Kennedy Health & Rehab

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

the incident.During an interview on 10/22/2025 at 3:23 PM the DON said the staff usually notified her of resident-to-resident altercations. She said she would ask staff if they had notified the Administrator and if

they had not then she would notify the Administrator. She said she immediately notified the Administrator of

the altercation with Resident #1 and Resident #2. She said the state agency should be notified within 2 hours of an abuse allegation.The facility Administrator was notified on 10/21/2025 at 12:35 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time.The facility's plan of removal was accepted on 10/22/2025 at 12:46 PM and included:PLAN OF REMOVAL FOR IMMEDIATE JEOPARDYAction Taken:Residents were separated from each and monitored until no further aggressive behaviors were demonstrated. Resident #5, #2 and #1 were referred to behavioral unit for impatient treatment. Resident #2 was sent to ER for evaluation and treatment. Prior to be admitted to inpatient behavior hospital #2 & #1 were sent to ER for evaluation and treatment. No other resident identified. Staff Re-Education: 10/21/2025 Regional Director of Operations educated Administrator and DON on types of abuse and policy to keep all residents free from abuse and neglect. All staff will be re-educated on the facility's Abuse/Neglect Policy by DON, Administrator, department supervisors and nurse manager including identification, prevention, and mandatory reporting requirements in services started on 10/20/25 and will continue all staff must be in serviced before starting their shift. Documentation of re-education and staff signatures were started on 10/21/25 all staff will be in serviced before starting their shift. Staff were instructed to immediately intervene and report any signs of resident-to-resident aggression or abuse to the Administrator and DON immediately. Department heads started safety survey assessments on 10/21/2025 at 1:20pm and will have all safety survey assessments completed by 4:00pm

on 10/21/2025 on all residents that could give a response at north nurse's station. 10/21/2025 Secured unit charge nurse contacting family members of residents on secured unit to complete safety survey for residents that have impaired cognition. Administrator will hold Resident council meeting is scheduled for 10/22/2025 to discuss abuse/neglect for residents that would like to attend. All residents that did not attend resident council will be talked to individual by department heads and family will be contacted for residents that have impaired cognition. Medical director notified of IJ in facility on 10/21/2025.Monitoring of the Plan of Removal included the following:Record review of in-service titled Abuse/Neglect Policy-reporting/investigating/Implementing dated 10/21/2025 signed by the DON and Administrator.

Record review of in-service titled Abuse and Neglect P&P dated 10/21/2025 signed by the DON and Administrator. Record review of in-service titled Resident Behaviors, De-escalation, & Prevention dated 10/22/2025 signed by 16 employees.Record review of in-service titled Abuse and Neglect Inservice which covered witness statements, and all incidents to be turned into the Administrator and DON dated 10/20/2025 signed by 57 employees.Record review of 61 resident safety surveys completed 10/21/2025 with no concerns for abuse or neglect.Record review of resident council minutes dated 10/22/2025 at 11:12 AM with 11 residents in attendance.During interviews conducted on 10/22/2025 between 3:00 PM and 4:30 PM the following staff were able to verbalize understanding of preventing abuse: Administrator, DON, ADON, SW, CNA A, CNA B, LVN C, Housekeeper D, LVN O, MDS Coordinator, MA E, CNA N, CNA F, LVN G, CNA H, and the Activity Director. On 10/21/2025 at 12:35 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/22/2025 at 4:30 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kennedy Health & Rehab

504 N John Redditt Dr Lufkin, TX 75904

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 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

In-services would be completed before staff worked the next shift. Monitoring: The facility's Abuse Reportable events Policy was reviewed and revised on 10/21/25 to clarify timelines for internal/external reporting and investigation steps.The revised policy was approved by the Governing Body and redistributed to all departments. Future new hires will receive abuse prevention and reporting training during orientation

before working any shift.The DON or designee will initiate and complete all abuse investigations within five days using the state-approved Form 3613-A process.All investigations will be reviewed and signed by the Administrator for accuracy and timeliness before submission.The Administrator or DON will audit all incident reports weekly for 90 days to ensure proper reporting, investigation, and documentation.Results will be presented to the QA Committee monthly for review and any needed corrective actions.The QA Committee will evaluate compliance and determine if further education or policy revisions are needed.

Monitoring of the POR included the following: Record review of inservice, dated 10/20/2025, titled Safety Surveys after abuse/neglect allegation which indicated random safety surveys must be completed after each abuse/neglect allegation signed by the SW . Record review of inservice, dated 10/21/2025, titled Documentation requirements for incidents which indicated all incident reports require the following documentation: head to toe assessments, progress notes, witness statements, monitoring log for behaviors, treatment orders for injuries, completed incident reports, and requested hospital documentation signed by 24 employees. Record review of 61 resident safety surveys completed 10/21/2025 documented no concerns for abuse or neglect. Record review of resident council minutes, dated 10/22/2025 at 11:12 AM, with 11 residents in attendance. Record review of inservice titled Form 3613 Quick Reference & Staff Training Guide, dated 10/21/2025, signed by the DON and Administrator. Record review of inservice titled Abuse and Neglect P&P, dated 10/21/2025, signed by the DON and Administrator. Record review of inservice titled Abuse/Neglect Policy-reporting/investigating/Implementing, dated 10/21/2025, signed by the DON and Administrator. During interviews conducted on 10/22/2025 between 3:00 PM and 4:30 PM the following staff were able to verbalize understanding of developing and implementing the facilities abuse policy: Administrator, DON, ADON, SW, CNA A, CNA B, LVN C, Housekeeper D, LVN O, MDS Coordinator, MA E, CNA N, CNA F, LVN G, CNA H, and the Activity Director. The Administrator was informed the Immediate Jeopardy was removed on 10/22/2025 at 4:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kennedy Health & Rehab

