Health inspection·June 29, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (6:03PM) Hospice was called to reorder lorazepam 1mg PRN, expected to be delivered 06/25/25. Observation on 06/24/25 at 8:48AM of Resident #34 sitting in wheelchair with bedside table in front of him. Resident breakfast tray was sitting on the bedside table Resident started choking excessively with face turning red and then blue. Resident call light was not in reach but sitting on resident bed by pillow that was at the head of resident bed. The surveyor called for help. Resident had eaten approximately 90 % of breakfast. On Resident plate was a 1/2 of toast and a small amount of what appeared to be oatmeal in bowl. LPN B arrived too room with 2 other staff members. When LPN B observed Resident #34's choking she said, Oh My GOD. LPN B attempted to apply the Heimlich maneuver while resident was sitting in wheelchair but was not successful. Resident continued to choke, and the surveyor called for more staff to come. LPN B was trying to lean Resident #34 forward in his wheelchair while patting on resident back. LPN B started preparing to place resident on oxygen via nasal cannula while LVN A agency nurse left the room and returned to room with oxygen saturation device to check resident oxygen saturation. At this time, resident was already receiving oxygen. By this time resident appeared to be in less stress with no further signs of cyanosis (blue skin). When LVN A agency nurse placed the oxygen saturation device on resident's finger, he said resident oxygenation was at 95%. Shortly after, LVN A agency nurse said resident oxygen saturation was ranging between 97-98 %. Resident remained on oxygen at the time of the readings. Before the surveyor exited Resident #34's room, she asked LPN B and LVN A agency nurse if they were going to notify the physician of resident choking incident. Both LPN B and LVN A agency nurse said yes repeatedly that they would notify the physician of the incident. Interview on 06/24/25 at 9:01 AM with CNA BB said she was Resident #34's CNA. CNA BB said resident was able to transfer himself to and from bed to his wheelchair freely. Interview on 06/25/25 at 1:28PM with Resident #34 said he recalled the choking incident on 06/24/25 during breakfast. Resident said the incident scared him. Resident said recently he was beginning to have issues with swallowing but did not say if he told anyone about this.Interview on 06/25/ 25 at 1:58PM the DON said Resident #34 did not experience choking instead, was just coughing. The DON said LPN B told her resident had anxiety episodes and was not choking. The DON said LPN B told her this on 06/24/25 after the incident had happen. The DON said therefore, LPN B administered oxygen to Resident #34. Further interview with the DON after being informed by the surveyor that Resident #34 was eating his breakfast at the time of the incident. The DON said she was not aware that resident was eating during the time of the incident and that she would immediately start in-service with the staff on choking precautions, assessment, and inquiring what type of diet resident was on, if resident diet needed to be changed, and reporting change in condition to resident physician, or hospice doctor if resident was on hospice. The DON said by not assessing the resident properly and reporting to the physician in a timely manner could place the resident at risk for aspiration. The DON was asked for the facility policy on reporting to the physician when there was a change in condition, resident assessment, and choking precautions. Interview on 06/25/25 at 2:04PM with LPN B said she worked at the facility from 6AM-6PM full time. LPN B said when the surveyor called for the nursing staff to come to Resident #34's room, she observed the resident sitting in front of his breakfast tray coughing excessively and had his hands on his wheelchair with his eyes closed and mouth open. LPN B said she attempted the Heimlich maneuver, but it was hard to wrap her arms around resident waist. LPN JB said the other nurse that came in the room was an LVN A agency nurse and CNA RR. LPN B said she pulled out her phone to shine light in resident mouth and did not see any food in resident mouth. LPN B said because she did not see any food in resident's mouth and resident had calmed down, she had determined that resident was not choking. LPN B said some signs and symptoms of silent aspiration were blue lips, drop in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 2 of 21 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 06/29/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few oxygen saturation, not being able to move. LPN B said the reason she placed resident on oxygen via nasal cannula was because resident was coughing for so long. LPN B said the reason she did not document the incident or contact the NP, or physician was because resident had calm down and was able to respond. LPN B said when a resident experienced a change in condition example choking and it was not reported to the physician or NP in a timely manner, it placed the resident at risk for aspiration pneumonia and respiratory distress. LPN B said she had been working at the facility since April of 2025 and that she was a brand-new nurse. LPN B said his was her first job as a nurse. LPN B said she had not received any in-service on choking or silent aspiration. In a later interview on 06/29/25 at 12:10PM with LPN B said she had been-in serviced on the signs and symptoms of choking (cyanosis, grabbing at the throat, not being able to cough), notify the resident doctor immediately along with the family, DON, and the Administrator. LPN B said she had to complete an SBAR because it would be considered a change in a resident's condition. LPN B said when an SBAR was done, it automatically uploaded in the Nursing Progress Notes. LPN B said some signs that a resident could be experiencing silent aspiration was wheezing and abnormal lung sounds. LPN B said she was aware that Resident #34 had dysphagia (difficulty swallowing).Interview on 06/25/25 at 2:23PM with CNA MM said when she went to Resident #34's room, he was coughing non-stop and resident breakfast tray was sitting in front of him. CNA MM said she also passed out snacks to the residents and had never witnessed Resident #34 coughing while eating. CNA MM said she could not remember if the facility had in-serviced her on choking due to the facility giving so many in-services. CNA MM said if she witnessed a resident coughing excessively non-stop or choking, she would check to see if resident had something in their mouth, attempt to perform the Heimlich maneuver, and let the nurse know what happened so they could assess the resident. CNA MM said she had been working at the facility for 3 years. Interview on 06/25/25 at 4:30PM with NP R at the facility said she was not the NP for Resident #34. NP R said she heard the DON in-servicing the staff and asked what was going on. NP R said the DON told her that Resident #34 had experienced a coughing episode on 06/24/25 and asked her to assess resident. NP R said she assess Resident #34 and resident lung sounds were clear. NP R said she gave a stat order for a chest x-ray to rule out aspiration. NP R said some signs of silent aspiration could be difficulty breathing and respiratory distress, and excessive coughing while eating meals. NP R said this would be considered a change in a resident's condition. NP R said she would want to be notified right away so that she could intervene by giving orders one being a chest x-ray. NP R said if notification to the physician/NP was delayed it placed the resident at risk for respiratory illness. Interview on 06/26/25 at 11:15AM with LPN B said on 06/24/25 she was not Resident #34's primary care nurse. LPN B said the primary care nurse for Resident #34 was LVN J. LPN B said she told LVN J resident had experienced some excessive coughing while eating breakfast. LPN B aid she did not notify the Physician, just told LVN J about the incident and did not know what LVN J after she told her. Interview on 06/26/25 at 11:25AM via phone with LVN J said she worked at the facility on the 6AM-6PM shift. LVN J she was Resident#34's primary are nurse on 06/24/25 for the 6AM-6PM shift. LVN J said she was told by LPN B that a surveyor had said that resident was choking while eating breakfast. LVN J said LPN B told her that Resident #34 was not choking when she arrived too resident room and that resident coughing had resolved. LVN J said she called the hospice company, and they did not provide any new orders. LPN J said she did not document her actions taken regarding the incident. LVN J said when a resident experience a change in condition the physician needed