Inspection·July 21, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 07/20/23 at 09:30 a.m. revealed Resident #41 was up in his room. He had a t-shirt on and on his left upper chest he had a scar for the cardiac pacemaker. Interview on 07/20/23 at 09:40 a.m. with Resident #41, he stated he had the cardiac pacemaker since he was admitted and the nurses monitor it, he also stated he received pain medication and assessments for his lower back pain. He said the scar was where his cardiac pacemaker was located. Interview on 07/20/2023 at 2:00 p.m. with the DON revealed that Resident #41 was monitored and assessed for pain and his cardiac pacemaker. She stated the MDS nurse was not available for interview, but that she had talked to her, and she agreed that the pain and cardiac pacemaker needed to be coded as Active Diagnoses to accurately reflect Resident #41's care. She stated that the accuracy of the MDS assessment was needed to further develop Resident #41's plan of care and to meet his health needs. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 revealed Section I: ACTIVE DIAGNOSES .the items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring or risk of death. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676173 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenedy Health & Rehabilitation 7882 S Hwy 181 (No Mail Service) Kenedy, TX 78119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for one resident (#4) out of 5 residents reviewed for accident hazards in that: LVN A disposed of the lancet she used to check Resident #4's blood glucose level in the regular trash container on the medication cart and not the sharps container. This deficient practice could affect residents and could result in injury. The findings were: Review of Resident #4's electronic face sheet dated 07/19/2023 revealed he was admitted to the facility on [DATE] with diagnoses of dementia (loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities) and type II diabetes mellitus with diabetic chronic kidney disease (the body doesn't use insulin properly and dysfunction of the kidneys can occur). Review of Resident #4's quarterly MDS assessment with an ARD of 04/17/2023 revealed he scored a 09/15 on his BIMS which indicated he was moderately cognitively impaired. Review of Section I, Active Diagnoses revealed he was checked off to have diabetes mellitus. Review of Resident #4's Active Orders As Of: 07/19/2023 revealed NovoLOG Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if 151 - 200 = 2 Units; 201 -250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units; 401 - 450 = 12 Units; 451- 500 = 14 Units; 501+ If greater than 500, call MD., subcutaneously (fatty tissue just under skin) before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (high sugar level in blood) Active 03/04/2021 . Review of Resident #4's comprehensive care plan with a revision date of 10/07/2021 revealed Focus .potential for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) r/t diabetes mellitus .Interventions/Tasks .Administer medications for diabetes as ordered. Observation on 07/19/2023 at 12:23 p.m. of LVN A perform an accucheck for Resident #4 revealed she did not discard the used lancet into the sharps container. She disposed of it into the regular trash bin located on the side of her medication cart. Interview on 07/19/2023 at 12:25 p.m. with LVN A revealed she should have discarded the used lancet into the sharps container because someone else could get stuck when emptying the trash and could be injured. She stated she was not thinking about it at the time and just discarded her used supplies together. Interview on 07/20/2023 at 2:00 p.m. with the DON revealed that LVN A should have discarded the lancet she used to check Resident #4's blood sugar into the sharps container on the medication cart and not the trash. She stated that someone handling the trash could stick themselves and get hurt or an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676173 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenedy Health & Rehabilitation 7882 S Hwy 181 (No Mail Service) Kenedy, TX 78119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm infection. She stated staff were trained by nursing management on how to dispose of sharp items such as lancets and needles. Review of the facility policy and procedure titled Discarding of Sharps dated 2003 revealed Definition Sharps .3. All lancets used for finger sticks .Procedure .4. Place used sharps, intact, into sharps container. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676173 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenedy Health & Rehabilitation 7882 S Hwy 181 (No Mail Service) Kenedy, TX 78119 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for one resident (#29) of three residents reviewed for oxygen therapy, in that: Residents Affected - Few Resident #29's oxygen was set to 4L/NC instead of 3L/NC as ordered by the physician. This deficient practice could affect residents who receive oxygen therapy and could result in respiratory distress. The findings were: Review of Resident #29's electronic face sheet dated 07/19/2023 revealed he was admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems). Review of Resident #29's annual MDS assessment with an ARD of 05/22/2023 revealed he scored a 15/15 on his BIMS which indicated he was cognitively intact and that he received oxygen therapy while a resident. Review of Resident #29's comprehensive care plan revised date, 06/26/2023 revealed Focus .has Oxygen Therapy .Interventions/Tasks .administer oxygen as ordered by doctor. See current physician orders for oxygen. Review of Resident #29's Active Orders As Of: 07/19/2023 revealed May use oxygen @ 3 l/m via nasal canula every day and night shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED . Active 01/13/2023. Review of Resident #29's TAR dated 07/01/2023 - 07/31/2023 revealed that his oxygen saturation level was being checked every day by the nursing staff and his order for 3L/nc of oxygen was being initialed off by the nursing staff. Observation on 07/18/2023 at 10:00 a.m. revealed Resident #29 was in his