Health inspection·March 16, 2023

F 0640 Level of Harm - Minimal harm or potential for actual harm Review of Resident #58's most recent MDS assessment revealed it was completed on 10/03/22, for a significant change in status. Review of Resident #58's clinical record revealed a discharge MDS assessment was completed on 10/14/22; however, it was not transmitted. Residents Affected - Few 4. Review of Resident #6's face sheet dated 03/16/23 revealed the resident was a [AGE] year-old male admitted on [DATE] with diagnosis including cerebral infarction, chronic obstructive pulmonary disease, and essential hypertension. Review of Resident #6's most recent MDS assessment revealed it was completed on 09/28/22, and it was an admission assessment. Review of Resident #6's clinical record revealed Resident #6 was discharged on 11/03/22, and the resident's return was not anticipated. The record did not contain a discharge MDS assessment. Interview on 03/16/22 at 4:00 PM with MDS Coordinator C and MDS Coordinator D revealed they were responsible for completing the residents' MDS assessments. MDS Coordinator D stated they completed MDS assessments upon admission, quarterly, annually, upon change in condition, and upon discharge. MDS Coordinator C stated she was responsible for completing Resident #6 and Resident #84's discharge MDS assessments. She stated she missed them and did not complete the assessments. MDS Coordinator C stated Resident #58's discharge MDS assessment was completed but not transmitted. She stated she forgot to transmit. MDS Coordinator B stated she was responsible for completing Resident #46's discharge MDS assessment. She stated she also missed it. MDS Coordinator C stated discharge MDS assessments needed to be completed per regulation. She stated as of right now it was currently reflecting all four residents were still at the facility even though they were not. MDS Coordinator D stated they received a report during morning meetings of upcoming resident discharges, and they were responsible for completing the discharge MDS assessments once the resident was discharged . Interview on 03/16/22 at 4:12 PM with the DON revealed she was not aware that MDSs were not completed. She stated it was the MDS Coordinators' responsibility to complete the MDS annually and quarterly and to transmit them. She stated they had an MDS Regional Coordinator who oversaw the facility MDSs to ensure they were completed. She stated she had not received any emails regarding missing MDS assessments. Record review of facility's current MDS Completion and Submission Timeframes policy and procedure, revised July 2017, reflected the following: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 2 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure necessary treatment and services to promote healing for 1 of 3 residents (Residents #31) reviewed for wounds. Residents Affected - Few LVN G failed to follow-up with Resident #31's surgical wound dressing after being informed Resident #31's wound dressing came off. This failure could place residents at risk of severe pain, and lead to systemic infections causing harm for residents. Findings included: Record review of Resident #31's face sheet, dated 03/16/23, revealed an initial admission date of 01/07/22 and readmission on [DATE] with diagnoses that included bacteremia (viable bacteria in the blood), Type 2 diabetes mellitus with diabetic nerve damage, elevated lipids, high blood pressure, and infection from an unspecified organism. Record review of Resident #31's MDS assessment, dated 01/10/23, revealed Resident #31 had a BIMS score of 15 which indicated his cognition was intact. The assessment reflected Resident #31's MDS revealed Section M - Skin Condition: Foot Problem - E. Surgical Wound. Review of Resident #31's care plan, dated 08/17/22, reflected: Resident has amputation: right toes, Left AKA [above the knee amputation]. Goal: Stump will heal without complication/infection daily and ongoing over the next 90 days. Interventions: Teach about phantom pain, monitor pain, protect stump with transfers, monitor incision for signs of infection, maintain the wrap on the stump to enhance healing. Review of Resident #31's physician orders, dated 03/14/23, reflected: Cleanse right foot with ns [normal saline], Pat dry and apply collagen and dressing daily Observation and interview on 03/16/23 at 10:00 AM revealed Resident #31 lying in bed, and the resident's right foot did not have a dressing. Resident #31 had a surgical wound on his right foot. Resident #31 stated he had a dressing on last night before going to sleep and when he woke up this morning around 7:00 AM he no longer had the dressing on. He stated CNA I was the one who told him that his dressing had come off. Resident #31 denied any pain. Interview on 03/16/23 at 10:08 AM with LVN F revealed she provided Resident #31's wound care yesterday (03/15/23). LVN F stated she was not made aware of Resident #31 needing wound care. LVN F entered Resident #31's room and observed Resident #31's right foot and stated Resident #31's surgical wound needed wrapping. LVN F stated any nurse could put a new dressing on. LVN F stated the risk of not having a dressing was that it could cause an infection. Interview on 03/16/23 at 10:15 AM with LVN G revealed she was the nurse for Resident #31. LVN G stated she conducted her rounds this morning and did not observe Resident #31's right foot. LVN G stated she was notified about five minutes ago by CNA I that Resident #31's dressing had come off. LVN G stated she was assisting another resident. LVN G stated she would be putting a new dressing on . LVN G stated the risk of not having a dressing on was that it could cause an infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 3 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/16/23 at 10:18 AM with CNA I revealed she assisted Resident #31 this morning around 6:45 AM and noticed that Resident #31's dressing had come off. CNA I stated she notified LVN G right away. She stated at around 8:30 AM when she went back to Resident #31's room to pick up the resident's breakfast tray and observed Resident #31's dressing was still not on. CNA I stated she notified LVN G again. She stated LVN G informed her that Resident #31 had an appointment today and to get him ready. CNA I stated she reminded LVN G once again about the dressing before she went back to the 600 Hall. CNA I stated Resident #31 did not complain of pain. Interview on 03/16/23 at 2:19 PM with the DON revealed when a wound dressing came off her expectation was for staff to review the orders and