to be notified. LVN J said she had been working at the facility for over 3 years and could not remember if she had received in-service on choking/silent aspiration, maybe when she was first hired. LVN J said some signs of silent aspiration was excessive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 3 of 21 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 06/29/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few coughing while eating and shortness of breath.Interview on 06/27/25 at 1:12PM with the Medical Doctor at the facility said he was Resident #34's physician. The Medical Doctor said Resident #34 was on hospice service. The Medical Doctor said resident had Parkinson's disease and had a history of stroke with some dysphagia which resident sometimes had the tendency to choke but had never aspirated. The Medical Doctor said resident was on a mechanical soft diet chopped meats. The Medical Doctor said the facility had called him but could not remember on what day or the time telling him Resident #34 had choked but coughed it up. The Medical Doctor said his NP was NP RR. The Medical Doctor said his NP RR gave the facility an order to do a stat chest x-ray and speech evaluation. The Medical Doctor said his NP RR spoke with Resident #34 as well. The Medical Doctor said he would want to be notified right away if a resident experienced continuous coughing or choked while eating for the safety of the resident and due to the risk of aspiration. The Medical Doctor said some signs and symptoms of silent aspiration was coughing when trying to eat especially when consuming liquids, wheezing, change in the color of resident skin turning red and going blue. Interview on 06/27/25 at 2:11PM with the DON said she called the NP RR on 06/24/25 she thinks around 11:00AM of Resident #34's coughing incident. The DON said she told NP RR Resident #34 was stable and therefore the NP RR did not give any further orders. The DON said she had also contacted the hospice company and informed them of resident coughing. The DON said hospice said they were going to come and see resident, but did not give a day when they would be coming to the facility. The DON said another reason she did not document was because she was busy doing other task at the facility and that the nurses had already assess Resident #34 and said that resident was okay. The DON said she did not learn until the next day 06/25/25 that the nurses did not document the incident or their assessment. The DON said she told the nurses that they needed to document as a late entry. The DON said she told LPN B that she needed to do an SBAR and document in the Nursing progress notes as well. The DON said it was important to do an SBAR because it was a form of communication regarding the resident's care. The DON said when resident care was documented, it placed the resident at risk for not receiving necessary treatment. Interview on 06/27/25 at 3:20PM via phone NP RR said she did not come to the facility often and could not remember the last time she had been at the facility. NP RR said she was the medical doctor who was seeing Resident #34's NP. NP RR said she only came to the facility with the medical doctor needed her to cover for him. NP RR said she could not remember what day the facility had called her regarding Resident #34. NP RR said the facility told her that Resident #34 had experienced a coughing episode. NP RR said she asked the facility if resident was okay. NP RR said the facility told her that Resident #34 was stable. NP RR said she did not give any new orders for Resident #34. NP RR said she thought that the facility had called the medical doctor about the incident. NP RR said that it was NP R that gave an order for stat chest X-ray. Interview on 6/29/25 at 9:39am Administrator said she did not know a lot of things that were happening in the facility. The Administrator said the staff needed to make sure resident care plans were addressing the resident needs. Interview on 06/29/25 at 10:27AM with the DON, the DON said when the nursing staff assessed resident, they did not document in a timely manner all interventions taken and had to document late entries. The DON said the facility had done in-services with the staff on choking vs. coughing, residents at high risk of aspiration who diagnoses included Parkinson's disease, CVA's, and dysphagia. The DON said the facility were now assigning staff to make rounds during mealtimes to monitor the residents at mealtimes. The DON said the Speech Pathologist came to the facility to elaborate on the importance of observing residents while eating, making sure resident's position was properly aligned when eating to prevent choking, and to facilitate better swallowing for the resident. The DON said she would continue to quiz and monitor the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 4 of 21 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 06/29/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete staff until the facility was confident that all staff understood the circumstances that could place resident at risk for harm. The DON said she would continue to review the resident's care plans, quarterly meetings, and know the revision timeline. The DON said she had updated a list for the nurses to contact the physician within in a shift involving incidents and accidents. The DON said the NF would be utilizing their resources; Speech Pathologist, Nurse Practitioners, and Physician to further educate the staff on residents with swallowing problems. Record review of the facility policy on Notification of Changes in condition revised May 2025 revealed in part: The purpose of this policy is to ensure the facility promptly informs the resident, consult the resident's physician; and notified, consistent with his or her authority, the resident's representative when there is a change requiring notification.Compliance Guidelines:The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.Circumstances requiring notification include:1. Accidentsa. Resulting in injury.b. Potential to require physician intervention.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.This may include:a. Life-threatening conditions, orClinical complications Event ID: Facility ID: 676160 If continuation sheet Page 5 of 21 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 06/29/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and furnish services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 11 residents (CR #1and Resident #34) reviewed for comprehensive care plans.The facility failed to care plan CR #1 for risk of elopement and document interventions prior to CR #1 eloping from the facility on 06/20/2025 around 4:45pm and did not know her whereabouts until 06/20/2025 around 8:40pm.The facility failed to assess and follow-up on Resident #34 in a timely manner when resident experienced excessive coughing/choking episode while eating breakfast on 06/24/25 at 8:48AM.This was determined to be an IJ on 6/26/25. The Administrator and DON were notified on 6/26/25 at 4:23pm. The DON and Administrator were provided with the IJ template on 6/26/25 at 4:27pm and a Plan of Removal was requested. The IJ was lowered on 06/29/2025 at 11:40am with the Administrator and DON. While the IJ was lowered, the facility remained out of compliance at a scope of isolation and a severity of no harm with potential for more than the minimal harm that is not an immediate jeopardy because of the facility's need for continued monitoring of implemented procedures.This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health.Findings Included: CR #1 Record review of CR #1's face sheet dated 06/25/2025 reflected an [AGE] year-old female originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included Alzheimer's Disease (a neurodegenerative disorder which causes decline in memory, thinking and behavior), Type 2 diabetes mellitus (high blood sugar), chronic kidney disease, Major Depressive Disorder (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities which disrupts the ability to function in everyday life), Hypertension (high blood pressure), overactive bladder, Dementia (a general term to describe decline in cognitive function, memory loss, difficulty communicating, impaired reasoning and changes in personality), and insomnia (difficulty or inability to sleep). Record review of CR #1's Quarterly MDS dated [DATE], CR #1 had a BIMS score of 6, indicating severe cognitive impairment. CR #1 required partial to moderate assistance with her ADLs including oral and personal hygiene, dressing, showering or bathing, and toileting. She required setup assistance for walking from 10 to 50 feet and supervision for walking 150 feet. CR #1 was frequently incontinent