Inspection·June 26, 2025

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some grievance each time as these are a priority of the residents. They all stated that they discuss their resident rights during meetings, but feel they are not being taken seriously. They stated they had never seen any kind of written paper or grievance form that reflected their concerns and requests during resident council or explained any resolution. They stated they had become tired of saying anything to the staff because nothing ever changed. They all stated with the turnover of SSs it is hard to get anything resolved. They stated they tried to speak with the SS two months back, they would go by her office, left a note almost weekly, and no response. Stated they have worked with the RECP to get a message to the new SS and even a phone message was left for her a week back and there is yet to be a response. They all stated the meal of the month is a small ask and has been discussed for more than six months now and when they thought it was going to happen and the DM scheduled a day for it last month it was cancelled without warning or information as to why. They all stated they drink coffee daily and have asked for better coffee, but this also falls on deaf ears. In an interview on 6/26/2025 at 3:00 PM Ombudsman stated he has attended the monthly Resident Council meetings on numerous occasions and the residents have addressed the meal of the month grievance as their top priority issue they would like addressed. He stated he has received individual food complaints from residents here at the facility and has been working directly with the ADM to address. He stated he has not received any information on resolution of said complaints other than an email from the ADM that it would be addressed. In an interview on 6/26/2025 at 11:48 AM AD stated Resident Council grievances are followed-up by the Resident Council President and VP. She stated she was voted in to help take the minutes at the monthly meetings and she doesn't give input or voice her opinions, she just takes notes for the group as they have challenges with writing and keeping order. She stated if there is a grievance addressed in the meeting, she will work with the resident council president and write a grievance report and give directly to the SS who in turn is responsible for passing it out to the head of department the concern addresses, it is investigated, reviewed by the ADM, signed, and entered in the grievance binder. She stated at the following resident council meeting she will read the resolution to the grievance. She stated the #1 complaint is food. AD stated the meal of the month grievance was provided to the dietary manager to address. She stated the DM stated the resident council could vote on 3 meals and he would choose one. AD stated the previous month she completed a grievance form, and the meal of the month was voted on, and the chili dogs and Fritos were chosen. She stated she did not receive the form back from the SS or ADM. When asked about following up on the grievance she stated she doesn't follow-up on grievances and this responsibility is that of the ADM and SS. She stated the SS has been employed a month at this facility and she was aware of this grievance and would be taking care of it. AD stated grievances are discussed in the morning meetings with all department heads in attendance. She stated she has brought up the Resident Council grievances regarding the meal of the month and coffee and the heads of the departments inform the ADM they would handle the grievance. AD stated that the potential impact of not having the Resident Council receive follow up on their concerns can be frustrating and disappointing. In an interview on 6/26/2025 at 1:45 PM RD stated she has not been made aware of the meal of the month grievance request. She stated she was not aware this was a request. She stated her understanding of this process would be to have the AD and DM plan the menu and consult with her on menu options. In an interview on 6/26/2025 at 2:00 PM CK J stated about a year back the facility did away with the meal of the month. She stated the DM has been made aware of this request but because he has only been in this position since December 2024, he has not been able to implement. She stated she and the DM were made aware of this grievance about two months back and the DM is planning to get to working (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 2 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on it as soon as he returns from vacation next week. She stated the kinds need to be worked out for the special meal of the month and believes this is the responsibility of dietician, DM, and ADM. She stated the meal of the month is needed in the facility as the residents want it and are constantly asking for this. She would like to see this implemented again. In an interview on 6/26/2025 at 3:00 PM SS stated she has been employed one month with this facility. She stated her first week here at the facility she was invited by the council to the monthly meeting to introduce herself and to discuss the submission of grievances. She stated the Resident Council residents stated they did not like agency staff, and this was documented on a grievance form. She stated to resolve this issue the residents were informed that staff would be utilized first then last resort to bring on