apply a new dressing. The DON stated it should have not taken hours to apply a new dressing. The DON stated the risk of not having a dressing on was that it could cause an infection. Record review of the facility's current, undated Wound Care policy and procedure, reflected the following: The purpose of this procedure is to provide guidelines for the care for wounds to promote healing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 4 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four sharps containers (Shower rooms on Hall 200, 400,500, and 600) of 12 sharps containers observed for safe storage of sharps. The facility failed to monitor the sharps containers in the shower rooms on Halls 200, 400, 500 and 600 for fill levels and safe storage of contaminated sharps. These failures placed residents at risk of being exposed to contaminated sharps and possible bloodborne pathogens. Findings included: Observation on 03/14/23 at 12:14 PM of the Hall 500 Shower Room revealed a sharps box, without a sharps container (used to store sharp medical instruments). Inside the box were two used razors that had been deposited in the box. Observed residents ambulating on the hall, and the shower room door was not locked. Observation on 03/14/23 at 12:22 PM of the Hall 200 Shower Room revealed the sharps container was over filled and had three used razors on top of the sharps box. Observed residents ambulating on the hall, and the shower room door was not locked. Observation on 03/14/23 at 12:28 PM of the Hall 600 Shower Room revealed a sharps box, without a sharps container. Inside the box were five razors that had been deposited in the box. Observed residents ambulating on the hall, and the shower room door was not locked. Observation on 03/14/23 at 12:32 PM of the Hall 400 Shower Room revealed the sharps container was over filled. Observed residents ambulating on the hall, and the shower room door was not locked. Observation on 03/15/23 at 9:20 AM revealed the sharps boxes and sharps containers in the shower rooms on Halls 200. 400, 500, and 600 were unchanged. Observation and interview on 03/15/23 at 9:30 AM with the ADON revealed the sharps boxes and sharps containers being left in that condition was unacceptable. The sharps containers should be emptied when they reached the full level mark. The nurses were responsible for emptying the containers, and the CNAs should notify the nurse when the sharps containers needed to be changed. Interview on 03/16/23 at 12:00 PM, the DON stated the CNAs should notify a nurse or a manager when a sharps container in the shower room was nearly full so it could be changed out. The DON stated depositing used razors into a sharps box without a sharps container was dangerous because someone would have to remove the razors and place them in a container, exposing them to possible bloodborne pathogens if they were cut by the razors. Review of the facility's current, undated Sharps Disposal policy reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 5 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0689 2 Contaminated sharps will be discarded into containers that are: Level of Harm - Minimal harm or potential for actual harm a. Closeable b. Puncture resistant Residents Affected - Some 4. When moving containers from the area employees must: a. Close the container immediately prior to removal to prevent contents from spilling or protruding during handling and storage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 6 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for three (Resident #83, Resident #81, and Resident #90) of seven residents reviewed for enteral nutrition, in that: 1. The facility failed to follow the physician orders for enteral feedings for Residents #83 and #81. 2. The facility failed to notify the physician of Resident #90's refusal for continuous feedings during the day and to obtain new orders to address the need for tube feeding at night if Resident #90 was not able to eat my mouth. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk of health complications. Findings included: Record review of Resident #83's face sheet, dated 03/16/23, revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE] with a readmission on [DATE]. The resident had diagnoses that included the inability to swallow following a stroke requiring the use of a feeding tube and reflux. Record review of Resident #83's MDS assessment, dated 02/15/23, revealed a BIMS assessment was not conducted due to the resident rarely/never being understood. The assessment reflected Resident #83 required extensive assistance with ADLs. Resident #83's weight was 89 pounds, and the resident's nutritional approach was feeding tube. Record review of Resident #83's Order Summary Report for 02/21/23 revealed a physician order to administer Jevity 1.5 through enteral feeding at 40 cc/hour for 24 hrs/day continuous and to check every shift. The physician order had a start date of 02/21/23 with no end date. The Order Summary reflected: Enteral hydration: Flush 150 ml Q4 hours with a start date of 02/21/23. Record review of Resident #83's care plan, dated 02/9/23, reflected: Resident receives all nutrition and medication via g-tube d/t dx: dysphasia with difficulty chewing and swallowing and is on puree diet, thin liquids via spoon only, no straws or no cups d/t swallowing precautions- speech is to feed only. Resident will maintain adequate nutritional status and food oral hygiene daily and ongoing over the next 90 days. Observation on 03/14/23 at 10:42 AM revealed Resident #83 was lying in bed. A feeding pump next to Resident #83's bed was infusing. A bag of enteral feeding, which was dated 03/14/23, untimed and without initials of who administered the feeding, was hanging from the pole of the feeding pump. No start time was written on the bag. The formula infusion rate was set at 45 ml/hr, and there was approximately 400 ml of Jevity formula remaining, water flush rate was set at 40 ml/hr every 4 hours and there was approximately 600 ml of water left. Observation on 03/14/23 at 12:25 PM revealed Resident #83's feeding pump remained infusing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 7 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0693 Observation on 03/14/23 at 1:22 PM revealed Resident #83's feeding pump remained infusing. Level of Harm - Minimal harm or potential for actual harm Interview and observation on 03/14/23 at 1:24 PM with LVN H revealed she was the nurse for Resident #83. LVN H stated Resident #83 had a g-tube and could not recall the exact formula rate. LVN H reviewed Resident #83 physicians orders and stated Resident #83 had an order for 40 cc/hr and 150 ml/every 4 hours. LVN H entered Resident #83's room and observed the feeding pump. LVN H stated the rate was not correct. LVN H was not able to adjust the feeding pump rate and requested assistance from ADON A. ADON A adjusted the feeding pump at a rate of 40 cc/hr and 150 ml/every 4 hours. LVN H stated she completed her rounds at the beginning of her shift with the night nurse; however, she did not check Resident #83's rate this morning to confirm if it was correct. LVN H stated the risk of not following physician orders was that it could lead to dehydration or overfeeding. Residents Affected - Few Interview on 03/14/23 at 2:01 PM with ADON A revealed her expectation was for nurses to know how to use the pump, follow physician orders, and complete rounds to ensure feeding pump rates were correct. ADON A stated she was not sure when the nurses had last been provided an in-service on how to use the feeding pumps. ADON A stated the risk of not following physician orders was that it could lead to dehydration, skin breakdown, or weight loss. Interview on 03/15/23 at 3:34 PM with the Dietitian revealed she had not been made aware Resident #83's feeding pump rate was incorrect. She stated her expectation was for the nurses to review her recommendations, provide the recommendations to the nurse practitioner, and if approved the nurses should follow the physician orders. The Dietitian stated for this case there was no risk if Resident #83 received more formula. She stated Resident #83 benefited from it due to her weight; however, if Resident #83 did not receive the correct flushes it could cause dehydration. Interview on 03/15/23 at 3:52 PM with the DON revealed her expectation was for her staff to follow physician orders and check feeding pump rates during rounds and during medication pass. She stated she was made aware of Resident #83's feeding pump rate being incorrect. The DON stated the potential risk of not following physician orders was that it could lead to dehydration. Record review of Resident #81's face sheet, dated 03/16/23, revealed the resident was an [AGE] year-old male with an initial admission date of 10/12/22 and with diagnoses that included obstructive and reflux uropathy (blockage along the urinary tract) , dysphagia (difficulty swallowing food or liquid), pharyngeal and oropharyngeal phase (difficulty pushing food into the esophagus), gastro-esophageal reflux disease without esophagitis, pneumonia. Record review of Resident #81's MDS assessment, dated 01/19/23, revealed a BIMS score of 4 which indicated the resident had severe cognitive impairment. The assessment reflected Resident #81 required the extensive assistance of one person for eating. Resident #81's weight was 138 pounds, and the resident's nutritional approach was feeding tube. Record review of Resident #81's Order Summary Report for 03/14/23 revealed the following orders: - a physician order, dated 03/14/23 - no end date to administer Isosource through enteral feeding, feeding pump at 60 cc/hour for 22 hours/day continuous. - a physician order, dated 03/03/23 - no end date: may substitute Isosource HN for Jevity 1.5 as needed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 8 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - a physician order. dated 01/25/23 - no end date: flush peg with 65 ml/hour x 22 hours bowel rest from 8:00 AM-10:00 AM Record review of Resident #81's undated Care Plan revealed the following care areas: - Resident #81 was at risk for weight loss related to poor meal intake and has a new g-tube in place and NPO and received all nutrition and medication by g-tube due to diagnosis: Dysphasia with Difficulty chewing and swallowing. Intervention included: Diet as ordered: Enteral: Administer water through enteral g-tube via feeding pump at 35 ml/hr for 22 hours a day for total of 770 ml of free water. Resident #81 is NPO and will receive all nutrition and medication via g-tube due to diagnosis of Dysphasia with difficulty chewing and swallowing. - Resident #81 at risk or potential for GI distress, nausea, vomiting, or ascites due to diagnosis of liver disorders. Interventions include to observe/monitor/report for signs and symptoms of distress, nausea, vomiting, and report to physician. - Resident #81 at risk or has potential for complications related to diagnosis of GERD such as belching, indigestion, esophageal/tooth erosion, and or bad/chest discomfort. Interventions include assess daily for signs and symptoms of burning pain in the chest after eating and worsen when lying down, belching, heartburn, regurgitation, discomfort in upper abdomen or dry cough and report, avoid irritants, such as spicy or acidic foods, alcohol, caffeine. - Resident #81 at risk for episodes of constipation and irregular bowel pattern. Interventions included administer medication (Lactulose) as ordered and report effects to physician. Notify physician if bowel regimen is not working. - Resident #81 has history of difficulty swallowing related to diagnosis of dysphagia. Interventions included providing a diet as ordered: enteral feeding g-tube feeding pump Jevity 1.5 for 22 hours a day, bowel rest from 8:00 AM-10:00 AM, and assessing daily for signs of aspiration, observing, monitoring, and reporting any signs and symptoms of side effects of dysphagia. Observation on 03/15/23 at 8:43 AM revealed Resident #81 was lying in bed. A feeding pump next to Resident #81's bed was infusing and had not been shut off according to physician orders. Interview on 03/15/23 at 8:50 AM, LVN K revealed Resident #81's feeding pump remained infusing. LVN K stated she was not aware of Resident #81's feeding orders and reviewed them in the computer. LVN K stated Resident #81 was on 22 hours of continuous feeds with bowel rest from 8:00 AM-10:00 AM. LVN K stated she had not shut him down for bowel rest and would do it now. LVN K stated she was working Halls 200 and 600 with a heavy schedule, and she had missed the order. She stated she had not gotten around to him. LVN K stated the risk of not shutting down his feeding pump included him having a lot of residual, nausea, diarrhea, and abdominal extension. LVN K stated nurses were responsible for shutting the machine down and returning him back to feeding. Interview on 03/15/23 at 3:32 PM with the DON revealed her expectation was for staff to follow physician orders by shutting Resident #81's feeding machine down at 8:00 AM. The DON stated since his machine was still going, LVN K should contact the doctor to let them know that