene care. LVN F stated the risk of having the pills at the bedside was Resident #40 had not received the therapeutic effects of his medication and the drugs could have been taken by someone else. LVN F identified the drugs and the residue as escitalopram, lisinopril, honey, carvedilol, and gabapentin. During an interview on 09/15/2023 at 03:00 PM the DON stated all medications should always be secured. The DON stated the medication storage room was to be secured locked when not attended. The DON stated nurses are to administer residents' drugs by witnessing the administration and are never to leave medications at the bedside. The DON stated the risk to residents was not receiving the therapeutic effects of their medication and misappropriation of their property. A record review of the facility's undated Medication Security Policies and Procedures policy revealed, Medications must be kept secured at all times . The central medication storage shall be kept locked when facility staff is not actually in or at the storage area . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 31 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure it was administered in a manner than enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 34 of 34 residents (Residents #1, 4, 5, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 28, 30, 31, 33, 36, 41, 43, 44, 45, 46, 47, 48, 49) reviewed for pharmacy, nursing, and physician cooperation with Administration oversight, in that: Residents Affected - Many The facility failed to present the pharmacist's recommendations to the residents' physician for medication regimen reviews for 3 reviewed monthly pharmacist recommendations (June, July, and August 2023). This failure placed residents at risk for significant health status declines. The findings included: Record review of Resident #1 Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: paraplegia, unspecified (paralysis of the legs and lower body), epilepsy, unspecified, not intractable, without status epilepticus (disorder characterized by recurrent seizures), and radiculopathy, lumbosacral region (pain syndrome caused by compression or irritation of nerve roots in the lower back). Record review of Resident #1 MDS assessment dated [DATE] reflected a BIMS Score of 13, reflecting intact cognition. Record review of Resident #4 Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: Parkinson's disease (disorder of the central nervous system that affects movement), heart failure, and hypothyroidism (a condition in which the thyroid does not produce enough thyroid hormone). Record review of Resident #4 MDS, dated [DATE] reflected a BIMS of 12, reflecting moderately impaired cognition. Record review of Resident #5 Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Presence of Cardiac Pacemaker (small electrical device used to treat when a heart is not beating regularly), Unspecified Diastolic Heart Failure (Congestive) and Dementia (the loss of cognitive functioning). Record review of Resident #5 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #6's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Dementia, Diabetes (a group of diseases that result in too much sugar in the blood). Record review of Resident #6 MDS, dated [DATE] reflected a BIMS of 14, reflecting intact cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 32 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #7's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted to the facility on [DATE] with diagnosis that included: Acute respiratory failure (inability to breathe properly), congestive heart failure, and atrial fibrillation (an abnormal heartbeat), and long-term use of anticoagulants (blood thinners). Residents Affected - Many Record review of Resident #7 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #9's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: dementia and chronic anemia (low concentration of iron in blood). Record review of Resident #9 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #11's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Alzheimer's (progressive disease that destroys memory and other important mental functions), Diabetes, and heart disease. Record review of Resident #11 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #12's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart disease, heart failure, and kidney disease. Record review of Resident #12 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #13's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease, Alzheimer's disease, and diabetes. Record review of Resident #13 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #14's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Alzheimer's disease, and lymphedema (swelling in the arms or legs). Record review of Resident #14 MDS, dated [DATE] reflected a BIMS of 14, reflecting intact cognition. Record review of Resident #15's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Dementia, diabetes, and kidney failure. Record review of Resident #15 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #16's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, COPD (a group of lung diseases that block airflow and make it difficult to breathe), and myocardial infarction (blockage of blood to the heart). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 33 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #16 MDS, dated [DATE] reflected a BIMS of 9, reflecting moderately impaired cognition. Record review of Resident #17's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: atrial fibrillation, COPD, and diabetes. Residents Affected - Many Record review of Resident #17 MDS, dated [DATE] reflected a BIMS of 6, reflecting severely impaired cognition. Record review of Resident #19's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: chronic kidney disease, COPD, and dementia. Record review of Resident #19 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #20's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: cerebral palsy (permanent neuromuscular disorder causing limitation on all four limbs following a lesion on the developing brain), hyperlipidemia (abnormally high concentration of fats in the blood), and essential (primary) hypertension (abnormally high blood pressure). Record review of Resident #20 MDS, dated [DATE] reflected a BIMS of 13, reflecting intact cognition. Record review of Resident #21's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: atrial fibrillation. Record review of Resident #21 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #22's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease and dementia. Record review of Resident #22 MDS, dated [DATE] reflected a BIMS of 7, reflecting severely impaired cognition. Record review of Resident #23's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: diabetes. Record review of Resident #23 MDS, dated [DATE] reflected a BIMS of 15, reflecting intact cognition. Record review of Resident #24's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: paraplegia, calculus of kidney (small hard deposit that forms in the kidneys). Record review of Resident #24 MDS, dated [DATE] reflected a BIMS of 12, reflecting moderately impaired cognition. Record review of Resident #25's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 34 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 admitted on [DATE] with diagnosis that included: dementia. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #25 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Residents Affected - Many Record review of Resident #26's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: hydrocephalus (buildup of fluid deep within the brain), hypertension (high blood pressure), and polyneuropathy (malfunction of peripheral nerves). Record review of Resident #26 MDS, dated [DATE] reflected a BIMS of 11, reflecting moderately impaired cognition. Record review of Resident #28's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: senile degeneration of the brain, and Sjogren's syndrome (immune system disorder). Record review of Resident #28 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #30's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart disease, kidney failure, and diabetes. Record review of Resident #30 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #31's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease. Record review of Resident #31 MDS, dated [DATE] reflected a BIMS of 10, reflecting moderately impaired cognition. Record review of Resident #33's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: Bacteremia (the presence of bacteria in the blood stream), and a urinary tract infection. Record review of Resident #33 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #36's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Parkinson's disease, kidney disease, and heart disease. Record review of Resident #36 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #43's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, and atrial fibrillation. Record review of Resident #43 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #44's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: recent joint replacement. Record review of Resident #44 MDS, dated [DATE] reflected an incomplete BIMS Assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 35 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Record review of Resident #45's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: Sjogren's syndrome, heart failure, and installed pacemaker. Record review of Resident #45 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #46's Face Sheet dated 9/15/2023 reflected a [AGE] year-old resident admitted on [DATE] with diagnosis that included: diabetes, and an acquired absence of left leg below knee. Record review of Resident #47's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), and diabetes. Record review of Resident #47 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of Resident #48's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, atrial fibrillation, and chronic kidney disease. Record review of Resident #49's Face Sheet dated 9/15/2023 reflected an [AGE] year-old resident admitted on [DATE] with diagnosis that included: heart failure, COPD, diabetes, and kidney disease. Record review of Resident #49 MDS, dated [DATE] reflected an incomplete BIMS Assessment. Record review of documents titled Consultant Pharmacist's Monthly Report for [Facility], dated June 18 & 19, 2023; July 23 & 24, 2023; and August 20 & 21, 2023 reflected the pharmacist had made medication regimen review recommendations for the residents' physician to review. The record review of pharmacy medication regimen review Note To Attending Physician/Perscriber revealed 33 residents had no interventions to support the pharmacist recommendations. Interview on 9/14/2023 at 10:30 AM, the DON stated that pharmacist recommendations are sent to the physician by the pharmacist at the end of the day after the pharmacist has finished their review of medications. The DON stated it is regular for the facility to not hear back from the physicians regarding these pharmacy medication regimen reviews. Interview on 9/14/2023 at 3:07 PM, the DON stated that ensuring pharmacy medication regimen review were sent to physicians and sent back to the facility was the shared responsibility between the DON, the MDS Nurse, and the Social Worker. The DON stated that since there is not an ADON present, the MDS Nurse and Social Worker assisted the DON in processing pharmacy medication regimen reviews. Interview on 9/14/2023 at 4:13 PM, the Pharmacist stated he was contracted to review the facility's residents for medication regimen review and to attend QAPI meetings. The pharmacist stated he had made monthly pharmacy reviews to include recommendations for the residents' physicians to review. The pharmacist stated he did not provide the physicians with the pharmacy medication regimen review paperwork, and that it was the responsibility of the facility to provide the pharmacy medication regimen recommendations to the residents' physicians. The pharmacist stated he had attended QAPI meetings and could not say if the QAPI meeting produced any quality improvement interventions to ensure residents physicians were addressing his recommendations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 36 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 9/14/2023 at 5:00 PM, the Medical Director stated he openly discussed the difficulties that have been occurring with the primary care physicians of residents not signing or reviewing the pharmacy recommendations during QAPI approximately 6 months ago. The Medical Director stated that the difficulties discussed during the QAPI meeting had continued and he believed there needed to be a system put in place where he can assist with pharmacy review. The Medical Director stated the risks associated with not reviewing or implementing pharmacy recommendations to include gradual dose reductions can vary but can include medications building up in the residents' bodies to toxic levels. Interview on 9/14/2023 at 5:50 PM, the Administrator stated she could not recall exactly what date, but at QAPI meetings the difficulty of having residents' physicians