Inspection·April 25, 2023

F 0604 Intervention: Anticipate needs and meet them as able. Keep call light in reach when in room. Level of Harm - Minimal harm or potential for actual harm Review of facility self-report worksheet dated 04/03/2023 revealed the following: On 04/03/2023 around 9:30 am, CNA A told DON Resident #1 was found restrained in bed last night 04/02/2023 round 10:45 pm. CNA A stated Resident #1 had a sheet wrapped around him and another strap was also used to restrain resident into bed. There was no injury to resident and by statements gathered it was during a time frame of 1 hour and 15 minutes. No staff admit to restraining resident. Residents Affected - Few During the entrance interview on 04/04/2023 at 10:20 AM Administrator and DON said Resident #1 was found restrained on 04/02/2023 around 10:45 PM. He was put to bed around 9 PM possibly restrained over an hour. He was extremely combative and physically assaulted one of the aids. On 04/03/2023 he was ordered Lorazepam 1 milligram intermuscular (a sedative) by his primary physician for his agitation and combativeness and sent to the hospital for a possible urinary tract infection. DON said Resident #1 may have had a urinary tract infection because he was hallucinating seeing people in his room that was not there. She said he was a fall precaution and was frequently checked on during shifts. When CNA A went to check on him, she pulled back the covers and found him restrained to his bed. DON said CNA did not report the incident until she saw her in the morning. During an interview on 04/04/2023 at 10:20 AM CNA A said she was doing her first round at the change of shift (10 PM to 7AM) passing ice and water on her floor (Hall 2100), Resident #1 was the last resident on the hall. She said she went to check on him as part of her rounds and pulled back his covers revealing he was restrained to his bed with a black strap extended from the middle of the mattress reaching across his midsection (hip area) and tied to the other side of the bed. She said also Resident #1 had a draw sheet wrapped around the bottom half of his pelvic area like a diaper and a portion of the strap knotted around the diaper tight to the extent it was difficult to remove the diaper (draw sheet). During an observation on of Resident #1's room on 04/04/2023 at 10:45 AM revealed a bare mattress with a long black strap approximately 3 to 4 feet long at the head of the bed. The strap was attached to the mattress and securely attached, making it difficult to break or remove. CNA A assisted in the observation by lying on the mattress and indicating there was also another black strap located in the middle of the mattress and stretched across the midsection of Resident #1. The black strap located in the middle of the mattress (left side of the bed away from the wall) was missing, CNA A said she did not know what happened to it. She continued the demonstration by saying Resident #1 had a draw sheet wrapped around his pelvis area like a diaper and said the black strap located in the middle of the mattress (right side of bed near the wall) was knotted around the diaper and she had a hard time removing the knot. She said she unrestrained Resident #1 but did not tell the charge nurse about Resident #1 being restrained. She said she felt she should report her findings directly to the DON when she came in to work in the morning recognizing it was going to be at least 8 hours after finding Resident #1 restrained. She said she waited to tell DON in the morning because she felt that was what she was supposed to do and confirmed she did not report her findings to the charge nurse. CNA A said she was not afraid of her co-workers and not afraid of retribution in reporting Resident #1 restraint. During an interview on 04/04/2023 at 3:30 PM Resident #1 (who was admitted an acute care hospital) said he could not remember what happened prior to his admission to the acute care hospital. He said he was blind and could not tell surveyor Who did what to him and could not remember how he got to the hospital or why. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 2 of 8 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 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 04/05/2023 at 12:45 PM Resident #1's friend who was visiting him said Resident #1 told him he could not remember how or why he was admitted to the hospital. During an interview on 04/05/2023 at 1:00 PM LVN B (charge nurse) said, Resident #1 was up and ambulating in the hallway beginning the 2pm-10pm shift stating he wants to go home and trying to look for his truck. He (charge nurse) fed Resident #1 during dinner and towards the end of the shift the nurse aides put the resident to bed and around 9 PM the Resident #1 was hitting the wall and appeared agitated. He (charge nurse) went to check on Resident #1 and he was laying down covered up with a white sheet. Asked him what the problem was, and he said he wanted to go home. Charge nurse told Resident #1 that the weather was bad, and he should wait till the next day. Resident #1 was satisfied with the answer and quieted down. Charge left