he was an hour late getting off and would need to extend the time to complete the 2 hour down time. According to the DON, the risk for residents not being shut down according to physician orders would include resident feedings being more than ordered, nausea, vomiting, becoming too full, and having an extended abdomen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 9 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #90's face sheet, dated 03/16/23, revealed the resident was a [AGE] year-old male with an initial admission date of 01/08/23 and a readmission on [DATE] with diagnoses that included pneumonitis due to inhalation of food and vomit, dysphagia, oropharyngeal phase (difficulty swallowing), gastro-esophageal reflux disease without esophagitis (stomach acid flows backwards), Parkinson's disease (disorder that affects the nervous system), dehydration, abnormal weight loss, disturbance of salivary secretion. Record review of Resident #90's MDS assessment, dated 01/24/23, revealed the resident had a BIMS score of 13 which indicated the resident's cognition was intact. The assessment reflected Resident #90 was totally dependent upon one person for assistance with eating. The MDS reflected the resident had the ability to use suitable utensils to bring food/liquid to the mouth and swallow once the meal was placed before the resident with substantial/maximal assistance. Resident #90's weight was 102 pounds, and the resident's nutritional approach was parentera feeding and feeding tube. The proportion of total calories the resident received through parenteral, or tube feeding was 51% or more with the average fluid intake per day by tube feeding to be 501 cc/day or more. Record review of Resident #90's Order Summary Report for March 2023 revealed the resident received Jevity 1.5 through enteral feeding (g-tube) feeding pump at 55 cc/hr for 22 hr/day, off from 8:00 AM-10:00 AM. The report reflected enteral hydration with 50 cc water every hour via pump for 22 hours. The physician order, dated 01/24/23, with no end date revealed Resident #90 was on a puree texture and thin liquid diet. Record review of Resident #90's March 2023 MAR revealed of Jevity 1.5 through enteral feeding (g-tube) feeding pump at 55 cc/hr for 22 hr/day, off 8:00 AM-10:00 AM and enteral hydration with 50 cc water every hour via pump for 22 hours, administered as ordered. There were no days shown of missed feedings or resident refusal. Order date: 03/15/23. Start date:03/16/23. Record review of Resident #90's January 2023 MAR for 01/24/23 revealed 50 cc water every hour via pump for 22 hours, order date: 01/24/23 and discontinue date: 03/16/23. Record review of Resident #90's Care Plan revealed Resident #90 required a feeding tube for nutrition due to dysphagia. The Care Plan reflected Resident #90 has a new order for puree diet, thin liquids. The interventions included monitoring for signs and symptoms of worsening condition, notifying the provider of changes, tube feeding as ordered, flush feeding tube with waster as ordered. The Care Plan also reflected Resident #90 had Parkinson's Disease with interventions to monitor the resident's weight and diet, and assure the resident was monitored during mealtime if needed. Observation and interview on 03/14/23 at 11:58 AM revealed Resident #90 was sitting in his wheelchair in his room next to his formula bag of enteral feeding. The bag was hanging from the pole of the feeding pump. The feeding pump was not infusing, and there was a full bag of formula remaining. The formula bag did not have a start time written on it. According to Resident #90, he had been on a puree diet since 03/10/23 and was only receiving enteral feedings overnight if he got hungry. Resident #90 stated he had Parkinson's disease and depending on the time of the medication administration and the reaction of the medication sometimes he was not able to eat the puree diet, and this was when he had the enteral feedings overnight. Observation and interview on 03/14/23 at 12:44 PM with LVN H revealed Resident #90 had requested to be on a puree diet. LVN H stated the Dietitian had been visiting with Resident #90. LVN H stated new orders were submitted for the puree diet, and the resident had been taking in the puree diet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 10 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few without complications so far. LVN H was attempting to get Resident #90 a puree diet tray, when the tray came, LVN H stated she would usually stay in the room with Resident #90 to monitor for any signs of distress. LVN H stated she did not reconnect Resident #90 at 10:00 AM because he refused to be connected to his external feeding. LVN H stated it was her responsibility to follow doctor's orders and notify the physician of any changes which she had not done. LVN H stated the risk involved could be poor nutrition and hunger. Observation and interview on 03/15/23 at 11:00 AM with Resident #90 revealed he was not connected to the enteral feeding machine. According to Resident #90, he was currently waiting to take his Parkinson's medication so that he may be able to eat his puree diet lunch tray. Resident stated he did have a puree diet breakfast this morning and took it in without any issues or concerns. Resident stated his Parkinson's medication did not work last night; therefore, he was not able to eat his puree diet dinner and had the enteral feeding machine hooked up about 6:30 PM. Interview on 03/15/23 at 11:07 AM with LVN L revealed Resident #90 had been on a puree diet and had been refusing to be connected to the enteral feeding machine. LVN L stated she was honoring Resident #90's wishes not to be connected. LVN L stated she had not documented and had not notified the DON or the physician about Resident #90's refusals. LVN L stated she would contact the physician to inform the physician Resident #90 was requesting to be off the enteral feeding machine. LVN L stated it was the responsibility of the nurses to communicate any changes with the physician. LVN L stated not following physician's orders could put Resident #90 at risk of not getting the proper nutrition, feeling of weakness or hunger, or weight loss. Interview on 03/15/23 at 3:47 PM with the DON revealed LVN L informed her Resident #90 did not want to be on the feeding machine and would refuse it because he wanted to eat by mouth. The DON stated she told her to call the doctor about the refusal and to monitor for weight loss. The DON stated the proper protocol would have been to contact the Dietitian and Speech Therapist, and care plan