with urine and occasionally incontinent with bowel. Record review of CR #1's care plan, she was care-planned for elopement on 6/20/25, with interventions including 1 to 1 assistance, anticipating and meeting resident needs and explaining/reinforcing why behaviors were inappropriate and/or unacceptable to the resident. CR #1 was not previously care-planned for being at risk of elopement. Record review of CR #1's Kardex care sheet, undated, under toileting focus area CR #1 had interventions for staff to report any attempts to exit the facility to the IDT, family & MD as indicated and record in the clinical record. She was also planned for IDT care plan over the phone with resident's RP to review current placement versus close/lock unit due to resident recent elopement. Record review of CR #1's progress notes, on 6/20/2025 at 1:34am she was resting in bed with no distress noted. On 6/20/2025 at 8:41pm, Interim DON was notified via phone that CR #1 was sitting on the floor by her walker near a college and taken to the ER. RP was notified 6/20/2025 at 9:01pm. On 06/21/2025 at 2:57am, a nurse documented that CR #1 was ordered to be on 1-to-1 supervision when she returned to the facility. CR #1 had returned from the hospital around 4:45am (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 6 of 21 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 06/29/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few that day. A later note at 1:27pm, CR #1 was documented as being one-on-one care with aide due to an elopement on 6/20/2025 and CR #1 door was open, and resident was able to come in and out with supervision. Further review showed from September 2024 to June 2025, CR #1 was not mentioned having any exit-seeking or elopement incident. Record review of CR #1's elopement risk assessments completed 1/15/2025 and 3/19/2025, the assessments reflected CR#1 had a history of elopement or attempted to leave the facility without informing staff. No interventions were selected for either assessment. An additional elopement risk assessment was completed 06/12/2025 which reflected that CR #1 was marked yes for verbally expressing desire to go home, packing belongings or stayed near the exit, and there was a note reading usually resident sits at the lobby. CR #1 was also selected yes for having Alzheimer's, being cognitively impaired with poor decision-making skills related to intermittent confusion, cognitive deficits or disorientation, ambulating independently and had a walker. Record review of CR #1's psychology assessment on 06/3/2025, CR #1 was seen in her room and reiterated she continued to miss her family and would like to be home with them. Record review of CR #1's skilled nurse charting on 06/21/2025, CR #1 was on 1-on-1 care with an aide due to elopement on 06/20/2025. Record review of CR #1's pain assessment done on 06/21/2025, CR #1 stated not being in pain. Record review of CR #1's skin evaluation done on 06/21/2025, CR #1 refused full body skin assessment, staff evaluated CR #1's upper and lower extremities only with no injuries. Record review of CR #1's 15-minute check sheet for 6/21/2025, she was monitored and staff signed off on her for reasons of fall between 6/21/25 at 4:45am to 9:00pm before being transferred to the hospital. Record review of CR #1's hospital records dated 06/21/2025, CR #1 was found by a bystander who called emergency services when she was found walking unsteadily on the road. Bystander assisted CR #1 to the side of the road until law enforcement came. CR #1 was witnessed falling twice and denied hitting her head or loss of consciousness. CR #1 was brought to the hospital after bystanders saw her acting confused. CR #1 complained of back and neck pain. CR #1 was seen for a fall, AMS and found walking on the road. CR #1 reported chronic lower extremity swelling and the hospital documented CR #1 with pain level of 6. CR #1's CT scan had no acute findings. CR #1 had right leg pain and UTI (asymptomatic). Record review of CR #1's Order Summary, there were no orders for monitoring due to wandering or exit-seeking. CR #1 had orders for Aricept Oral Tablet 10 MG with an order date of 5/21/2025 for dementia, Divalproex Sodium Tab Delayed Release 125 MG with a start date of 11/6/24 for mood disorder, and Escitalopram Oxalate Tab 10 MG with a start date of 11/6/24 for Major depressive disorder. In an interview on 06/25/2025 at 11:40am with CR #1's RP, she said she received a call on 06/202/25 on 9:49pm stating that CR #1 walked out of the building, was fine and going to the hospital. She said when she spoke to staff at the hospital stated her mom was there for 2 hours already and CR #1 was covered in feces. The RP said CR #1 reported to her that she fell in the street. She said the doctor said she had an X-Ray and CT scan completed and the hospital discharged CR #1 back to the facility on [DATE] at 5:00am. Interview on 06/25/2025 at 1:20pm with CNA GG, CNA GG worked at the facility since March 2025 and worked 6am-2pm and 2pm-10pm as needed. CNA GG was not working at the facility when CR #1 eloped and had never seen CR #1 leave before but said CR #1 was always wandering and walking down one particular hall. CNA GG said staff are to round on residents at least every two hours and had in-services on elopement and residents with dementia. Interview on 06/25/2025 at 1:29pm with CNA O, CNA O was assisting in the dining room on 06/20/2025 when CR #1 eloped. CNA O received notification CR #1 was missing between 7pm-8pm that same day. CNA O never heard CR #1 saying she wanted to leave the facility. Staff should round every two hours and CNA O rounds every 30 minutes to 1 hour. If a resident was missing, CNA O would try to look for them and if unsuccessful would report the missing resident to the nurse, charge (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 7 of 21 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 06/29/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few nurse and Administrator immediately. Interview on 06/25/2025 at 1:39pm with CNA P, CNA P worked the morning shift on 06/20/2025 and did not see CR #1 leave the facility. The last time CNA P saw CR #1 was around 2:00pm at the end of CNA P's shift. CNA P never saw CR #1 try to leave or vocalize the desire to leave the facility. CNA P did 1-to-1 monitoring for CR #1 when CR #1 was re-admitted to the facility on [DATE].CNA P received 1-to-1 and facility-wide in-service about the elopement policies and procedures. CNA P said she had received in-services on resident elopement and resident with dementia since working at the facility. In an interview on 06/25/2025 at 2:00 PM CNA GP, she stated she had been working at the facility for 3 years. CNA GP said she was not present at work when CR #1 eloped. CNA GP said CR #1 would like to stay in her room a lot but, would come out her room for coffee and activities, and that she was mobile with her walker. CNA GP said CR #1 would say she wanted to go home often and be with her family. She said the hallway exit doors are all locked and would set off the alarms, but the front door to the facility was not locked but now are locked since CR #1 eloped. CNA GP said the front door is important with lots of traffic after dinner because families leave out and sometimes will hold the door open for residents thinking they are okay to be outside alone. She said she doesn't know all the details but believed CR #1 went through the front door. CNA GP stated she has no concerns of any abuse, neglect, or elopement at the facility. In an interview on 06/25/2025 at 3:00 PM with NP B stated she was shocked that CR #1 left the community as CR #1 was not an elopement risk and she was not care-planned for elopement because NP B had not witnessed or heard CR #1 wanting to leave the community. NP B said she was not concerned about change of condition for CR #1 and was aware the results from the hospital returned negative. NP B said CR #1 was mobile with her walker and was active with therapy services and that CR #1 was normally calm and to herself and liked to eat lunch in her room. NP B stated the community was not a restraint/ locked community and did not utilize a wander guard system. NP B said staff were not aware that CR #1 was exit seeking. Staff had been in-serviced since the incident. Interview on 06/25/2025 at 3:05pm with LVN I, LVN I said CR #1 walked around a lot depending on her mood and would sit at nurse's station. In the past, CR #1 would sometimes walk up to and rattle the double doors and staff had to redirect her, but this was not recent. LVN I said CR #1's family was aware of this. LVN I was not there when CR #1 eloped. LVN M had received in-services on resident elopement and resident with dementia. CR #1 had never gotten out of the facility so LVN I did not know if risk of elopement would be care-planned but that CR #1 was assessed for risk. Interview on 06/25/2025 at 2:54pm with CNA C, CNA C heard that CR #1's exit-seeking behavior had been going on for some time and staff would redirect her back. CNA C had seen CR #1 in the dining room eating on 6/20/2025 at 5:30pm to 5:40pm and CNA C was taking another resident to their room. CNA C had been notified CR #1 had left around 7:30pm-8:30pm during last rounds. CNA C said when CR #1 came back to the facility she was observed trying to leave the building again. CNA C received in-services on resident elopement and resident with dementia. CNA C would report elopements or missing residents and report it to the charge nurse and document it. CNA C would redirect residents back to the facility if she saw them leave. Interview on 06/25/2025 at 3:44pm with the Administrator and DON, the Administrator said she was the Interim Administrator and began work on 06/02/2025 and the DON was Interim and had started working in the building at the end of May 2025. The Administrator said that her investigations found that CR#1 left unassisted. CR #1 told the Administrator she wanted to walk by the college to the hospital. The Administrator said an aide last saw CR #1 on 6/20/2025 around 5:45pm in the front lobby and a CMA last gave CR #1 medication at 6:00pm but the Administrator could not remember who the CMA was. The DON received a phone call from the facility's Marketing Director on 6/20/2025 at 8:45pm that a bystander found CR #1 walking down the road, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 8 of 21 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 06/29/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and that bystander called the Marketing Director to see if CR #1 was a resident at the facility. The DON then told the Administrator and Quality Assurance Nurse who were both still in the building. The facility did a head count, and the DON called CR #1's doctor and RP after speaking to the bystander to locate CR #1. The bystander told the DON that CR #1 was on the floor near the college and was with the bystander and another unidentified male. CR #1 had an incontinent episode. The bystander reported that she called EMS who came and took CR #1 to the hospital. The DON said the hospital did not report any injuries, and CR #1's blood and UA tests came back negative, and CR #1 was discharged back to the facility. When CR #1 came back to the facility she reported wanting to leave again and became agitated, so she was placed on 1-to-1 monitoring every 15 minutes before she was moved to a hospital psych unit for treatment. The Administrator and DON were not aware CR # 1 was an elopement risk. The DON said CR #1 was later assessed and found to be an elopement risk, and she was placed in the elopement binder. The DON had about 5 residents who have wandering behaviors, but none expressed wanting to go out and leave the building. CR #1's RP told the Administrator and DON after the elopement incident that CR #1 was found having left the building in the past, but no date was clarified. The Administrator said the front doors locked at 7pm daily. The Administrator put red boxes on all facility doors including the front door so if anyone tried to open the door the alarm would activate. The DON said the facility notified the family members regarding the new alarm system and if families wanted to visit after hours to call the phone number located on a sign at the front door. The Administrator and DON in-serviced staff to not share the code to the doors. The DON said the facility had no elopements since this incident. The DON said risk of elopements should be in the care plan but at the facility was previously under a different company so all of the old care plans might not have transferred over. The DON assessed all current residents for elopement and put residents at risk in the binder. The DON said there were no wander guards, and the facility would not be able to accept CR #1 again because she was a fast walker, could walk on her own and was adamant about leaving. The bystander's information was requested from the DON, but it was not provided by survey exit. Interview on 06/26/2025 at 10:31am with LVN FZ, he said on 06/20/2025 he got to work early at 5:20pm and remembered seeing CR #1 in the lobby. LVN Z did not report to work until 6:15pm after a meeting. He did not hear about CR #1 being an elopement risk, and that he would get that information through reports. If a resident tried to leave he would redirect them to their rooms, ensure their safety, assess, document and tell someone from Administrator. LVN FZ would check all the rooms and bathrooms and if the resident could not be found LVN FZ would call the DON and Administrator. Interview on 06/26/2025 at 4:27pm with the MDS Consultant, she said she was not the facility's main MDS Nurse but now she came to assist with the facility as needed. The facility's Clinical team was in charge of care plans now and that the facility did not have an in-house MDS Nurse. The MDS Nurse said she did not assist with care planning. The MDS Nurse said that nurses reviewed charts, 24-hour reports and meetings to care plan for residents and that residents at risk of elopement should have been care-planned. If residents' needs were not in the care plan, staff would not know how to care for them Record review of the facility policy on Quality of Care revised February 2023 reflected in part: .Each resident will be provided care and services to attain or maintain his/or her highest practicable physical, mental, and psychosocial well-being.A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan. Record review of the facility policy on Resident Rights revised January 2025 reflected in part: .The facility will ensure that all directed care and indirect staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Record review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 9 of 21 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 06/29/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the facility's policy on comprehensive care plans last reviewed or revised 01/2025 read in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress . Record review of the facility's policy on documenting in the medical record last reviewed or revised 04/2025 read in part, Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation .Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record . Record review of the facility policy and procedure entitled, Accidents and Supervision date revised 1/25 read in part. The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes Identifying hazard(s) and risk(s).Evaluating and analyzing hazard(s) and risk(s).Implementing interventions to reduce hazard(s) and risk(s).Monitoring for effectiveness and modifying interventions when necessary. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. This was determined to be an IJ on 5/26/25. The Administrator and DON were notified on 5/26/25 at 4:23pm. The DON and Administrator were provided with the IJ template on 5/26/25 at 4:27pm and a Plan of Removal was requested. The IJ was lowered on 05/29/2025 at 11:40am with the Administrator and DON, While the IJ was lowered, the facility remained out of compliance at a scope of isolation and a severity of harm with potential for more than the minimal harm that is not an immediate jeopardy because the facility's need for continued monitoring of implemented procedures. The following plan of removal was accepted on 5/27/25 at 2:24pm. PLAN OF REMOVAL [Name of Facility] Date: 6/26/25 F 656 Comprehensive Care Plans Problem: - The facility failed to develop and implement a comprehensive person-centered care plan for each resident when CR #1 was not care planned for being an elopement risk when CR #1 eloped from the facility on 06/20/2025 and was last accounted for at 5:50pm. CR #1 was located by a bystander who saw CR #1 walking down the street from the facility and called emergency services and CR#1 went to the hospital. CR#1 No longer reside in the facility. Immediate action: 1. 6/20/25 The facility administrator completed a self-report incident to HHSC due to resident elopement. 2. 6/26/25 The facility DON/Designee conducted an audit of residents with high risk for elopement based on updated assessment and history of exit seeking behaviors to ensure their comprehensive person-centered care plans are updated, are appropriate and meet their individual needs. 