504 N John Redditt Dr Lufkin, TX 75904

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 0610 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

review of inservice titled Abuse/Neglect Policy-reporting/investigating/Implementing, dated 10/21/2025, completed by the DON and Administrator. Record review of inservice titled Resident Behaviors, De-escalation, & Prevention, dated 10/22/2025, completed by 16 employees. Record review of inservice titled Abuse & Neglect In-Service Timely Reporting, dated 10/20/2025, completed by 74 employees. Record

review of inservice titled Abuse and Neglect P&P, dated 10/21/2025, completed by the DON and Administrator. Record review of inservice titled Abuse and Neglect Inservice which covered witness statements, and all incidents to be turned into the Administrator and DON, dated 10/20/2025, completed by 57 employees. Record review of inservice, dated 10/21/2025, titled Documentation requirements for incidents completed by 24 employees. Record review of 61 resident safety surveys completed 10/21/2025 documented no concerns for abuse or neglect. Record review of resident council minutes dated 10/22/2025 at 11:12 AM with 11 residents in attendance. During interviews conducted on 10/22/2025 between 3:00 PM and 4:30 PM the following staff were able to verbalize understanding of developing and implementing the facilities abuse policy: Administrator, DON, ADON, SW, CNA A, CNA B, LVN C, Housekeeper D, LVN O, MDS Coordinator, MA E, CNA N, CNA F, LVN G, CNA H, and the Activity Director. The Administrator was informed the Immediate Jeopardy was removed on 10/22/2025 at 4:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kennedy Health & Rehab

504 N John Redditt Dr Lufkin, TX 75904

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 0640

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to

the CMS System within 14 days after a facility completes the resident's assessment for 1 (Resident #4) of 6 residents reviewed for MDS transmission, in that: The facility failed to complete and transmit an Entry and Discharge MDS assessment for Resident #4 within 14 days of completion.These failures could place residents at risk of not having their assessment and care plan completed timely, which could result in denial of services and/or payment for services.Findings include: Record review of a facility face sheet dated 10/20/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE REDACTED] with diagnoses including: Bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression) and Epilepsy (seizures). Face sheet indicated also indicated a discharge date of 9/25/25 to a psychiatric hospital. Record review of an MDS tab

in Resident #4's electronic medical record indicated there had been no MDS assessments completed. MDS tracking tab in PCC indicated an entry MDS was due with an ARD of 9/9/25, a discharge MDS was due with an ARD of 9/11/25, an entry MDS was due with an ARD of 9/23/25, and a discharge MDS was due with an ARD of 9/23/25. None had been completed, nor transmitted. During an interview on 10/21/25 at 2:43 pm MDS nurse said she started as the MDS nurse on 9/29/25 and she had no prior experience with MDS assessments. She said she had had a little bit of training with the previous MDS nurse where she would show her regulations in RAI, but she had received no formal training. She said all residents should have an entry MDS on admission and a discharge assessment with discharged . She said she did remember reading that in the RAI manual. She said she was not doing MDSs when Residents #2 and #4 were admitted and discharged . She said the Administrator did tell her yesterday (10/20/25) that there were

a lot of MDSs that had not been done, completed, or transmitted. She said she was trying to get them completed now and able to submit. She said if MDSs are not completed timely, accurately and not submitted as required, the facility would not receive payments. She said care plans may not be completed accurately, and staff would not know how to take care of the residents. During an interview on 10/22/25 at 3:23 pm DON said the MDS coordinator was responsible for completing and transmitting MDS assessments. She said the care plans may not be up to date if MDSs are not completed timely. She said going forward she would be responsible for monitoring and ensuring timely completion and submissions.

During an interview on 10/22/25 at 4:19 pm the Administrator said she would be responsible for MDS being completed and transmitted going forward. She said care plans could be missed if MDSs were not completed timely and transmitted as required and residents could be at risk of harm. Record review of a facility policy titled Electronic Transmission of the MDS dated September 2010 read: .All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kennedy Health & Rehab

504 N John Redditt Dr Lufkin, TX 75904

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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed for 1 of 6 residents (Resident #4)reviewed for care plans . The facility failed to complete baseline care plans within 48 hours of admission for Residents #4. This failure could place residents at risk of not receiving care and services to meet their needs.Findings included:Record review of a facility face sheet dated 10/20/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE REDACTED] with diagnoses including bipolar disorder (a mental health condition characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression) and Epilepsy (seizures).Record review of an MDS tab in an electronic medical record for Resident #4 indicated there had been no MDS assessment completed.Record

review of a care plan tab in an electronic medical record for Resident #4 indicated there had been no comprehensive care plan completed.Record review of an assessments tab in an electronic medical record for Resident #4 indicated there had been no baseline care plan completed.During an interview on 10/21/25 at 2:43 pm MDS Coordinator said she had started doing MDSs on 9/29/25 and had no prior experience.