with Resident #90 and his representative if he had one. The DON stated she did not recall being told the resident had been refusing enteral feedings or not receiving continuous feedings. The DON stated it was the nurses' responsibility to notify her of any changes and refusals through morning meetings or simply by the nurses coming to her and letting her know what was happening with residents on their halls. The DON stated it was her expectation that nurses followed orders from the doctor. The DON stated residents had the right to refuse and nurses were expected to document any refusals. The DON stated the risk to the resident would be weight loss and not having enough nutrition for therapy services, getting sick, and upset stomach if taking medications. Record review of facility's current Enteral Nutrition policy and procedure, revised November 2018, reflected the following: .Adequate nutritional support through enteral nutrition is provided to resident as ordered 11. The nurse confirms that orders for enteral nutrition are completed. Completed orders include: e. volume and rate of administration; f. the volume/rate goals and recommendations for advancement toward there; and instructions for flushing (solution, volume, frequency, timing and 24-hour volume) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 11 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 - Some 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 interview and record review, the facility failed to use the service of an RN for at least eight consecutive hours a day, seven days a week in the facility for 20 of 30 days (12/04/22, 12/17/22, 12/18/22, 12/25/22, 01/21/23, 01/22/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23, 02/11/23, 02/12/23, 02/18/23, 02/19/23, 02/25/23, 02/26/23, 03/04/23, 03/05/23, 03/11/23, and 03/12/23) reviewed during a look back period from 12/03/22 to 03/12/23. The facility failed to have RN coverage in the facility for eight consecutive hours on 12/04/22, 12/17/22, 12/18/22, 12/25/22, 01/21/23, 01/22/23, 01/28/23, 01/29/23, 02/04/23, 02/05/23, 02/11/23, 02/12/23, 02/18/23, 02/19/23, 02/25/23, 02/26/23, 03/04/23, 03/05/23, 03/11/23, and 03/12/23. This failure could place residents at risk for missed resident nursing assessments, interventions, care, and treatment. Findings included: Review of the facility's undated Labor Hours Report sheets reflected there was not eight consecutive hours of coverage by an RN on weekends. The dates were as follows: Sunday 12/04/22 - 0 hours Saturday 12/17/22 - 0 hours Sunday 12/18/22 - 5.75 hours Sunday 12/25/22 - 0 hours Saturday 01/21/23 - 0 hours Sunday 01/22/23 - 0 hours Saturday 01/28/23 - 0 hours Sunday 01/29/23 - 0 hours Saturday 02/04/23 - 0 hours Sunday 02/05/23 - 0 hours Saturday 02/11/23 - 0 hours Sunday 02/12/23 - 6 hours Saturday 02/18/23 - 0 hours Sunday 02/19/23 - 0 hours (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 12 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 Saturday 02/25/23 - 0 hours Level of Harm - Minimal harm or potential for actual harm Sunday 02/26/23 - 0 hours Saturday 03/04/23 - 4.25 hrs then a 11 hr. break 4 hours Residents Affected - Some Sunday 03/05/23 - 0 hours Saturday 03/11/23 - 0 hours and Sunday 03/12/23 - 0 hours Interview with the DON on 03/16/23 at 10:46 AM revealed her shifts were 8 hour shifts. The DON stated the facility was struggling with having a full-time RN on the weekends. She stated she was the only RN in the facility and not having RN coverage on the weekends would lead her to work 7 days a week, so she counted on the previous RN to be present. The DON stated the previous weekend nurse would call in at the last minute leaving the facility without coverage. The DON stated an RN was recently hired, and she was hoping to have coverage with the new staff. The DON stated it was her responsibility to ensure there was full-time RN coverage in the facility, and not doing so would put residents at risk of not receiving proper care. Review of facility's current Staffing policy, revised October 2017, revealed a Registered Nurse was to work at least 8 hours per 24 hours, which may include the DON. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 13 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 four (Resident #63, Resident #9 and Resident #29, Resident #30) of 8 residents reviewed for medication administration and labeling and storage. 1. MA E left a cup of pills at the bedside of Resident #63 and MA M left a cup of pills at the bedside of Resident #30, failing to observe the resident take the pills. 2. The facility failed to monitor the MARs and narcotic logs for Hall 200 and Hall 500 hall for Residents #9 and #29 to ensure the narcotics were being administered. These failures placed residents at risk of not receiving medications as prescribed, decreased therapeutic effects of the medications,risk for drug diversion,delay in medication administration and worsening of their medical conditions. Findings included: Review of Resident # 63's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included diabetes, depression, pressure ulcers, liver disease, kidney disease, seizures, and high blood pressure. Review of Resident #63's quarterly MDS, dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Resident #63's Functional Status indicated she required supervision only of her ADLs. Her Swallowing Status indicated no issues with swallowing. Review of Resident #63's care plan, dated 12-29/22, revealed she was at risk for seizures, high and low blood pressure, depression, and irregular heart beats. Observation on 03/14/23 at 11:04 AM revealed a cup with 10 pills sitting on Resident #63's bedside table, and resident was asleep in bed. Interview on 03/14/23 at 11:06 AM, ADON B stated it was not acceptable for medications to be left at the bedside of a resident unless there was a physician order for the resident to self-administer medications. ADON B stated otherwise the MA must watch the resident take their medications before leaving the bedside. Interview on 03/14/23 at 11:10 AM, MA E stated she had left the cup of pills on Resident #63's table while she administered medications to her roommate around 7:00 AM. She stated Resident #63 had been awake at the time, but must have gone back to bed before taking her pills. MA E stated Resident #63 did not self-administer her medications, and she should have watched the resident take her medications. Observation on 03/14/23 at 11:15 AM revealed the pill cup for Resident #63 contained: - Potassium 20 mEq, replaces potassium depleted by Lasix (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 14 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 - Keppra 500 mg, seizure medication Level of Harm - Minimal harm or potential for actual harm - Iron 325 mg, for anemia - Zinc Sulfate 220 mg, low zinc levels Residents Affected - Some - Xifaxan 550 mg, anti-diarrhea - Cymbalta 20 mg, anti-depressant - Lasix 40 mg, removes excess fluid from the body - Gabapentin 100 mg, seizures and nerve pain - Metoprolol 50 mg, high blood pressure - Tramadol 50 mg, pain medication Interview on 03/14/23 at 11:18 AM, ADON B stated she had given MA E the resident's Tramadol 50 mg to administer with the rest of the resident's medications. ADON B stated she had rounded on the resident around 9:30 AM and had not observed the pill cup at the bedside. Review of Resident #63's NAR revealed ADON B had signed out Resident #63's Tramadol at 10:00 AM. ADON B stated MA E must have been mistaken about the time she had medicated Resident #63. Review of Resident #9's face sheet dated 03/16/23 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included muscles weakness, pain, chronic obstructive pulmonary disease, and high blood pressure. Review of Resident #9's quarterly MDS, dated [DATE], revealed Resident #9 had a BIMS score of 3, indicating severe cognition impairment. Review of Resident #9's care plan, dated 02/02/23, revealed the resident was at risk for pain due to history of hip fracture and generalized pain due to late effects of Parkinson's disease. The care planned interventions were to administer Norco medication as ordered and report effects and effectiveness to physician as indicated. Review with the DON of Resident #9's August 2022 MAR reflected Hydrocodone-Acetaminophen 5/325 mg give 1 tablet twice a day. The MAR reflected the facility staff signed the MAR showing the Hydrodocone-Acetaminophen was given for the entire month of August 2022. Review of the NAR with the DON revealed no Hydrocodone-Acetaminophen 5/325 mg was signed off on the NAR on 08/02/22 AM and PM, 08/03/23 AM, 08/09/23 AM, 08/15/23 AM, 08/17/23 AM, 08/18/23 AM, 08/21/23 AM, and 08/27/23 AM and PM. Review of the NAR log and count for Hall 200 revealed the count was balancing. Review of Resident #29's face sheet dated 03/16/23 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included congestive heart failure, diabetes, chronic kidney failure, and anxiety disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 15 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 Review of Resident #29's quarterly MDS, dated [DATE] revealed Resident #29 had a BIMS score of 3, indicating severe cognition impairment. Review of Resident #29's care plan, dated 01/26/23, revealed she was at risk for adverse reaction to psychotropic drug use due to anti-anxiety (lorazepam) of anxiety. The care planned intervention was to administer lorazepam as ordered and to report adverse effect. Review with the DON of Resident #29's February 2023 MAR for Lorazepam 0.5 mg give 1 tablet by mouth twice daily revealed the facility staff were signing the MAR as administered all dates apart from 02/13/23 PM, 02/19/23 AM, 02/23/23 PM, and 02/28/23 AM and PM that Resident #29 did not get administered the Lorazepam. Review of the NAR with the DON revealed no Lorazepam 0.5 mg was signed off on the NAR on the following dates: 02/03/23 AM, 02/04/23 AM, 02/13/23 AM, 02/15/23 PM, 02/16/23 PM, 02/18/23 AM, 02/25/23 PM, 02/27/23 PM, 02/06/23 AM and PM, 02/7/23 AM and PM, 02/8/23 AM and PM, 02/09/23 AM and PM, 02/10/23 PM, 02/11/23 AM and PM, 02/12/23 AM and PM, 02/12/23 AM, 02/14/23 AM and PM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 16 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 02/15/23 PM, Level of Harm - Minimal harm or potential for actual harm 02/16/23 PM, 02/18/23 AM, Residents Affected - Some 02/25/23 PM, and 02/27/23 PM. Review of the NAR log and observation of the narcotic count on the medication cart for Hall 500 revealed these balanced with no discrepancy. Interview with LVN P on 03/16/23 at 1:22 PM revealed she had signed the MAR for Resident #29 even though she did not administer the medication. LVN P stated if the resident had refused it would show on the MAR. LVN P stated she was aware she was supposed to document on the MAR after administering medication to a resident and log out on the NAR. LVN P stated if the resident did not take a medication, they should destroy the medication with two nurses. She stated she knew she was supposed to sign-out on the narcotic count sheet after administration and on the MAR, but she did not. She stated failure to do that could lead to a narcotics diversion and the resident being agitated. For Resident #29, she stated she knew she was supposed to sign-out on the narcotic count sheet after administration and on the MAR, but she did not. She stated she thought that day she was moving very fast, and she forgot to administer the medication she was just clicking on given and not administering. She stated failure to administer a pain pill to Resident #9 would lead to the resident's pain not being controlled. Interview with the DON on 03/16/23 at 12:51 PM revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the MAR and to sign on the narcotic log. She stated nurses were responsible for ensuring the narcotic sign-in sheet was correct, and the managers were responsible for monitoring the charts and narcotic logs. She revealed the result of nurses not logging on the narcotic logs was that it could lead to diversion. She stated it could also cause the resident to miss a dose since the incoming nurse might think the resident's medication was administered, and this may cause the residents pain not to be well controlled. The DON stated she had not trained her staff regarding the NAR and MAR signing before administration since she had not noticed there was a problem. She had trained them on signing narcotics once delivered from pharmacy. Interview with LVN Q on 03/16/23 at 4:18 PM revealed she was one of the managers. She stated she was responsible for ensuring the nurses were administering medication as scheduled. She stated she had not been following on the log to see the dates on medication administration were matching with the dates on the NAR. She stated she was only checking for the holes on the MAR that would reflect in red. She stated if there were dates missing on the NAR it meant Resident #29 and Resident #9 were missing their doses. She stated she was supposed to have caught the mistakes on the NAR and MAR and report to the DON for staff to be trained. She stated if residents were not getting medication as scheduled it could lead to the residents being agitated and their pain being not controlled. She gave an example of 02/28/23, LVN Q worked night shift, and Resident #29 was agitated so she had to administer lorazepam at 11:30 PM. When she checked the MAR, she noted Resident #29 had not received that day medications. LVN Q stated she did not follow-up because she forgot. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 17 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 Review of Resident #30's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paraplegia, muscle weakness, high blood pressure, dysphagia (difficulty swallowing), urinary tract infections, major depression disorder, anxiety disorder. Review of Resident #30's quarterly MDS, dated [DATE] revealed a BIMS score of 15, indicating intact cognition. Resident #30's Functional Status indicated she required supervision only of her eating ADLs. Her Swallowing Status indicated no issues with swallowing. Review of Resident #30's care plan, dated 03/16/23, revealed she was at risk for adverse reaction to psychotropic drug use related to anti-hypnotic medication. Interventions included administering the anti-hypnotic, Melatonin, as ordered and to report effects to the physician as indicated. The are plan reflected Resident #30 was on a regular diet, thin liquids due to difficulty swallowing, high blood pressure, risk for falls, diabetes, history of urinary tract infections, suprapubic catheter. Interventions included allowing sufficient time to feed and for the resident to eat, providing hand over hand assist with eating and reminding the resident to tuck her chin when swallowing. The care plan also reflect to provide a diet as ordered, regular diet, thin liquids, and to assist the resident by opening containers and cutting up food. Observation and interview on 03/16/23 at 8:30 AM revealed a cup with 15 pills on Resident #30's bedside table, and the resident was attempting to take the pills. Resident #30 stated the MA delivered the cup of pills this morning and left them on the bedside table so she could take them after breakfast, which she had done before. Interview on 03/16/23 at 8:37 AM, LVN H stated medications should not be left at bedside for residents to administer. LVN H stated it put residents at risk of choking, not taking the medications, or spilling the medications on the floor. Interview on 03/16/23 at 8:40 AM, MA M stated she had left the cup of pills on Resident #30's table so that she may take them after she finished her breakfast. MA M stated, I should not have left the pills for her to administer without me being present. MA M stated anything could happen, pills lost, choking, someone else could get hold of them. MA M stated she was responsible for making sure residents were taking the medications she administered them, and to monitor for issues or concerns. Observation on 03/16/23 at 8:45 AM revealed a pill cup located in Resident #30's hand, in her room, that contained: Allegra 180 mg, antihistamine Calcium 600, supplement Vitamin D3 200, supplement Colace 100 mg cap, stool softener Duloxetine HCL DR 20 mg, anti-depressant Iron sulfate 325 mg, for anemia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 18 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 Lactobacillus tab, probiotic Level of Harm - Minimal harm or potential for actual harm Hyoscyamine ER .375 mg, anti-cramping for the intestines Losartan Potassium 50 mg, high blood pressure Residents Affected - Some Metformin HCL 1000 mg, anti-diabetic Multivitamin tab, supplement Oxybutynin CL ER 10 mg, bladder spasms Simethicone 80 mg, anti-gas Vitamin D3 1000, supplement Xarelto 20 mg, blood thinner Interview with the DON on 03/16/23 at 10:40 AM revealed it was not the protocol to leave any type of medication at the bedside for Resident #30 to administer on her own. The DON stated leaving the mediation for her to take later put Resident #30 at risk of choking, missing a dose of medication or another resident having access to Resident #30's medication. The DON stated MA M was responsible for ensuring all medications that she administered were taken before walking away from the resident. Review of the facility current Administering Medications policy, revised March 2022, reflected the following: .Medications should be administered in accordance with the orders ,including any required time frame. .12. Individual administering the medication must document medication administered on the MAR after giving each medication and before administering the next one Review of the facility's undated policy Administering Oral Medications revealed: . 21. Remain with the resident until all medications have been taken FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 19 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the facility's only kitchen for food service safety. Residents Affected - Few Cook J failed to ensure foods were handled in a manner to prevent contamination (bare hand contact). This failure could place residents who eat from facility's only kitchen at increased risk of exposure to food-borne illnesses. Findings included: Observation on 03/14/23 at 12:46 PM revealed [NAME] J plating the lunch meal. [NAME] J did not to have gloves on and was using utensils to plate the food. [NAME] J touched the food with her bare hands to plate two plates, placed them on the service line, and then went back to using utensils without washing her hands. The State Surveyor intervened and asked the Dietary Manager to remove the two plates from the service line before they were served to the residents. The Dietary Manager asked [NAME] J to wash hands and to wear gloves. Interview on 03/14/23 at 12:52 PM with [NAME] J revealed she made a mistake by using her hand to touch the food. [NAME] J stated she was in a rush and was nervous that State Surveyor was observing her. She stated the risk for not using utensils was that it could cause cross contamination. Interview on 03/14/23 at 12:55 PM with the Dietary Manager revealed his expectation was for staff to use gloves and to use utensils when serving food. He stated staff should never use their hands to touch the food when plating. The Dietary Manager stated the risk of not using utensils was that it could cause cross contamination. Record review of facility's current Employee Sanitation policy and procedure, dated October 1, 2018, reflected the following: .5. Hand Washing: a. Employee must wash their hands and exposed portions of their arms at designated hand washing facilities at the following items: V. