Health inspection·March 13, 2025

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 understood others and made himself understood. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated Resident #1 was cognitively intact. The MDS assessment indicated Resident #1's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record review of Resident #1's care plan, dated on 1/3/19, indicated Resident #1 had an ADL Self Care Performance Deficit. The care plan goal included, the resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. The care plan interventions included Bed Mobility: supervision as needed, Eating: supervision as needed, resident chooses to grow his hair out, resident chooses to have a beard and mustache, toileting: supervision as needed and walking: provide supervision as needed. Record review of the intake worksheet dated 3/7/24 at unknown time indicted, On 03/07/25, facility LVN A reported she overheard Resident #1 stating that the community support advocate IDD and independent trainer who was employed with IDD office, Community Support Advocate B allegedly purchased a candy bar for himself with Resident #1's purchases. Community Support Advocate B assisted with shopping and offered to take Resident #1 shopping. The date and location of the incident is unknown. The desired outcome is to report the situation that occurred. Record Review of Resident Bank Statement dated 3/12/25 at 1:33 p.m., indicated Resident #1 was advanced $60.00 in cash on 2/18/25. The Bank statement indicated Resident #1 was advanced $60.00 in cash on 12/11/24. Record Review of leave of absence form revised dated 9/14/2016 indicated Resident#1 last checked out of the facility on 12/17/24 at 8:37 a.m. and returned on 12/17/24 at 9:15 a.m. During a phone interview on 3/11/25 at 3:23 p.m., Confidential complainant stated an allegation had been made towards one of the workers at outside of the facility where she worked at independent living skills office. Confidential complainant stated it was overheard and she was not sure if this incident even occurred that her employee Community Support Advocate B had purchased a candy bar with Resident #1's money. Confidential complainant stated her coworkers name was Community Support Advocate B who was suspected of taking money from the resident to buy candy from the vending machine Confidential complainant stated the Community Support Advocate B informed her that he did not purchase a candy bar with the resident's money. Confidential complainant stated she wanted to make sure the resident was not being taken advantage of. During a phone interview on 3/11/25 at 4:38 p.m., Community Support Advocate B stated he never used the resident's money to purchase a fountain drink. Community Support Advocate B stated he did not use the resident's money to purchase a candy bar from the vending machine. Community Support Advocate B stated he came to see the resident every Wednesday morning. Community Support Advocate B stated he had never told the resident that he had authority over him. Community Support Advocate B stated he just makes sure the resident was safe when he leaves the building and when he comes back to the facility. During an interview on 3/11/25 at 3:45 p.m., Resident #1 stated the Community Support Advocate B always buys his drinks with Resident#1's money. Resident #1 stated Community Support Advocate B buys coca cola fountain drinks with Resident #'1's money. Resident #1 stated the Community Support Advocate B always asked the resident how much money he had and was his money in his account. Resident #1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675802 If continuation sheet Page 2 of 9 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 675802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kemp Care Center 1351 South Elm Street Kemp, TX 75143 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated when Community Support Advocate B would take him to the store that he would tell him, Don't go that way, come this way. Resident #1 stated he did not like Community Support Advocate B telling him not to go certain places in the store. Resident #1 stated he went shopping every week with Community Support Advocate B. Resident #1 stated he did not like shopping every week. Resident #1 stated Community Support Advocate B always asked him, How much money you got, and I got authority over you. Resident #1 stated he did not like Community Support Advocate B stating that he had authority over him. Resident #1 stated he did not know anything about Community Support Advocate B buying candy from the vending machine using his money. During an interview on 3/11/25 at 4:29 p.m., LVN A stated she did not overhear Resident #1 say anything regarding Resident #'1s money being spent on the community Support Advocate B from the vending machines. LVN A stated in the morning meeting someone had told her, Hey, off the cuff I overheard that the PASRR guy had used the resident #1's money to purchase a candy bar. LVN A stated that, Resident #1 thought that Community Support Advocate B had put a candy bar up there for him to pay for it one time when they were out at the store. LVN A stated that this information was said to her at the morning meeting on Friday 3/7/25. LVN A stated she did not remember who brought it up in the morning meeting. LVN A stated all of the department heads attended the morning meetings. LVN A stated the rumor on the Community Support Advocate B using the resident's money for a candy bar at the vending machine should have been reported to the Administrator, but she figured everyone heard the discussion at the morning meeting. LVN A stated she notified IDD office. LVN A stated she reported to IDD office because Community Support Advocate B was not one of the facility's employees. LVN A stated Community Support Advocate B