7 residents identified to be at risk, all included to the elopement binder. Completed 6/27/25 3. On 6/26/25 The VP of Clinical Services conducted a 1:1 in-service with the Admin and DON on the facility Elopement Policy focusing on timely implementation of interventions aimed to prevent and manage residents with wondering and exit seeking behaviors, to include adding chosen interventions to the person center care plans upon admission/readmission and with changes in condition. Interventions: 4. On 6/27/25 the DON/Designee conducted a 1:1 in-service with the facility interim MDS Nurse and nurse managers on timely care planning of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 10 of 21 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 06/29/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents identified to have wondering behaviors and or who are at Elopement risk upon admission/readmission and with changes in condition. Completed 6/27/25 5. On 6/26/25 the DON/Designee initiated an in-service with the facility staff how to identify residents who are at risk for elopement/ exit seeking as indicate in the plan of care/Kardex, resident care profile and the elopement binder. Projected completion on 6/27/25 6. On 6/26/25 the DON/Designee initiated an in-service with the facility nursing staff on immediately reporting residents with escalating exit seeking behavior to the nurse, DON, and or Administrator to seek guidance and ensure appropriate interventions are put in place. Projected completion 6/27/25 7. On 6/26/25 the DON/Designee initiated and in-service with the nurse managers and licensed nurses on the Facility Policy Elopement and Wandering Residents focusing on promptly updating resident Elopement Risk Assessment and placing adequate interventions in place following a new admission/readmission and exit seeking/elopement episode to include interventions to meet the residents' individualized needs, DON/MDS nurse and Designee will monitor care plans for appropriateness and completion. Completion date 6/27/25 Ongoing Projected completion 6/27/25 Any staff member not present or in service, will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring: 8. On 6/26/25 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 6/27/25 9. Starting on 6/26/25 the facility Adm/Don and designee will review prior day Elopement assessments risk/exit seeking behaviors documentation to ensure the comprehensive care plan is up to date and include individualized, appropriate and effective interventions. Any identified concerns will be addressed at that time. Completed 6/27/25 10. 6/26/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 6/26/25 Record review of the IJ plan binder: -The Facility Administrator completed a self-report on 06/20/2025 after CR #1 left the facility with her walker unassisted. At 5:45pm 81 y/o female left Facility grounds with her walker unassisted. Hospital notified of resident update, no fractures. Family, Physician, Interim DON and Interim Administrator informed, head count for all residents. Implementation of critical behavior log. -On 06/26/2025 the facility audited all residents at high risk for elopement and had listed out their risk scores and categories of risk (no, low and high risk). There were 8 residents' facesheets including CR #1 which had their photos. The 8 residents had updated elopement risk assessments, physician orders for monitoring of behavior every shift and updated care plans as of 06/29/2025. -The Administrator and DON received a 1-to-1 in-service from the VP of Clinical Services on the facility's Elopement Policy which was last revised 07/2023 whose topics included timely implementation of interventions, adding chosen interventions to care plans upon admission/readmission and with changes in condition. The Administrator DON signed separate sheets confirming they received the in-service on 06/26/2025. -VP of Clinical Services conducted a 1-1 in-service with the Administrator and DON on the facility Elopement Policy. [NAME] RN was VP of Clinical Services. Date: 6/26/25, subject was Elopement policy and procedure. [NAME] signed the policy in-service titled Elopements and Wandering Residents with a date implemented 07/2023. [NAME] LNFA signed 06/26/25 Elopement policy and procedures. -DON/Designee conducted in-services with interim MDS nurse and nurse managers on timely care planning of residents identified to have wandering behaviors and those at risk upon admission/readmission with changes in condition. Completed 6/27/25. The MDS Consultant signed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 11 of 21 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 06/29/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 6/26/25, instructed by the VP of Clinical Operations and ensure timely and accurate completion of care plans upon admission/readmission and changes in condition. It should be in the care plan development should include appropriate interventions such as adding residents to the binder. Quality Assurance Nurse was in-serviced. - 6/26/25 the Don/Designee initiated in-service to be completed 6/27/25 with facility staff how to identify residents who are at risk of elopement/exit seeking as indicated in the Plan of care/Kardex, resident care profile and elopement binder. - On 6/26/25 DON initiated an in-service on immediately reporting residents with escalating exit seeking behavior to the nurse, DON and or Administrator to seek guidance and ensure appropriate interventions. Completed on 6/27/25. - On 6/26/25 DON/Designee initiated in-service with the nurse manager and licensed nurses on the Facility Policy Elopement and Wandering Residents focusing on promptly updating resident Elopement Risk Assessment and adequate interventions. DON/MDS Nurse and Designee to monitor care plans for appropriateness and completion. -6/26/25 DON/designee - will begin a questionnaire to validate the effectiveness of the training. Immediate re-education will be completed if staff unable to answer. Projected completion 6/27/25. Quizzes placed in the binder. -6/26/25 review prior day Elopement assessment risk/exit seeking behaviors documentation to ensure the comprehensive care plan is up to date and include individualized, appropriate and effective interventions. Completed 6/27/25. -6/26/25 an impromptu QAPI meeting was conducted with facility's MD to notify potential for non-compliance. Plan approved 6/26/25. Interview on 06/28/2025 at 1:43pm with LVN AA, she received in-services on protocols on elopement, elopement prevention and exit-seeking behaviors and how to reset the alarm. LVN AA said nurses had a key to reset alarms if it went off, if residents were missing staff should spread out and attempt to locate the resident and after 30 minutes if resident is still missing staff should notify the Administrator and DON. If a resident was wandering toward the door, they should be placed under 1-to-1 monitoring and the family should be notified. Staff should keep an eye on residents and lay eyes on residents every two hours. LVN AA said residents' exit-seeking behaviors should be in their care plan and in their orders for monitoring of exit-seeking behaviors. Interview on 06/28/2025 at 2:07pm with the Quality Assurance Nurse, she said she received and conducted in-services for staff on elopement. The Quality Assurance Nurse covered topics such as exit-seeking behaviors like forcing doors open and verbalizing things like having to go home to their kids and staff should redirect if they can. The Quality Assurance Nurse said the eight residents in the Elopement Binder were identified as high risk because they had verbalized wanting to go home. The Quality Assurance Nurse said floor nurses did not do care plans, but MDS Nurses and nurse managers could. Interview with the MDS Consultant on 06/28/2025 at 2:13pm, she said she received elopement, care plan and changes in condition in-services. The MDS Nurse learned about the process of elopement such as the code and alarms, head counts, and notifying the Administrator, DON, physician and family when there are changes in condition such as an elopement. Interview on 06/28/2025 at 11:44pm with CNA MM, she worked from 10pm to 6am. She received in-services on elopement and care plans. Signs of elopement included verbalizing the desire to leave and going towards the exit door. If CNA MM saw a resident do these things, she would bring them back and keep an eye on them and tell the nurses. Interview on 06/28/2025 at 6:40pm with RN TT, she worked night shift and received in-services on elopement and wandering residents and care plans and that she should report any signs of elopement such as residents asking to go home to the doctor, family and management. She said incidents should be documented and nurses should make a report. A resident's plan of care would be found in their medical chart and the Kardex (a list of focus areas and interventions