review the pharmacists' recommendations was addressed. The Administrator could not identify what quality improvement measures were decided upon to address the failure of the resident's physician's lack of reviewing the pharmacist's recommendations. The Administrator stated she was not aware the failure was not corrected. The Administrator stated she believed the failure was addressed by the DON and the Medical Director. The Administrator stated the DON had not reported the continued failure to have resident's physician's review the pharmacist's recommendations. The ADM stated the responsibility for ensuring QAPI interventions were decided and implemented was upon the medical director, the DON, and the pharmacist. Interview on 9/15/2023 at 4:30 PM, the DON stated there was a long-term breakdown to have residents' physicians review the pharmacist's medication regimen review. The DON stated she had been the DON since May 2023 and has had difficulty having resident's physician's sign and document rationales for the resident's pharmacist medication regimen review. The DON stated that they were not aware of any adverse outcomes related to the pharmacy medication regimen reviews not being provided to the physicians. The DON stated she had reported the lack of physician reviews to the Administrator and the medical director on multiple occasions and at QAPI monthly meetings. The DON stated there had been no quality improvement measures decided at the June, July, or August 2023 QAPI meetings. The DON stated she believed the pharmacist drug regimen recommendations were not submitted to the residents' physicians because the pharmacist understood the recommendations were sent by the facility, whereas the facility understood the pharmacist was responsible for sending the pharmacy medication regimen reviews. The DON later stated the facility is ultimately responsible for sending the pharmacy medication regimen reviews to the residents' physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 37 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interviews and record reviews the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility assessment must address or include: All personnel, including managers, staff as well as their education and/or training and any competencies related to resident care, for 1 of 1 facility reviewed for the facility assessment, in that; The facility assessment was developed without complete assessment data and solely by the MDS nurse without training to complete the facility assessment. This failure could place residents at risk for not having their needs met. The findings included: A record review of the facility's CMS 802 Resident Matrix dated 09/11/2023 revealed the facility census to be 38 residents. A record review of the facility's facility assessment tool dated 08/01/2023, revealed Persons involved in completing assessment; Administrator: [The Administrator]; DON: [The DON]; Governing Body Rep [The Administrator]; Medical Director [The Medical Director]; Other: [The MDS nurse]. Further review revealed there were pages missing as compared to the CMS form Facility Assessment Tool. A comparison revealed the page missing was used to identify residents diagnoses and guidelines for assessment of the facility to meet those disease needs. Another page was found to be missing which had guidance for assessing the facility's ability to provide assistance with activities of everyday life. further review revealed the page with guidance foe assessing residents needs to include emergencies was missing. During an interview on 09/15/2023 at 02:30 PM the MDS nurse stated I don't remember well .but sometime late July 2023 she alone and without training was assigned the task of completing the Facility Assessment by the Administrator during the QAPI meeting. The MDS nurse stated she was given the CMS facility assessment tool and she proceeded to fill out the form by answering the questions. The MDS nurse stated, I thought the assessment was to identify the current [Resident] census, I did not realize the assessment was more than that. The MDS nurse stated she completed the form and submitted the form to the Administrator. The MDS nurse stated in some areas of the form she just forwarded data from the previous assessment for example the area of the form Persons involved in completing assessment; Administrator: [The Administrator]; DON: [The DON]; Governing Body Rep [The Administrator]; Medical Director [The Medical Director]; Other: [The MDS nurse]. The MDS nurse stated she had used the facility's schedules to answer the questions on the form regarding determine the overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each residents needs. The MDS nurse stated she documented herself as a full-time employee even though she only worked 3 days of the week. The MDS nurse stated the facility had scheduled 2 nurses per the day and evening shifts and 1 nurse for the overnight shift. The MDS nurse stated she was expected to perform her MDS duties and others as assigned, for example the facility assessment, while working at 2 different facilities'. During an interview at 09/15/2023 at 03:30 PM the DON stated the MDS nurse completed the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 38 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many assessment using the previous facility assessment. The DON stated she had not provided any training for the MDS nurse to complete the facility assessment and believed the facility assessment would be the responsibility of the Administrator. During an interview on 09/15/2023 at 04:00 PM the Administrator stated the facility assessment was the responsibility of the nursing staff and had been assigned and completed by the MDS nurse. The Administrator stated she had reviewed the facility assessment and believed it to be accurate to meet the needs of the residents. the Administrator stated she believed the DON would train the MDS nurse to complete the assessment. The Administrator stated she believed the current facility assessment would support the needs of the residents. A record review of the facility's undated [The Facility] Facility Assessment Policy revealed, The requirement for the facility assessment may be found in attachment one. Purpose; the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies . attachment one . rules and regulations, also see survey and certification memos and appendix PP in the state operations manual for additional information. Facility assessment: The facility assessment must address or include: the facilities resident population including but not limited to both the number of residents and the facilities resident capacity the physical environment equipment services and other physical plant considerations that are necessary to care for this population . all personnel including manager staff and volunteers as well as their education and or training and any competencies related to resident care . a facility based and community based risk assessment utilizing an all hazards approach. attachment 2; plan for the assessment: the administrator or designated individual assigns a person to lead the facility assessment process the leader identifies and invites team members to be on the assessment team including the Administrator, representative of the governing body, medical director, and the director of nurses and considers other persons to be on the team. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 39 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interviews and record reviews the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained for 1 of 1 facility reviewed for QAPI performance improvements, in that; The facility failed to develop quality improvement measures and or interventions after recognizing a failure to have the resident's physician address the pharmacists monthly drug regiment review recommendations. This failure could place residents at risk for harm by not receiving the benefits of the physician and the pharmacist's review. The findings included: Record review of documents titled Consultant Pharmacist's Monthly Report for [The Facility], dated June 18 & 19, 2023; July 23 & 24, 2023; and August 20 & 21, 2023 reflected the pharmacist had made medication regimen review recommendations for the residents' physician to review. The record review revealed 33 residents of the 33 sampled had no interventions to support the pharmacist recommendations. Interview on 9/14/2023 at 4:13 PM, the Pharmacist stated he was contracted to review the facility's residents for medication regimen review and to attend QAPI meetings. The pharmacist stated he had made monthly pharmacy reviews to include recommendations for the residents' physicians to review. The pharmacist stated he did not provide the physicians with the pharmacy medication regimen review paperwork, and that it was the responsibility of the facility to provide the pharmacy medication regimen recommendations to the residents' physicians. The pharmacist stated he had attended QAPI meetings and could not say if the QAPI meeting produced any quality improvement interventions to ensure residents physicians were addressing his recommendations. During an interview on 9/14/2023 at 05:00 PM, the Medical Director stated he openly discussed the difficulties that have been occurring with the primary care physicians of residents not signing or reviewing the pharmacy recommendations during the QAPI meeting approximately 6 months ago. The Medical Director stated that the difficulties discussed during the QAPI meeting had continued and he believed there needed to be a system put in place where he can assist with pharmacy review. The Medical Director stated the risks associated with not reviewing or implementing pharmacy recommendations to include gradual dose reductions can vary but can include medications building up in the residents' bodies to toxic levels. During an interview on 9/14/2023 at 5:50 PM, the Administrator stated she could not recall exactly what date, but at QAPI meetings the difficulty of having residents' physicians review the pharmacists' recommendations was addressed. The Administrator could not identify what quality improvement measures were decided upon to address the failure of the resident's physician's lack of reviewing the pharmacist's recommendations. The Administrator stated she was not aware the failure was not corrected. The Administrator stated she believed the failure was addressed by the DON and the Medical Director. The Administrator stated the DON had not reported the continued failure to have resident's physician's review the pharmacist's recommendations. The Administrator stated the responsibility for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 40 of 41 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 675740 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Knopp Nursing & Rehab Center Inc 202 Billie Dr Fredericksburg, TX 78624 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some ensuring QAPI interventions were decided and implemented was upon the medical director, the DON, and the pharmacist. Interview on 9/15/2023 at 4:30 PM, the DON stated there was a long-term breakdown to have residents' physicians review the pharmacist's medication regimen review. The DON stated she had been the DON since May 2023 and has had difficulty having resident's physician's sign and document rationales for the resident's pharmacist medication regimen review. The DON stated she had reported the lack of physician reviews to the Administrator and the medical director on multiple occasions and at QAPI monthly meetings. The DON stated there had been no quality improvement measures decided at the June, July, or August 2023 QAPI meetings. The DON stated she believed the pharmacist drug regiment recommendations were not submitted to the residents' physicians because the pharmacist understood the recommendations were sent by the facility, whereas the facility understood the pharmacist was responsible for sending the pharmacy medication regimen reviews. A record review of the facility's undated quality assurance and performance improvement QAPI program revealed, this facility shall develop, implement, and maintain an ongoing, facility wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents . authority; the owner and or governing board body of our facility is ultimately responsible for the QAPI program. the governing board owner evaluates the effectiveness of itsQAPI program at least annually and presents findings to the QAPI committee. the administrator is responsible for assuring that this facilities QAPI the program complies with federal, state, and local Regulatory agency requirements. The QAPI committee reports directly to the Administrator. The QAPI plan describes the process for identifying and correcting quality deficiencies. key components of this process include: tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systemically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action performance improvement activities and revising as needed. the committee meets monthly to review reports, evaluate data, and monitor QAPI related activities and make adjustments to the plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675740 If continuation sheet Page 41 of 41