sees Resident #1 once a week. LVN A stated she was not sure if they went to the store every week. During an interview on 3/12/25 at 9:01 a.m., LVN A stated the Administrator oversaw her. LVN A stated she was the MDS Coordinator. LVN A stated the abuse coordinator was the Administrator. LVN A stated she did not know when the exact time frame of when Community Support Advocate B was supposed to have used the resident's money for the candy bar. LVN A stated she last completed abuse and neglect in-services yesterday 3/11/25. LVN A stated, It would be important to report ANE (Abuse, Neglect, exploitation) to prevent and to protect the residents against any forms of abuse and exploitation; be a voice for them when they cannot be a voice for themselves. During an interview on 3/12/25 at 9:17 a.m., with the Administrator, she stated she had been the Administrator since the middle of December 2025. The Administrator stated she oversaw the MDS Coordinator. The Administrator stated she was the abuse coordinator. The Administrator stated she last provided in-services on abuse and neglect yesterday 3/11/25. The Administrator stated she did not remember overhearing about misappropriation of property for Resident #1. The Administrator stated she was responsible for reporting ANE to State. The Administrator stated this incident should have been reported to State and investigated. The Administrator stated the reason why it was not investigated and reported was because she was not made aware of the incident by LVN A. The Administrator stated the State guideline and the facility's policy for reporting ANE was 24 hours. The Administrator stated this incident occurred at a local store. The Administrator stated the resident stated it was a little package of donuts that the resident reported to her of what Resident #1 spent with his money. The Administrator stated she did not know how often Resident #1, and Community Support Advocate B went to the store. The Administrator stated it was important to investigate, report and follow facility's policy on ANE to protect the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675802 If continuation sheet Page 3 of 9 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 675802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kemp Care Center 1351 South Elm Street Kemp, TX 75143 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 69 (Resident #1) residents reviewed for abuse and neglect. The facility failed to report to the state agency within 24 hours of being notified of misappropriation of property for Resident #1. This failure to report could place the residents at risk for abuse. The findings included: Record Review of the abuse and neglect policy dated 3/29/18 indicated Abuse is the willful infliction of injury, unreasonable confinement, intimidation. Or punishment resulting physical harm. pain or mental anguish. Abuse also includes the deprivation by an individual. including a caretaker, of goods or services that are necessary to attain or maintain physical. mental. and psychosocial well-being. Instances of abuse of all residents. irrespective of any mental or physical condition. cause physical harm, pain or mental anguish. It includes verbal abuse. sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse. means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Adverse event. An adverse event is an untoward. undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. (9) Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. (3) Facility employees must report all allegation of: abuse, neglect, exploitation, mistreatment, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter I 9-1 7 dated 7 / l 0/1 9. (a.) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours. (b) If the allegation does not involve abuse or serious bodily injury. The report must be made within 24 hours of the allegation. Record review of Resident #1's face sheet dated 3/11/25 at 6:19 p.m., indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining), acute chronic systolic (congestive) heart failure (heart is unable to pump enough force to push enough blood into circulation), osteoarthritis (degeneration of joint cartilage and the underlying bone), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to) and essential hypertension (high blood pressure). Record review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 understood others (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675802 If continuation sheet Page 4 of 9 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 675802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kemp Care Center 1351 South Elm Street Kemp, TX 75143 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and made himself understood. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated Resident #1 was cognitively intact. The MDS assessment indicated Resident #1's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record review of Resident #1's care plan, dated on 1/3/19, indicated Resident #1 had an ADL Self Care Performance Deficit. The care plan goal included, the resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. The care plan interventions included Bed Mobility: supervision as needed, Eating: supervision as needed, resident chooses to grow his hair out, resident chooses to have a beard and mustache, toileting: supervision as needed and walking: provide supervision as needed. Record review of the intake worksheet dated 3/7/24 at unknown time indicted, On 03/07/25, facility LVN A reported she overheard Resident #1 stating that the community support advocate IDD and independent trainer who was employed with IDD office, Community Support Advocate B allegedly purchased a candy bar for himself with Resident #1's purchases. Community Support Advocate B assisted with shopping and offered to take Resident #1 shopping. The date and location of the incident is unknown. The desired outcome is to report the situation that occurred. Record Review of Resident Bank Statement dated 3/12/25 at 1:33 p.m., indicated Resident #1 was advanced $60.00 in cash on 2/18/25. The Bank statement indicated Resident #1 was advanced $60.00 in cash on 12/11/24. Record Review of leave of absence form revised dated 9/14/2016 indicated Resident#1 last checked out of the facility on 12/17/24 at 8:37 a.m. and returned on 12/17/24 at 9:15 a.m. During a phone interview on 3/11/25 at 3:23 p.m., Confidential complainant stated an allegation had been made towards one of the workers at outside of the facility where she worked at independent living skills office. Confidential complainant stated it was overheard and she was not sure if this incident even occurred that her employee Community Support Advocate B had purchased a candy bar with Resident #1's money. Confidential complainant stated her coworkers name was Community Support Advocate B who was suspected of taking money from the resident to buy candy from the vending machine Confidential complainant stated the Community Support Advocate B informed her that he did not purchase a candy bar with the resident's money. Confidential complainant stated she wanted to make sure the resident was not being taken advantage of. During a phone interview on 3/11/25 at 4:38 p.m., Community Support Advocate B stated he never used the resident's money to purchase a fountain drink. Community Support Advocate B stated he did not use the resident's money to purchase a candy bar from the vending machine. Community Support Advocate B stated he came to see the resident every Wednesday morning. Community Support Advocate B stated he had never told the resident that he had authority over him. Community Support Advocate B stated he just makes sure the resident was safe when he leaves the building and when he comes back to the facility. During an interview on 3/11/25 at 3:45 p.m., Resident #1 stated the Community Support Advocate B always buys his drinks with Resident#1's money. Resident #1 stated Community Support Advocate B buys coca cola fountain drinks with Resident #'1's money. Resident #1 stated the Community Support Advocate B always asked the resident how much money he had and was his money in his account. Resident #1 stated when Community Support Advocate B would take him to the store that he would tell him, Don't go (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675802 If continuation sheet Page 5 of 9 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 675802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kemp Care Center 1351 South Elm Street Kemp, TX 75143 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few that way, come this way. Resident #1 stated he did not like Community Support Advocate B telling him not to go certain places in the store. Resident #1 stated he went shopping every week with Community Support Advocate B. Resident #1 stated he did not like shopping every week. Resident #1 stated Community Support Advocate B always asked him, How much money you got, and I got authority over you. Resident #1 stated he did not like Community Support Advocate B stating that he had authority over him. Resident #1 stated he did not know anything about Community Support Advocate B buying candy from the vending machine using his money. During an interview on 3/11/25 at 4:29 p.m., LVN A stated she did not overhear Resident #1 say anything regarding Resident #'1s money being spent on the community Support Advocate B from the vending machines. LVN A stated in the morning meeting someone had told her, Hey, off the cuff I overheard that the PASRR guy had used the resident #1's money to purchase a candy bar. LVN A stated that, Resident #1 thought that Community Support Advocate B had put a candy bar up there for him to pay for it one time when they were out at the store. LVN A stated that this information was said to her at the morning meeting on Friday 3/7/25. LVN A stated she did not remember who brought it up in the morning meeting. LVN A stated all of the department heads attended the morning meetings. LVN A stated the rumor on the Community Support Advocate B using the resident's money for a candy bar at the vending machine should have been reported to the Administrator, but she figured everyone heard the discussion at the morning meeting. LVN A stated she notified IDD office. LVN A stated she reported to IDD office because Community Support Advocate B was not one of the facility's employees. LVN A stated Community Support Advocate B sees Resident #1 once a week. LVN A stated she was not sure if they went to the store every week. During an interview on 3/12/25 at 9:01 a.m., LVN A stated the Administrator oversaw her. LVN A stated she was the MDS Coordinator. LVN A stated the abuse coordinator was the Administrator. LVN A stated she did not know when the exact time frame of when Community Support Advocate B was supposed to have used the resident's money for the candy bar. LVN A stated she last completed abuse and neglect in-services yesterday 3/11/25. LVN A stated, It would be important to report ANE (Abuse, Neglect, exploitation) to prevent and to protect the residents against any forms of abuse and exploitation; be a voice for them when they cannot be a voice for themselves. During an interview on 3/12/25 at 9:17 a.m., with the Administrator, she stated she had been the Administrator since the middle of December 2025. The Administrator stated she oversaw the MDS Coordinator. The Administrator stated she was the abuse coordinator. The Administrator stated she last provided in-services on abuse and neglect yesterday 3/11/25. The Administrator stated she did not remember overhearing about misappropriation of property for Resident #1. The