She said the floor nurses should be responsible for completing the baseline care plan, but she said she did not know how long the facility had to complete the baseline care plan. She said if they were not completed

the staff may not know how to take care of the residents. During an interview and observation on 10/21/25 at 3:15 pm LVN J said she was a floor nurse but said she did not complete the baseline care plans. She said she thought the ADON did them. She said she thought they must be done by an RN. She gave me a checklist from a book at the nurses' station that she said the floor nurses use to complete admissions.

Baseline care plan was not included on the checklist. During an interview on 10/21/25 at 3:50 pm LVN J brought another list that she said came out with the checklist in July or August and baseline care plans were included on that list. She said she was not aware that they were to be completing them.During an

interview on 10/22/25 at 10:45 am ADON said she had worked at the facility since July 2024, but she had been ADON since 10/1/25. She said she did not know baseline care plans were supposed to be done on admission until yesterday (10/21/25). She said she did not know how long the facility had to do a baseline care plan. She said moving forward her and the DON would be checking over new admissions to make sure baseline care plans were done. She said staff would not know how to take care of the residents without the baseline care plan.During an interview on 10/22/25 at 3:23pm DON said the admission nurse would be responsible for baseline careplans going forward. She said going forward her and the ADON would be responsible for making sure those are being completed. She said residents potentially would not be cared for properly without a baseline care plans.During an interview on 10/22/25 at 4:19pm Administrator said the MDS coordinator would be responsible for baseline care plans. She said care could be missed if baseline care plans were not completed and residents could be at risk of harm. Record review of a facility policy titled Care Plans - Baseline dated December 2016 read: .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. and .To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Kennedy Health & Rehab

504 N John Redditt Dr Lufkin, TX 75904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 9 resident hallways (Hallway 900 secured unit) and 2 of 3 entrances (north and south lobby entrance) reviewed for environmental concerns, in that:1. The facility failed to ensure the ceiling on the 900 hall was in good repair and did not leak water on 10/20/25, 10/21/25 and 10/22/25.2. The facility failed to ensure the lobby ceiling located at the south entrance (near the secured unit) was in good repair and did not leak water on 10/20/25, 10/21/25 and 10/22/25.3. The facility failed to ensure the lobby ceiling located at the north entrance was in good repair and did not have a hole and missing sheet rock exposing the frame and insulation on 10/20/25, 10/21/25 and 10/22/25.These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.Findings included: During multiple observations on 10/20/25, 10/21/25 and 10/22/25 between 9:00 am to 4:00 pm

the ceiling on 900 hall and the ceiling at the south lobby entrance were leaking water and there were towels and buckets under the leaks catching water. The north entrance lobby ceiling had missing sheet rock exposing the frame and insulation. During an interview on 10/22/25 at 9:15 am CNA A said she had worked at the facility almost 2 1/2 years and the ceiling on 900 hall and the ceiling in the lobby entrances leak anytime it rains. She said she was not sure how long there had been a hole in the north entrance ceiling.

She said the staff know to place towels and buckets to catch the water. She said the maintenance supervisor works on the roof regularly to remove the water, but nothing has fixed the problem. She said the housekeepers also regularly empty the buckets as needed and clean daily. She said the residents deserved better and the leaking could cause falls and injuries. During an interview on 10/22/2025 at 10:50 am the Maintenance Supervisor said that the roof was the problem and when it rains it leaks. She said she had sealed the roof twice already, but it was not working. She said she had been in contact with her corporate maintenance personnel, and he instructed her to continue to seal the roof. She said the area at the north entrance was better and was now dry and she was going to replace the sheet rock in the next week or so.

She said the area on 900 hall and the south lobby continued to leak despite repairs. She said a ceiling that leaks and was in disrepair could cause falls, changes in resident condition and overall affect their health and dignity. During an interview on 10/22/25 at 11:00 am the Administrator said maintenance was responsible for the repairs of the facility and had been on the roof, applied sealant but despite the repair the roof continued to leak. She said they had reached out to corporate and was instructed to seal the roof as needed. She said a leaking ceiling and ceiling in disrepair could affect the residents overall health, safety and dignity. She said she expected the environment to be free of hazards and would continue to work to see the repairs were completed. Record review of a facility policy titled Quality of Life - Homelike Environment dated June 2024 indicated, .Residents are provided with a safe, clean, comfortable and homelike environment. 2. the facility staff and management shall maximize to the extent possible the characteristics of the facility that reflect a personalized setting; a. clean, sanitary, and orderly environment; daily cleaning and monthly deep cleaning .

Event ID:

Facility ID:

If continuation sheet