that could be accessed by any staff). RN TT had in-services on how the alarm system worked. Interview on 06/28/2025 at 7:33pm with LVN PP, she worked night shift and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 12 of 21 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 06/29/2025 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 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete said information on a resident's elopement risk would be in the Elopement Binder at the nurse's station. LVN PP was in-serviced on monitoring residents if they showed signs of exit-seeking and to assign someone to monitor 1-on-1 and inform the Administrator, DON, the physician and the resident's RP about attempts or actual elopements. LVN PP received an elopement drill. Residents at risk of elopement would be care-planned which could be found in their medical chart and Kardex. Interview on 06/28/2025 at 10:16pm with CNA IM, she said she received a list of residents with elopement risks, elopement drills, and exit-seeking prevention strategies like monitoring, checking doors, and providing activities to keep residents occupied. Signs and symptoms of exit-seeking were talking about eloping, bringing up old memories and wandering. If CNA IM saw a resident elope, she would report it to the charge nurse, and she could find the information in the resident's medical chart and Kardex. CNA IM said staff should round every 1-2 hours on residents. Interview on 06/28/2025 at 11:48pm with LVN OO, she said she was an agency staff and worked night shift. LVN OO had in-services and huddles on elopement and care-plans. During an elopement, nurses should print out the census and check on rooms. LVN OO received an elopement drill training. If a resident stated leaving or packing up room, staff were to redirect residents and let their supervisor know, do a change in condition assessment and let the Administrator, DON, the physician and family know. LVN OO said staff could look at white binder for elopement risk residents with facesheet, and also look in the resident's medical chart for demographics, special [TRUNCAT Event ID: Facility ID: 676160 If continuation sheet Page 13 of 21 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 06/29/2025 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 0685 Assist a resident in gaining access to vision and hearing services. 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 that 1 (Resident #61) of 5 residents reviewed for hearing services, received proper treatment to maintain hearing capabilities. -The facility did not complete an Audiology (hearing) referral for Resident #61 who was hard of hearing until 06/27/25. -The facility failed to identify that Resident #61's hearing aids were not functioning properly when resident placed new batteries in hearing aids. This failure could place residents at risk for further decrease in communication, social engagement, and decrease in quality of life.Findings included: Record review of Resident #61's face sheet dated 06/26/25 revealed an [AGE] year-old male admitted to the facility on [DATE] and again on 04/02/24. Resident's diagnoses included dementia (brain disorder that causes problems with thinking, memory, and behavior), type 2 diabetes mellitus (body has trouble controlling blood sugar and using for energy), heart failure, heart disease, depression, adult failure to thrive, and hypertension (high blood pressure). Record review of Resident #61's quarterly MDS dated [DATE] section B (Hearing, Speech, and Vision) reflected resident had a hearing aide with moderate difficulty in hearing. Further review reflected a BIMS score of 4 indicating severe cognitive impairment. Record review of #61's Physician Order Summary Report for the month of June 2025 reflected the following order: -Dated 11/07/24 Audiology (hearing) as needed. Record Review of the facility Audiology binder for residents receiving services for Audiology did not reflect Resident #61 being on the list for services. Record review of Resident #61's Comprehensive Care Plan not dated reflected that Resident #61 was being care planned for impaired communication AEB hearing loss right/left both AEB wearing hearing aids. The interventions included: refer to audiology for hearing consult as ordered, report to the nurse changes in ability to communicate, possible factors which cause/make worse/better communication problems. Observation on 06/24/25 at 9:47AM was Resident #61 awake in bed with TV on in his room. While trying to communicate with resident, it was observed that resident was significantly having difficulty hearing the surveyor. Interview on 06/24/25 at 9:47AM with Resident #61 said he could not hear good and had been waiting on getting some help with his hearing aids. Interview on 06/26/25 at 12:43PM with MDS Consultant she said she had been working for the company for 8 years. The MDS Consultant said she was working in the place of the facility MDS nurse due to this staff member being on leave. The MDS Consultant said it was a team effort that consisted of herself, MDS nurse in the facility, charge nurse, nurse manager, and the DON that ensured residents were receiving the necessary social services. The MDS Consultant said she did not participate in the meetings held at the facility. The MDS Consultant said the surveyor would have to refer to the DON. The MDS Consultant said the facility did not have a full time Social Worker in the facility, but the Corporate Social Worker came to the facility when needed. Interview on 06/26/25 at 3:02PM with the DON said it was herself, and a Social Worker from a sister facility that was ensuring that residents that required social services including audiology were being seen by the physician. Interview on 06/26/25 at 4:46PM with LVN ZZ said he was an agency nurse and was Resident #61's primary care nurse . LVN ZZ said it was his first day working at the facility. LVN ZZ said he was not aware that Resident #61 was hard of hearing. LVN ZZ said he received report from the night nurse who he believed was an agency nurse as well that reported no changes. Interview on 06/27/25 at 2:11PM with the DON said she would have to see if a referral had been done for Resident #61 to receive audiology services. Interview on 06/27/25 at 3:15PM said she sent a referral to Audiology on 06/27/25 because Resident #61was not on the list for audiology services. Interview on 06/28/25 at 10:29AM with the DON she said she assessed Resident #61 on 06/27/25 and that Resident #61 had hearing aids, but apparently something happened to his hearing Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 14 of 21 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 06/29/2025 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some aids. The DON said Resident #61 said his hearing aid was not working. The DON said Resident #61 had been seen by audiology services but could not locate a documentation of resident being seen by audiology. The DON said she did not speak with the staff to see if they were aware of Resident #61's hearing aids were not working. When the DON was asked what did it place Resident #61 at risk for when resident was hard of hearing, hearing aids not working properly, and resident not receiving audiology services, the DON said she did not know, and that the surveyor would have to speak with the Social Worker to answer that question. Interview on 06/28/25 at 12:27PM with the Social Worker via phone she said she only came to the facility once a month. The Social Worker said she was at the facility on June 6th and reviewed all residents' charts regarding their CODE status. The Social Worker said she spoke with the residents to see if they had any concerns about anything. The Social Worker said the previous DON was working at the time when she was last at the facility. The Social Worker said she had been working with the present DON remotely on a weekly basis sometimes more than once a week about any questions or referrals that needed to be done, or anything related to social services. The Social Worker said her job description included getting the following services for residents that needed them: Podiatry (a branch of medicine that focus on the study and diagnoses of the foot, ankle, and lower limb), Psychology (study of the mind and behavior), vision, hearing, and dental. The Social Worker said she spoke with the present DON on 06/27/25 regarding audiology referrals for a few residents at the facility but she did not remember who the residents were. The Social Worker said the DON was needing guidance on how to fill out a referral. The Social Worker said she did not assess the residents for the above services mentioned. The Social Worker said it was the role of a