Administrator stated she was responsible for reporting ANE to State. The Administrator stated this incident should have been reported to State and investigated. The Administrator stated the reason why it was not investigated and reported was because she was not made aware of the incident by LVN A. The Administrator stated the State guideline and the facility's policy for reporting ANE was 24 hours. The Administrator stated this incident occurred at a local store. The Administrator stated the resident stated it was a little package of donuts that the resident reported to her of what Resident #1 spent with his money. The Administrator stated she did not know how often Resident #1, and Community Support Advocate B went to the store. The Administrator stated it was important to investigate, report and follow facility's policy on ANE to protect the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675802 If continuation sheet Page 6 of 9 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 675802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kemp Care Center 1351 South Elm Street Kemp, TX 75143 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure in response to allegations of abuse, neglect, or mistreatment, have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse, neglect, or mistreatment while the investigation was in progress. And report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1of 69 (Resident #1) residents reviewed for Abuse and Neglect. Residents Affected - Few The facility's Administrator failed to ensure on Resident #1's misappropriation of property was thoroughly investigated. This failure could place residents at risk for ANE. Findings included: Record Review of the abuse and neglect policy dated 3/29/18 indicated Abuse is the willful infliction of injury, unreasonable confinement, intimidation. Or punishment resulting physical harm. pain or mental anguish. Abuse also includes the deprivation by an individual. including a caretaker, of goods or services that are necessary to attain or maintain physical. mental. and psychosocial well-being. Instances of abuse of all residents. irrespective of any mental or physical condition. cause physical harm, pain or mental anguish. It includes verbal abuse. sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse. means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Adverse event. An adverse event is an untoward. undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. (9) Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. (3) Facility employees must report all allegation of: abuse, neglect, exploitation, mistreatment, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter I 9-1 7 dated 7 / l 0/1 9. (a.) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours. (b) If the allegation does not involve abuse or serious bodily injury. The report must be made within 24 hours of the allegation. Record review of Resident #1's face sheet dated 3/11/25 at 6:19 p.m., indicated Resident #1 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining), acute chronic systolic (congestive) heart failure (heart is unable to pump enough force to push enough blood into circulation), osteoarthritis (degeneration of joint cartilage and the underlying bone), Muscle weakness (a lack of muscle strength, meaning the muscles may not contract or move as easily as they used to) and essential hypertension (high blood pressure). Record review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 understood others and made himself understood. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated Resident #1 was cognitively intact. The MDS assessment indicated Resident #1's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675802 If continuation sheet Page 7 of 9 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 675802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kemp Care Center 1351 South Elm Street Kemp, TX 75143 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #1's care plan, dated on 1/3/19, indicated Resident #1 had an ADL Self Care Performance Deficit. The care plan goal included, the resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score) through the review date. The care plan interventions included Bed Mobility: supervision as needed, Eating: supervision as needed, resident chooses to grow his hair out, resident chooses to have a beard and mustache, toileting: supervision as needed and walking: provide supervision as needed. Record review of the intake worksheet dated 3/7/24 at unknown time indicted, On 03/07/25, facility LVN A reported she overheard Resident #1 stating that the community support advocate IDD and independent trainer who was employed with IDD office, Community Support Advocate B allegedly purchased a candy bar for himself with Resident #1's purchases. Community Support Advocate B assisted with shopping and offered to take Resident #1 shopping. The date and location of the incident is unknown. The desired outcome is to report the situation that occurred. Record Review of Resident Bank Statement dated 3/12/25 at 1:33 p.m., indicated Resident #1 was advanced $60.00 in cash on 2/18/25. The Bank statement indicated Resident #1 was advanced $60.00 in cash on 12/11/24. Record Review of leave of absence form revised dated 9/14/2016 indicated Resident#1 last checked out of the facility on 12/17/24 at 8:37 a.m. and returned on 12/17/24 at 9:15 a.m. During a phone interview on 3/11/25 at 3:23 p.m., Confidential complainant stated an allegation had been made towards one of the workers at outside of the facility where she worked at independent living skills office. Confidential complainant stated it was overheard and she was not sure if this incident even occurred that her employee Community Support Advocate B had purchased a candy bar with Resident #1's money. Confidential