Health inspection·September 7, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 09/07/2023 at 9:25am with the DON, she said that she has been designated to complete self-reported investigations and report to the SSA by the Administrator. She said that she completed the PIR's for intakes 419917, 422526, and 438333. She said that the completed investigation was submitted by email to the SSA within 5 days, she was not sure why the completed PIR's were not uploaded in the SSA database, and she did not have email confirmation that the complete PIR's were submitted. She said that completed investigation are submitted to the SSA within 5 days according to their policy on abuse and neglect to include reporting. She said that the information is shared with the Administrator and the Executive Director of Clinical Services. She said that the importance of completed investigations being sent to the SSA was the facilities regulations policy to ensure that the facility had addressed issues in a timely manner. She said that the risk to resident was a negative outcome that could cause infection spread. In an interview on 09/07/2023 at 10:30am with the Administrator, she said that she is the Abuse Coordinator but had designated the DON to complete investigations and submit to the SSA. She said that completed investigation should be submitted within 5 days. She said that the facilities Abuse and Neglect policy is used for timelines on reporting for all self-reported incidents. She said that she was not aware of there to be PIR's that had not been submitted to the SSA prior to entrance. She said that the DON said that the PIR's were submitted by email to the SSA, but the DON did not have assess to the emails after her computer stopped working. She said that she was not included on the emails. She said that the importance of completed investigations being submitted to the SSA is the regulations and the facilities policy to ensure that the facility had addressed the issue timely. She said that the risk to residents is that infection could spread. In an interview on 09/07/2023 at 9:52am with the IP, she said that she started at the facility in 2022, and she is an LVN. She said that the abuse coordinator is the Administrator, the DON was designated to complete investigations and report to the SSA, but the Administrator was the oversight. She said that completed investigations are submitted to the SSA within 5 days. She said that completed investigations should be reported to the SSA to ensure the facility had not missed something and done everything to prevent the spread of infection to other residents in the facility. In an interview on 09/07/2023 at 10:19am with ADON, she said that she started at the facility in 2012. She said that the abuse coordinator is the Administrator, the DON was designated to complete investigations and report to the SSA, but the Administrator was the oversight. She said that the facilities Abuse Investigation and Reporting policy stated that completed investigations are submitted to the SSA within 5 days. She said that completed investigations should be reported to the SSA to ensure the facility had done what is needed to prevent the spread of infection, and if the facility had not done what was needed there was a risk of infection spreading to other residents. In a phone interview on 09/07/2023 at 12:00pm with the Executive Director of Clinical Services, she said that she has worked for the corporate office for 9 years. She said that she is informed when there is a self-reported incident at the facility, and the facility should utilize the policy for Abuse Investigation and Reporting for time frames for submission of completed investigations. She said that completed investigations should be completed and submitted to the SSA within 5 days She said that the Administrator or designee should ensure that the task is completed. She said that completed investigations for infection control should be submitted to ensure that infection control policies and procedures were completed to prevent the spread of infection. Record Review of the facilities policy titled Infection Prevention and Control Program dated January 2018, read in part .6. a. Outbreak management is a process that consist of: (9) c. The medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 2 of 3 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 09/07/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete staff will hep the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases. Record Review of Number: PL 18-20 titled Incident Reporting Requirements with revised date of January 19, 2023, read in part .This letter describes the information that a provider must include in an initial reportable incident report made to HHSC Complaint and Incident Intake(CII) and in the provider investigation report (PIR) submitted to CII .A provider must submit a PIR to CII using HHSC Form 3613-A .The PIR must include all information from the initial incident report and any additional information the provider has obtained since making the initial report, including witness statements. The provider must submit the PIR within the applicable required time frame, as follows: o Five working days for .NF or skilled NF; Event ID: Facility ID: 676160 If continuation sheet Page 3 of 3