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 20 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to adequately equip resident rooms to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, toilet and bathing facilities for three (Residents # 43, #65, and #197) of 12 residents reviewed for call lights. Residents Affected - Some The facility failed to provide a call light button, or an alternative, for Residents # 43, #65, and #197. These failures placed residents at risk of not receiving immediate care in the event of an emergency. Findings included: Review of Resident #43's EHR revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, communication deficit, and blindness related to syphilis. Review of Resident #43's quarterly MDS, dated [DATE], revealed a BIMS score of 2, indicating severe cognitive impairment. Her Functional Status indicated she required extensive assistance with toileting and hygiene, and moderate assistance with the rest of her ADLs. Review of Resident #43's care plan, dated 01/06/23, revealed she was at risk of impaired vision, breathing difficulties related to asthma and heart disease, and heart issue related to heart disease irregular heart beats, and high blood pressure. Review of Resident #65's EHR revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included inability to speak and swallow related to stroke, enlarged heart, Parkinson's disease, and kidney failure requiring dialysis. Review of Resident #65's admission MDS, dated [DATE], revealed a BIMS score of 6 indicating severe cognitive impairment. Her Functional Status indicated she required extensive assistance with all of her ADLs except eating. Review of Resident #65's care plan, dated 03/07/23, revealed she was at risk of complications of dialysis, weakness related to anemia, and falls related to stroke. Review of Resident #197's EHR revealed the resident was re-admitted to the facility on [DATE] on hospice care for infection in the brain, kidney failure, and breathing failure. Review of Resident #197's admission MDS, dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. Her Functional Status indicated she was completely reliant on staff for all of her care. Review of Resident #197's care plan, dated 03/13/23, revealed she was at risk for increasing confusion related to her brain infection and an old traumatic brain injury, she received all nutrition via a feeding tube, and she was incontinent of bowel and bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 21 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 03/14//23 at 11:32 AM revealed Resident #65 had no call light cable connected to the call system. Observation on 03/14/23 at 11:53 AM revealed Resident #43 had no call light for her side of the room. Observation on 03/14/23 at 1:58 PM revealed Resident #197 lying in his bed and his call light was not within reach. The call light was observed in the bedside drawer. Observation on 03/15//23 at 9:45 AM revealed the call light status for the Residents #43, #65, and #197 was unchanged. Observation on 03/16/23 at 12:00 PM revealed Resident #65 lying in bed. The call light was plugged into the system, but it was on the floor out of reach of the resident. Interview on 03/16/23 at 12:10 PM, LVN F stated residents were rounded on a minimum of every two hours, and call lights were answered as quickly as possible. LVN F stated all residents needed to have a call light available to call for help when needed. Interview on 03/16/23 at 12:20 PM, ADON A stated call lights must be left where residents could reach them in the event they needed help. Residents with visual or movement problems were provided a different type of activation button, but it was tied into the call system. Interview on 03/16/23 at 12:51 PM, the DON stated all residents were required to have a call light available, regardless of their ability to activate it. she stated the family or staff needed the call light to activate in the event the need help. Review of the facility's current, undated Answering the Call Light policy reflected: .4. Be sure the call light is plugged in at all times 5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach. 6. Some residents may not be able to use their call light. Be sure to check on these residents frequently FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 22 of 23 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 676160 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kingwood Rehabilitation and Healthcare Center 23775 Kingwood Place Kingwood, TX 77339 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 1 (room [ROOM NUMBER] ) of 15 rooms observed. The facility failed to maintain room [ROOM NUMBER] in a safe and sanitary condition. This failure could place residents at risk for decreased quality of life. Findings included: Observation and interview on 03/14/23 at 10:44 AM of room [ROOM NUMBER] revealed two areas on the wall behind the head of the resident's bed that had deep gouges from the bed pressing against the wall. The resident's bed was in a low position, and the bed was level with the two gouged areas visible. The resident, who occupied the room, stated she was not aware of the gouges in the wall. Interview and observation on 03/15/22 at 11:07 AM with the Administrator revealed she had not been notified of any needed repairs for room [ROOM NUMBER], and she stated it looked bad. She stated her expectation was for staff to notify her right away regarding any needed repairs in the residents' rooms. She stated they had a maintenance repair logbook for any concerns and repairs. She stated they were in the process of remodeling rooms, and it was not the only room that needed repair, but the maintenance staff was on vacation. Record review of the facility's Maintenance Repair Logbook with the Administrator revealed no request for repair of room [ROOM NUMBER]. Interview on 03/15/23 at 11:16 AM with Housekeeper N revealed she was not aware of the damages and the hole in the wall for room [ROOM NUMBER]. Housekeeper N stated when a room needed repair, they documented it in the logbook, or they were supposed to notify maintenance. She stated the risk of having the holes in the wall was that it could cause the resident to get cold from the dust. Record review of facility's current Homelike Environment policy, revised May 2017, reflected the following: .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2). The facility staff and management shall maximize, to be extent possible, the characteristics of the facility that reflect a personalized, homelike setting FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 23 of 23