room sitting on the side of his bed. His oxygen concentrator was set at 4L/min. He had his nasal cannula on, and when asked by the surveyor what rate his oxygen was supposed to be on he responded 3 Liters I think. Observation on 07/19/2023 at 07:55 a.m. of Resident #29 revealed he was in his room eating breakfast. His oxygen concentrator was set on 4L/min. Interview on 07/20/2023 at 1:00 p.m. with LVN A revealed that she and another nurse had gone down the halls and checked the oxygen and made sure they were set to what the doctor had ordered because the surveyors were at the facility. She stated it was important to check the oxygen because too much or too little for a resident could cause respiratory distress. Interview on 07/21/2023 at 09:30 a.m. with LVN B who worked with Resident #29 on 07/18/2023 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676173 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenedy Health & Rehabilitation 7882 S Hwy 181 (No Mail Service) Kenedy, TX 78119 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed she did not check his oxygen concentrator to see if it was on the correct amount. She stated she signed it off on his TAR, but she did not check it. She said she realized it was important to check it because it could result in respiratory distress for Resident #29, especially with his breathing issues. Interview on 07/20/2023 at 2:00 p.m. with the DON revealed that the nursing staff should be checking the oxygen rates for residents on oxygen therapy so that they get the amount ordered. She stated that Resident #29 had COPD and it was important that he was on the rate ordered by the physician to prevent respiratory distress. Review of the facility policy and procedure titled Oxygen Administration dated revised February 13, 2007 revealed the resident will maintain oxygenation with safe and effective delivery of prescribed oxygen. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676173 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenedy Health & Rehabilitation 7882 S Hwy 181 (No Mail Service) Kenedy, TX 78119 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 - Few 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, interviews and record reviews, the facility failed to ensure all drugs and biologicals are stored locked compartments and permit only authorized personnel to have access to the keys for 1 of 5 residents (Resident #19) reviewed for storage of medications, in that: Resident #19 had what appeared to be and smelled like cough medicine at his bedside in a specimen cup and an empty brown pill container without a label. This deficient practice could place residents at risk of ingesting unknown medications not ordered by their physicians in an unsupervised manner. The findings were: Review of Resident #19's electronic face sheet, dated 07/21/2023, revealed he was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), chronic obstructive pulmonary disease (common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), dysphagia (difficulty in swallowing food or liquid), history of malignant neoplasm of larynx (type of cancer that affects the voice box and can cause symptoms such as hoarseness, difficulty swallowing and breathing problems, and gastrostomy (an opening to the stomach from the abdominal wall, made surgically for the introduction of food). Review of Resident #19's quarterly MDS assessment with an ARD of 05/29/2023 revealed the resident scored a 06/15 on his BIMS, which indicated he was moderately cognitively impaired. Further review of his MDS assessment revealed that 51% or more of his total calories were from enteral feedings. Review of Resident #19's Active Orders As Of: 07/19/2023, revealed, guaiFENesin Oral Liquid 100 MG/5 ML (GuaiFENesin) (to treat cough or cold symptoms) Give 15 ml via G-Tube as needed for Cough /Congestion .Phone Active 05/15/2023 05/15/2023. Further reviewed no order for Resident #19 as NPO. Review of Resident #19's comprehensive care plan, revised on 12/30/2022, revealed, Focus .EATING .refuses to follow NPO recommendation and wants to eat food by mouth when he chooses to - states he will accept enteral nutrition but when he wants a snack or a drink - he will get it. Observation on 07/19/2023 at 1:26 p.m. revealed as LVN A provided Resident #19 a medication via G-tube medication there was one specimen container filled with a light brown syrup and one unlabeled brown pill bottle next to his bed. When Resident #19 was asked what it was, he stated it was cough syrup. The surveyor and LVN A smelled of the liquid and it smelled similar to cough syrup. When asked where the resident obtained the cough syrup, he stated from the nurses. Resident #19 stated he needed the cough syrup to take when he has coughing episodes. LVN A took both containers of the alleged cough syrup out of the room as Resident #19 was highly agitated at this time and started yelling at LVN A and the surveyor. Interview with LVN A on 07/19/2023 at 1:45 p.m., LVN A stated she did not know how Resident #19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676173 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kenedy Health & Rehabilitation 7882 S Hwy 181 (No Mail Service) Kenedy, TX 78119 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 obtained the cough syrup, and she had not noticed it before and it should not have been there. LVN A stated the resident could overdose with the medication or choke. Interview with the DON on 07/20/2023 at 2:00 p.m., the DON the medication should not have been at Resident #19's bedside. Residents Affected - Few Review of the facility policy and procedure titled Bedside Storage Of Medications dated 2003 revealed 1. A written order for the bedside storage of medication is placed in the resident's medical record .2. The facility interdisciplinary team must assess that the resident is capable of safely self-administering the medication and the assessment must be documented .5. Nursing staff will monitor the availability and utilization of all medications that are self-administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676173 If continuation sheet Page 8 of 8