him covered in a white sheet with the bed in low position and fall mat in place. He said he did not witness Resident #1 being restrained or see any black straps on or under the bed. During an interview on 04/05/2023 at 1:45 PM CNA C said she was working on the 2 PM to 10 PM shift and Resident #1 was in his wheel chair rolling around and we generally wait till the end of the shift to put him to bed because he was fall precaution and we (staff) were able to keep an eye on him until we put him to bed. She said she was assisted by another aide, and they removed his pants, and he had a small bowel movement. She said she cleaned him up and the other aid was assisting someone else. She said she put on a brief, and he had on a white t-shirt. She said he had a draw sheet under him, and she placed a cover over him and left. She said he was not restrained. She said she did not hear him hitting the wall or being combative at all during her shift. She said she only heard from the other shift the next day Resident #1 was being combative and agitated. During initial tour and investigation on 04/04/2023 (between 10:30 AM and 4:00 PM and 04/05/2023 (between 8:30 AM and 2:00 PM) staff (10 on first floor and 10 second floor) revealed they were in-serviced by administration on reporting immediately to administrator (identified as the abuse coordinator) any resident found to be restrained regardless of if on day, night or weekends. Staff interviewed said there in-servicing occurred after and during 04/03/2023. Interviewed staff also revealed as part of their employment they have training and education regarding the facility was restraint free. During observation (second floor) on 04/05/2023 between 12:30 PM till 1:00 PM, residents (3 identified by staff as being totally dependent) revealed they did not have any signs of restraints to their arms, hands, legs or ankles, 1 resident was interviewable and denied anyone ever attempting to restrain him. During an interview on 04/05/2023 at 1:30 PM Administrator said his expectation for reporting any resident restrained would be immediate and the risk for resident being restrained potentially would be the resident could be injured or failure to evacuate during a fire or emergency. During an interview on 04/05/2023 at 1:40 PM DON said her expectation for reporting any resident restrained would be immediate and the risk for resident being restrained potentially would be the resident could be injured or failure to evacuate during a fire or emergency. Review of facility records revealed all staff being or in the process of being in-service on facility restraint policy. Review of facility policy dated 10/24/2022 titled, Policy and Procedure: Abuse, Neglect and Exploitation revealed the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 3 of 8 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 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 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 0604 Definition: Level of Harm - Minimal harm or potential for actual harm Physical Abuse- includes but is not limited to hitting slapping, punching, biting, and kicking. It also includes controlled behavior through corporal punishment. Residents Affected - Few Involuntary Seclusion - refers to the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will . Review of facility policy dated 12/07/2013 titled, Physical Restraint, Side Rail Usage and Seclusion revealed the following: Policy- It is the policy of this facility that physical restraints shall be used as a last resort, through a system interdisciplinary review in the least restrictive manner, and only when it is considered medically necessary to treat a specific medical symptom. Procedure: 1. A licensed nurse will assess residents to identify the need for a device or a restrain quarterly and with a change of condition. Prior to initiating the use of any restraint or side rail, less restrictive devices and alternative intervention will be assessed and/or utilized/trialed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 4 of 8 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 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 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 observation, 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 are made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 1 (Resident #1) of 1 resident reviewed for abuse and neglect. This failure to report abue and neglect could cause residents to be abused and neglected. Findings included: Review of Resident #1's undated face sheet revealed he was an [AGE] year-old-male admitted on [DATE] with the diagnoses of: Type 2 diabetes mellitus (a blood sugar abnormality) hypertension, urinary tract infection, pneumonia, and legally blind. Review of admission MDS dated [DATE] revealed Resident #1 had a BIMS score of 12 indicating he had moderate cognitive impairment and able to make his needs known. Resident #1's MDS also revealed Section B (Hearing, Speech, and Vision) indicated he was visually impaired. Section G (Functional Status) revealed bed mobility, transfer, dressing, and toilet use required a