Social Worker to attend the clinical meetings held by the DON and gather information on what resident would benefit from certain social services. The Social Worker said it was the nurses, MDS Coordinator, and DON that divided up this task in assessing the residents for social services. The Social Worker said the facility had a big change in management and that she was not aware that Resident #61 was hard of hearing. The Social Worker said after reviewing Resident #61's chart, Resident #61 had been residing at the facility since 2021. The Social Worker said until resident could be seen by the audiologist, the facility could utilize a white board to communicate with Resident #61. The Social Worker said by not having Resident #61 on audiology services, it placed him at risk for decrease in communication and understanding. Interview on 06/28/25 at 2:30PM with the DON she said she had placed a communication book in Resident #61's room on 06/27/25. The DON said when she went to Resident #61's room on 06/27/25 she did not see any delay in communicating with Resident #61. The DON said it was the surveyor only that mentioned that Resident #61was hard of hearing. Interview on 06/29/25 at 10:15AM with LVN J said she was Resident #61's primary nurse. LVN J said Resident #61 had hearing aids but did not recall when the last time Resident #61's hearing aids or batteries for the hearing aid had been checked. LVN J said Resident #61 put his own hearing aids in his ear. Observation on 06/29/25 at 10:18AM of Resident #61 revealed he was awake in bed with personal belongings at the bedside along with a communication binder. LVN A was attempting to communicate with Resident #61. It was observed that Resident #61 was not hearing LVN J as she was trying to communicate with him. Resident #61 had batteries he said for his hearing aids and that the batteries were not working properly. Resident #61 took a pack of batteries that were at the bedside. Resident #61 took 2 batteries of the pack demonstrating that when he placed the batteries in his hearing aid, his hearing aids still did not work. LVN J attempted to use the communication binder, but Resident #61was not understanding what LVN J was trying to communicate to him. The expiration year on the battery package could not be read clearly. Interview on 06/29/25 at 10:20AM with LVN J she said Resident #61's hearing was not good. LVN J said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 15 of 21 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 06/29/2025 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete this placed Resident #61 at risk for not being able to communicate with staff therefore placing Resident #61at risk for withdrawal due to him not being able to communicate with people. Interview on 06/29/25 at 10:30AM with Resident #61 by way of writing questions on paper that he could read and answer the questions asked. Resident #61 said it was his family that bought him the batteries to place in his hearing aid. Resident #61said the batteries would not work and had been waiting to get help regarding his hearing. Resident #61said he could not remember the last time he had his hearing aids checked, or his hearing tested. Resident #61said he did not like not being able to hear or communicate with people. Interview on 06/29/25 at 10:57AM with CNA H she said she worked at the facility full time from 6:00AM-2:00PM. CNA H said Resident #61 was hard of hearing but could put his own hearing aids in his ears. CNA H said she was not aware of resident hearing aids not functioning properly. Record review of the facility policy on Social Services revised October 2024 reflected in part: .The facility, regardless of size, will provide medically-related social services to each resident, to assist in attaining or maintaining the resident's highest, practicable physical, mental, and psychosocial well-being.The Social Worker, or social service designee, will pursue the provision of any identified need for medically-related social services for the resident.The Social Worker, or social service designee, will monitor the resident's progress in improving physical, mental and psychosocial functioning. Event ID: Facility ID: 676160 If continuation sheet Page 16 of 21 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 06/29/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 3 errors out of 37 opportunities, resulting in a 8 percent medication error involving for 1 of 14 residents (Resident #67) reviewed for medication errors. LVN J did not administer the full dose of carvedilol oral tablet 3.125 mg (carvedilol=medication used to help lower blood pressure and reduce the workload of the heart).Misoprostol oral tablet 100 mcg (misoprostol= medication used to protect the stomach against acid damage, and decreases the amount of acid produced by the stomach) and Famotidine oral tablet 40 mg (famotidine) (medication used to reduce the amount of acid produced in your stomach) as ordered by the Physician to Resident #67 on 6/24/25. These failures could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.The findings included: Record review of Resident #67's face sheet, dated 6/24/25, revealed Resident #67 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses: chronic atrial fibrillation( irregular heart beat) atherosclerosis of coronary artery (fatty materials like build up inside your arteries) bypass graft(s), with angina pectoris, anorexia, diarrhea, unspecified, muscle wasting and atrophy, not elsewhere classified, other lack of coordination, muscle weakness (generalized other abnormalities of gait and mobility, cognitive communication deficit, dysphagia ( difficulty swallowing), depression ( mood swing), acute kidney failure, personal history of malignant neoplasm of breast (cancer) hemiplegia and hemiparesis ( paralysis of one side of the body) following cerebral infarction ( Stroke) affecting right dominant side, cerebral infarction, atrial fibrillation and flutter, gastro-esophageal reflux disease with esophagitis, without bleeding, acute cystitis ( sudden bladder infection) without hematuria (bleeding) , urinary tract infection, diabetes mellitus due to underlying condition with diabetic nephropathy and gastrostomy tube. Record review of Resident #67's quarterly MDS, dated [DATE], revealed Resident #67 had a BIMS score of 02 which indicated severe cognitive impairment. Resident #67 was dependent of staff for all ADLs. Record review of Resident#67's physician orders revealed the following: - Order date was 2/4/25 (carvedilol) give 1 tablet via g-tube every 12 hours related to chronic venous hypertension (idiopathic) with other complications. Famotidine oral tablet 40 mg (famotidine) give 1 tablet via peg-tube every 12 hours related to gastro-esophageal reflux disease with esophagitis. Misoprostol oral tablet 100 mcg give 1 tablet via g-tube before meals and at bedtime related to gastro-esophageal reflux disease with esophagitis, without bleeding. Sucralfate suspension 1gm/10ml take 10ml g tube before meal at bedtime. Observation on 6/24/25 at 8:45 AM, during medication pass with LVN J, Resident #67 was lying in bed. LVN J punched up blister packet of Carvedilol oral tablet 3.125 mg, Famotidine oral tablet 40 mg, Misoprostol oral tablet 100 mcg, and a bottle of Sucralfate suspension 1gm/10ml tablet from the medication and placed the medication on top of the medication cart. LVN J stated I have to check Resident #67's blood pressure before administering the medication and then picked up 60 cc syringe checked Resident residual via GT, it was 5cc return to stomach. At 9:13 AM LVN J went to prepare the medication left on the medication cart, stated I am sorry it took me a longer period to check the blood pressure. LVN J prepared the medication crushed each meds in a medication cup. At 9:21 am LVN J went in the Resident #67's room to administer medication after diluting it in water, LVN J did not stir or rinse the medications in the cup, LVN J had a lot of residue of Carvedilol, Famotidine and Misoprostol in the medication cup and after medication administration, LVN J was about to discarded the medication cup. The nurse surveyor picked up the medication cups and showed LVN J the residual and she acknowledged the residuals in the medication cups and then added water to the medication cups and administered it via Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 17 of 21 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 06/29/2025 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #67's GT. Interview with LVN J on 6/24/25 at 5:45 PM, she said if medication was not given in totality the resident would not get required effects of the medication. LVN J said she had GT training, she was