complainant stated her coworkers name was Community Support Advocate B who was suspected of taking money from the resident to buy candy from the vending machine Confidential complainant stated the Community Support Advocate B informed her that he did not purchase a candy bar with the resident's money. Confidential complainant stated she wanted to make sure the resident was not being taken advantage of. During a phone interview on 3/11/25 at 4:38 p.m., Community Support Advocate B stated he never used the resident's money to purchase a fountain drink. Community Support Advocate B stated he did not use the resident's money to purchase a candy bar from the vending machine. Community Support Advocate B stated he came to see the resident every Wednesday morning. Community Support Advocate B stated he had never told the resident that he had authority over him. Community Support Advocate B stated he just makes sure the resident was safe when he leaves the building and when he comes back to the facility. During an interview on 3/11/25 at 3:45 p.m., Resident #1 stated the Community Support Advocate B always buys his drinks with Resident#1's money. Resident #1 stated Community Support Advocate B buys coca cola fountain drinks with Resident #'1's money. Resident #1 stated the Community Support Advocate B always asked the resident how much money he had and was his money in his account. Resident #1 stated when Community Support Advocate B would take him to the store that he would tell him, Don't go that way, come this way. Resident #1 stated he did not like Community Support Advocate B telling him not to go certain places in the store. Resident #1 stated he went shopping every week with Community Support Advocate B. Resident #1 stated he did not like shopping every week. Resident #1 stated Community Support Advocate B always asked him, How much money you got, and I got authority over you. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675802 If continuation sheet Page 8 of 9 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 675802 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kemp Care Center 1351 South Elm Street Kemp, TX 75143 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #1 stated he did not like Community Support Advocate B stating that he had authority over him. Resident #1 stated he did not know anything about Community Support Advocate B buying candy from the vending machine using his money. During an interview on 3/11/25 at 4:29 p.m., LVN A stated she did not overhear Resident #1 say anything regarding Resident #'1s money being spent on the community Support Advocate B from the vending machines. LVN A stated in the morning meeting someone had told her, Hey, off the cuff I overheard that the PASRR guy had used the resident #1's money to purchase a candy bar. LVN A stated that, Resident #1 thought that Community Support Advocate B had put a candy bar up there for him to pay for it one time when they were out at the store. LVN A stated that this information was said to her at the morning meeting on Friday 3/7/25. LVN A stated she did not remember who brought it up in the morning meeting. LVN A stated all of the department heads attended the morning meetings. LVN A stated the rumor on the Community Support Advocate B using the resident's money for a candy bar at the vending machine should have been reported to the Administrator, but she figured everyone heard the discussion at the morning meeting. LVN A stated she notified IDD office. LVN A stated she reported to IDD office because Community Support Advocate B was not one of the facility's employees. LVN A stated Community Support Advocate B sees Resident #1 once a week. LVN A stated she was not sure if they went to the store every week. During an interview on 3/12/25 at 9:01 a.m., LVN A stated the Administrator oversaw her. LVN A stated she was the MDS Coordinator. LVN A stated the abuse coordinator was the Administrator. LVN A stated she did not know when the exact time frame of when Community Support Advocate B was supposed to have used the resident's money for the candy bar. LVN A stated she last completed abuse and neglect in-services yesterday 3/11/25. LVN A stated, It would be important to report ANE (Abuse, Neglect, exploitation) to prevent and to protect the residents against any forms of abuse and exploitation; be a voice for them when they cannot be a voice for themselves. During an interview on 3/12/25 at 9:17 a.m., with the Administrator, she stated she had been the Administrator since the middle of December 2025. The Administrator stated she oversaw the MDS Coordinator. The Administrator stated she was the abuse coordinator. The Administrator stated she last provided in-services on abuse and neglect yesterday 3/11/25. The Administrator stated she did not remember overhearing about misappropriation of property for Resident #1. The Administrator stated she was responsible for reporting ANE to State. The Administrator stated this incident should have been reported to State and investigated. The Administrator stated the reason why it was not investigated and reported was because she was not made aware of the incident by LVN A. The Administrator stated the State guideline and the facility's policy for reporting ANE was 24 hours. The Administrator stated this incident occurred at a local store. The Administrator stated the resident stated it was a little package of donuts that the resident reported to her of what Resident #1 spent with his money. The Administrator stated she did not know how often Resident #1, and Community Support Advocate B went to the store. The Administrator stated it was important to investigate, report and follow facility's policy on ANE to protect the residents FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675802 If continuation sheet Page 9 of 9