two-person physical assistance. Review of physician orders dated 04/03/2023 revealed Resident #1 had an order for lorazepam 1 milligram one time only for agitation. Review of Resident #1 Care Plan dated 1/19/2023 and 2/20/2023 revealed: Focus: Loneliness, anxiety, and sadness related to isolation precautions. Goal: Will have support as needed for feelings of loneliness and sadness Interaction: Maintain an environment conducive to rest and sleep Focus: Resident #1 was visual impaired and is at risk for falls, injury and decline in functional ability. Goal: Resident #1 will maintain optimal quality of life and not experience decline in ADLs (activity of daily living) functional ability or injury related to vision loss. Intervention: Anticipate needs and meet them as able. Keep call light in reach when in room. Review of facility self-report worksheet dated 04/03/2023 revealed the following: On 04/03/2023 around 9:30 am, CNA A told DON Resident #1 was found restrained in bed last night 04/02/2023 round 10:45 pm. CNA A stated Resident #1 had a sheet wrapped around him and another strap was also used to restrain resident into bed. There was no injury to resident and bystatements gathered it was during a time frame of 1 hour and 15 minutes. No staff admit to restraining resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 5 of 8 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 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 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 During the entrance interview on 04/04/2023 at 10:20 AM Administrator and DON said Resident #1 was found restrained on 04/02/2023 around 10:45 PM. He was put to bed around 9 PM possibly restrained over an hour. He was extremely combative and physically assaulted one of the aids. On 04/03/2023 he was ordered Lorazepam 1 milligram intermuscular (a sedative) by his primary physician for his agitation and combativeness and sent to the hospital for a possible urinary tract infection. DON said Resident #1 may have had a urinary tract infection because he was hallucinating seeing people in his room that was not there. She said he was a fall precaution and was frequently checked on during shifts. When CNA A went to check on him, she pulled back the covers and found him restrained to his bed. DON said CNA did not report the incident until she saw her in the morning. During an interview on 04/04/2023 at 10:20 AM CNA A said she was doing her first round at the change of shift (10 PM to 7AM) passing ice and water on her floor (Hall 2100), Resident #1 was the last resident on the hall. She said she went to check on him as part of her rounds and pulled back his covers revealing he was restrained to his bed with a black strap extended from the middle of the mattress reaching across his midsection (hip area) and tied to the other side of the bed. She said also Resident #1 had a draw sheet wrapped around the bottom half of his pelvic area like a diaper and a portion of the strap knotted around the diaper tight to the extent it was difficult to remove the diaper (draw sheet) . During an observation on of Resident #1's room on 04/04/2023 at 10:45 AM revealed a bare mattress with a long black strap approximately 3 to 4 feet long at the head of the bed. The strap was attached to the mattress and securely attached, making it difficult to break or remove. CNA A assisted in the observation by lying on the mattress and indicating there was also another black strap located in the middle of the mattress and stretched across the midsection of Resident #1. The black strap located in the middle of the mattress (left side of the bed away from the wall) was missing, CNA A said she did not know what happened to it. She continued the demonstration by saying Resident #1 had a draw sheet wrapped around his pelvis area like a diaper and said the black strap located in the middle of the mattress (right side of bed near the wall) was knotted around the diaper and she had a hard time removing the knot. She said she unrestrained Resident #1 but did not tell the charge nurse about Resident #1 being restrained. She said she felt she should report her findings directly to the DON when she came in to work in the morning recognizing it was going to be at least 8 hours after finding Resident #1 restrained. She said she waited to tell DON in the morning because she felt that was what she was supposed to do and confirmed she did not report her findings to the charge nurse. CNA A said she was not afraid of her co-workers and not afraid of retribution in reporting Resident #1 restraint. During an interview on 04/04/2023 at 3:30 PM Resident #1 (who was admitted an acute care hospital) said he could not remember what happened prior to his admission to the acute care hospital. He said he was blind and could not tell surveyor Who did what to him and could not remember how he got to the hospital or why. During an interview on 04/05/2023 at 12:45 PM Resident #1's friend who was visiting him said Resident #1 told him he could not remember how or why he was admitted to the hospital. During an interview on 04/05/2023 at 1:00 PM LVN B (charge