neruous. During an interview on 6/26/25 at 5:35 PM, the Administrator and DON they said the risk of not getting the medication as ordered by the doctor could affect therapeutic effectiveness. The DON said not giving medication as ordered by the doctor could cause more health issues and potency of the medication in the blood. She said she would be in-servicing the staff. Review of the facility policy revised 2012 and titled administering medications reflected, Medications shall be administered in a safe and timely manner, and as prescribed 3. Medications must be administered in accordance with the orders. Event ID: Facility ID: 676160 If continuation sheet Page 18 of 21 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 06/29/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to properly store, label, and/or secure medications and biologicals for 1 of 4 medication carts (400 hall medication cart), in accordance with State and Federal laws, all drugs and were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to for 1 of 14 residents reviewed for medication administration (Resident #67).The facility failed to ensure Resident #67 medication was not left unattended on [DATE], 600-hall medication cart had medication open not dated.This failure could place residents at risk to having access to unauthorized medication and/or lead to possible harm or drug diversion and receiving the appropriate medications and not reaching the intended therapeutic dose and possible exacerbation of health conditions.Findings included: Record review of Resident #67's face sheet, dated [DATE], revealed Resident #67 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of: chronic atrial fibrillation( irregular heart beat) atherosclerosis of coronary artery (fatty materials like build up inside your arteries) bypass graft(s), with angina pectoris, anorexia, diarrhea, unspecified, muscle wasting and atrophy, not elsewhere classified, other lack of coordination, muscle weakness, generalized other abnormalities of gait and mobility, cognitive communication deficit, dysphagia (difficulty swallowing), depression (mood swing), acute kidney failure, personal history of malignant neoplasm of breast (cancer) hemiplegia and hemiparesis (paralysis of one side of the body) following cerebral infarction (Stroke) affecting right dominant side, cerebral infarction, atrial fibrillation and flutter, gastro-esophageal reflux disease with esophagitis, without bleeding, acute cystitis ( sudden bladder infection) without hematuria (bleeding) , urinary tract infection, diabetes mellitus due to underlying condition with diabetic nephropathy and gastrostomy tube. Record review of Resident #67's quarterly MDS, dated [DATE], revealed Resident #67 had a BIMS score of 02 which indicated severe cognitive impairment. Resident #67 was dependent of staff for all ADLs. Observation on [DATE] at 8:45 AM, during medication pass with LVN J, Resident #67 was lying in bed. LVN J pulled up a blister packet of Carvedilol oral tablet 3.125 mg, Famotidine oral tablet 40 mg, Misoprostol oral tablet 100 mcg, and a bottle of Sucralfate suspension 1gm/10ml tablet from the medication and placed the medication on top of the medication cart. LVN J stated I have to check Resident #67's blood pressure before administering the medication Resident#67's bp was 84/39 p87, LVN J recheck bp 88/51 p86, and she left the room to the parked medication cart to get the manual bp cuffs at 9:00 am and left the medication cart unlocked and then checked bp it was bp 163/62 p69, and then picked up 60 cc syringe checked Resident residual via GT, it was 5cc return to stomach, the door was wide open. At 9:13 AM LVN J went to prepared the medication left on the medication cart, stated am sorry it took me a longer period to check the bp. LVN J prepared the medication crushed the meds and in a medication cup. at 9:21 am LVN J went in the Resident #67's room to administer medication and left the door open, did not pulled the curtain in-between the roommate and she left her medication cart unlocked while administering the medication. Interview with LVN J on [DATE] at 5:45 PM, LVN J said she was nervous and forget to close the door. Observation on [DATE] at 12:43 PM with LVN GG, she said she checks the medication cart for expired whenever she works.1. Voltaren (Arthritis pain) 150 gram (5.29 oz) open not dated and no name. Interview with LVN GG she did not know when it was opened, and it supposed to be dated2. Hydrocortisone cream 2 oz open not dated and no name3. Mupirocin cream USP 2% (30g net wet) opened not dated 4. Clobetasol Propionate USP 0.05% opened not dated 45grams 5. Triamcinolone Acetone 0.5% (15gm) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 19 of 21 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 06/29/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm opened not dated. In an interview with LVN GG on [DATE] at 1:04 PM she said she if the medications were opened and not dated, she would not know its effectiveness. In an interview on [DATE] at 3:00PM the DON and Consultant Pharmacist said the facility did not have any policy on dating the creams the pharmacist were not supposed to be dated it and the pharmacist dispensing those ointments always placed the opened date on them. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 20 of 21 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 06/29/2025 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 Provide and implement an infection prevention and control program. 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 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 2 (Residents #8 and #41) of 4 residents reviewed for infection control practices. -LVN A did not wipe his accu-check machine between after using it on Resident #8 and Resident #41 to check their blood glucose and did not store the accu-check machine properly to prevent infection on 06/24/2025. This failure could put residents at risk of a spread of infection and diseases due to not following infection control policies and procedures.Findings included: Record review of Resident #8's face sheet dated 06/25/2025, reflected she was a [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included obesity, type 2 diabetes mellitus (high blood sugar), personal history of urinary tract infections, hypertension (high blood pressure), blindness in one eye, and chronic kidney disease. Record review of Resident #41's face sheet dated 06/25/2025, reflected she was an [AGE] year-old female originally admitted on [DATE] and last re-admitted on [DATE]. Her medical diagnoses included type 2 diabetes mellitus (high blood sugar), hypotension (low blood pressure), iron deficiency, dementia (decline in cognitive function in areas like thinking, memory, and reasoning), and anxiety disorder (disorder characterized by prolonged periods of extreme worry). Observation on 6/24/25 at 9:47 AM of Resident #8's medication pass, revealed LVN A did not wipe the accu-check machine (machine used to measure blood sugar) after checking the blood glucose and placed it inside the medication cart. LVN A immediately went to Resident #41's room and checked Resident #41's blood glucose with the same machine. LVN A then placed it in his uniform pocket and then placed it in the top drawer of his medication cart without wiping or sanitizing the accu-check machine. In an interview on 6/24/25 at 10:23AM with LVN A, he said Residents #8 and #41 were not on isolation and in his previous state of employment, common practice was not to clean the accu-check machine between residents except if the residents were on contact isolation (a set of precautions to prevent spread of infectious diseases). LVN A said he did not have any orientation in the facility. LVN A said he knew wiping the accu-check machine was to prevent infection. He just started with the facility. In an interview on 6/26/2025 at 4:00pm with the DON, the DON said that she expected nurses to make sure they were preventing infections, agency staff were required to do competencies and quizzes before taking a shift, and that the DON would upload training to the agency staff communication portal so that transmission infection and disinfectant equipment could be addressed. The DON also said she expected staff to use the facility-provided antimicrobial wipes. Record review of the facility's policy on their infection prevention and control program last reviewed or revised 01/2025 read in part, all staff are responsible for following all policies and procedures related to the program, .environmental cleaning and disinfection shall be performed according to facility policy .all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676160 If continuation sheet Page 21 of 21