nurse) said, Resident #1 was up and ambulating in the hallway beginning the 2pm-10pm shift stating he wants to go home and trying to look for his truck. He (charge nurse) fed Resident #1 during dinner and towards the end of the shift the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 6 of 8 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 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 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 nurse aides put the resident to bed and around 9 PM the Resident #1 was hitting the wall and appeared agitated. He (charge nurse) went to check on Resident #1 and he was laying down covered up with a white sheet. Asked him what the problem was, and he said he wanted to go home. Charge nurse told Resident #1 that the weather was bad, and he should wait till the next day. Resident #1 was satisfied with the answer and quieted down. Charge left him covered in a white sheet with the bed in low position and fall mat in place. He said he did not witness Resident #1 being restrained or see any black straps on or under the bed. During an interview on 04/05/2023 at 1:45 PM CNA C said she was working on the 2 PM to 10 PM shift and Resident #1 was in his wheel chair rolling around and we generally wait till the end of the shift to put him to bed because he was fall precaution and we (staff) were able to keep an eye on him until we put him to bed. She said she was assisted by another aide, and they removed his pants, and he had a small bowel movement. She said she cleaned him up and the other aid was assisting someone else. She said she put on a brief, and he had on a white t-shirt. She said he had a draw sheet under him, and she placed a cover over him and left. She said he was not restrained. She said she did not hear him hitting the wall or being combative at all during her shift. She said she only heard from the other shift the next day Resident #1 was being combative and agitated. During initial tour and investigation on 04/04/2023 (between 10:30 AM and 4:00 PM and 04/05/2023 (between 8:30 AM and 2:00 PM) staff (10 on first floor and 10 second floor) revealed they were in-serviced by administration on reporting immediately to administrator (identified as the abuse coordinator) any resident found to be restrained regardless of if on day, night or weekends. Staff interviewed said there in-servicing occurred after and during 04/03/2023. Interviewed staff also revealed as part of their employment they have training and education regarding the facility was restraint free. During observation (second floor) on 04/05/2023 between 12:30 PM till 1:00 PM, residents (3 identified by staff as being totally dependent) revealed they did not have any signs of restraints to their arms, hands, legs or ankles, 1 resident was interviewable and denied anyone ever attempting to restrain him. During an interview on 04/05/2023 at 1:30 PM Administrator said his expectation for reporting any resident restrained would be immediate and the risk for resident being restrained potentially would be the resident could be injured or failure to evacuate during a fire or emergency. During an interview on 04/05/2023 at 1:40 PM DON said her expectation for reporting any resident restrained would be immediate and the risk for resident being restrained potentially would be the resident could be injured or failure to evacuate during a fire or emergency. Review of facility records revealed all staff being or in the process of being in-service on facility restraint policy. Facility policy on reporting abuse and neglect was not provided due to surveyor not requesting the policy. Review of facility policy dated 10/24/2022 titled, Policy and Procedure: Abuse, Neglect and Exploitation revealed the following: Definition: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 7 of 8 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 675852 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Advanced Rehabilitation and Healthcare of Wichita 4810 Kemp Blvd Wichita Falls, TX 76308 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 Physical Abuse- includes but is not limited to hitting slapping, punching, biting, and kicking. It also includes controlled behavior through corporal punishment. Involuntary Seclusion - refers to the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will Residents Affected - Few . Review of facility policy dated 12/07/2013 titled, Physical Restraint, Side Rail Usage and Seclusion revealed the following: Policy- It is the policy of this facility that physical restraints shall be used as a last resort, through a system interdisciplinary review in the least restrictive manner, and only when it is considered medically necessary to treat a specific medical symptom. Procedure: 1. A licensed nurse will assess residents to identify the need for a device or a restrain quarterly and with a change of condition. Prior to initiating the use of any restraint or side rail, less restrictive devices and alternative intervention will be assessed and/or utilized/trialed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675852 If continuation sheet Page 8 of 8