agency staff, but if staff are not available there is no other option as they need to have staff present on each shift. She stated the current grievance process is for staff to assist resident with filling out a grievance form, getting it over to her or ADM so it can be assigned to the department head to address. She stated depending on the type of grievance there should be a 72-hour turnaround, it is then returned to her for review and to provide follow-up. She stated she and the ADM will provide resolution information to the individual or group. She stated if the grievance is given directly to the department head, she is sure it will be worked on. She stated her understanding is that the resolution of a grievance would be provided at the next meeting by the AD. She stated she is sure this information would get passed on to the residents. When asked how the grievance is tracked to ensure it was returned by the department head or if it was resolved and residents notified, she stated she is not currently doing this. She stated if no resolution or response to a grievance is provided to residents it can impact them. She stated if just one grievance on a particular issue may not cause an impact, but if continuously happening residents can become upset. She stated she was not aware of the meal of the month grievance, but she is familiar with the better coffee grievance. She stated there are few residents who have a concern with the quality of the coffee and those few residents have been notified they can get a better-quality coffee from the nurses' stations. In an interview on 6/26/2025 at 5:50 PM DON stated she has been employed only two weeks at this facility. She stated grievances are discussed in morning meetings, SS will discuss any new or pending grievances. She stated she has not heard of any Resident Council grievances mentioned. She stated when grievances are not addressed this can impact the resident by feeling they are not important, or their concern is not a priority, and this can cause mental health anguish. In an interview on 6/26/2025 at 6:15 PM ADM stated grievance forms are located directly outside of her door, the RECP helps log them and assigns them to head of department staff to be resolved within 5 days. She stated individual and group grievances are addressed in the morning meetings and assigned to department heads. She stated she and the SS will usually go and speak to the individual or resident council to follow-up on grievance and to notify them of the resolution. She stated she was notified of the meal of the month grievance filed by the Resident Council a few months back, but she couldn't recall the month. ADM stated the DM took over the position 6 months back, has worked a lot of shifts himself, has had to fire staff not following regulations in the kitchen and hire and train new staff. She stated the DM would like to coordinate more with the Resident Council on the meal of the month, but he doesn't have the ability to do this at this time, hard to make progress, and if going to commit he needs to have enough staff to do this monthly. She stated the meal of the month is on hold and can be revisited later. She stated this information has been provided to the Resident Council members. Review of Grievance/Concern Report dated 5/1/2025, reflected: Resident Council communicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 3 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0565 Level of Harm - Minimal harm or potential for actual harm concern, get some decent coffee was assigned to the DM by the SS and the date of resolution was 6/6/2025 noting, No changes have been made to the coffee that has been ordered over the last year, nor under this dietary manager. Each nurse's break room has a Keurig if residents want a more specialized coffee than either resident or family can purchase, and staff can make the coffee and temp prior to serving. The investigation results and resolution reported to resident council. Residents Affected - Some Review of facility admission Packet dated 9.2022 and titled 15. Resident Grievances reflected the following: We urge you to bring any grievances concerning the Facility to the attention of the Facility Administrator. Please know that you have the right to voice grievances to the Facility personnel without reprisal. Review of facility admission Packet dated 9.2022 and titled Statutory Patient's Rights - Statement of Resident's Rights in Texas reflected the following: 7. You have a right to: Complain about the facility and to organize or participate in any program that presents residents' concerns to the administrator of the facility. Review of facility admission Packet dated 9.2022 and titled Resident's Rights Under Federal Regulations reflected the following: A facility must protect and promote the rights of each resident, including each of the following rights: (f) Grievances. A resident has the right to - (1) Voice grievances without discrimination or reprisal; and (2) Prompt efforts by the facility to resolve grievances the resident may have. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: h. be supported by the facility in exercising his or her rights. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: u. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal and v. have the facility respond to his or her grievances. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: 2. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider, and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents and 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 4 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0567 Honor the resident's right to manage his or her financial affairs. Level of Harm - Minimal harm or potential for actual harm Based on interviews and records review, the facility failed to allow residents to manage his or her financial affairs for 1 of 1 resident council reviewed. Residents Affected - Some The facility failed to ensure all residents whose funds are managed by the facility had ready access to his or her funds upon request in a timely manner, including non-business days, Saturday, and Sundays. Note: The nursing home is disputing this citation. This failure could place all residents whose funds were managed by the facility of not receiving funds deposited with the facility and not having their rights and preferences honored. Findings included: During a Resident Council meeting on 6/25/2025 at 2:00 PM, 16 anonymous residents stated they were allowed to access their petty trust funds during the week. They all stated they were not aware of a petty cash fund policy, but they know it is accessible on the weekdays and to work with RECP to withdraw petty cash. They all stated they liked to get dollar bills for the vending machines. They all stated they were not able to access funds during the weekend as the RECP did not work those days. The VP and President both stated there was a time when they could access funds on the weekend when there was an employed RECP, but it had been over a year since one was employed. They all stated they wanted to see the facility hire a new staff to help with this task for residents. In an interview on 6/25/2025 at 3:27 PM RECP stated petty cash for trust fund accounts could be accessed by residents only Monday - Friday, 8 AM - 4 PM. She stated there was no weekend access to funds. She stated she locked up the petty cash on Friday and no other staff had access. RECP stated she was given a daily balance if a resident inquired on their fund availability. She stated some residents would visit her daily for a few dollars as they enjoyed making purchases out of the soda and snack vending machines and required dollar bills. RECP stated the residents were aware there was no weekend access to the petty cash and to make sure on Friday to withdraw funds for the weekend if needed. She stated there was a weekend receptionist for a few months to help with petty cash, but she didn't last long. She stated she was not sure if there was a specific policy for resident access to their funds. In an interview on 6/26/2025 at 11:48 AM AD stated for the residents that require funds for community outings she worked with RECP to withdraw funds. She stated funds could be accessed Monday - Friday as there was no weekend RECP. She stated residents were aware of the rule to withdraw funds Monday Friday. AD stated last year, resident council asked about money on the weekends and facility hired a receptionist, and they had access to it on the weekend, after one month she quit, and they never hired another receptionist. Weekend petty cash access was implemented for a month. She stated she was not familiar with the policy on trust funds and to reach out to the Business Office Manager for more details. In an interview on 06/26/2025 at 3:20 PM BOM stated RECP is responsible for trust fund petty cash for residents. She stated every morning she would provide RECP a total account balance that gives totals for each resident and if the residents asked to withdraw petty cash funds, they would sign the money out with RECP. She stated the petty cash funds were available Monday-Friday 8 AM - 5 PM. She stated she had open communication with all the residents and if they needed money for the weekend, she would be happy to assist, but the residents made sure they came up on Fridays to get the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 5 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Note: The nursing home is disputing this citation. appropriate amount for weekends. BOM stated some residents did not remember withdrawals occurred Monday - Friday but it was repetitive. She stated a few residents would ask the same questions. The BOM stated she believed 99% of the residents were aware of how to access funds on the weekend. She stated there was no policy in place that outlined when trust fund petty cash was available and how the residents could access it. She stated a resident would not go without funds on the weekend and ADM or DON would be notified if funds were needed. She stated residents were notified of trust funds with their admission paperwork and she talked to residents individually and passed this information on. She stated the residents would not have a negative impact as there was always a way to accommodate the resident's trust fund petty cash needed it just was not documented in a policy. In an interview on 6/26/2025 at 6:15 PM ADM stated the petty cash process was taken care of by RECP, it was available to residents Monday - Friday 8 AM - 5 PM and it was not available on weekends as she did not have anyone at the facility to access the funds on the weekends. She stated a while back a few residents asked if someone could be available on the weekends to access personal funds and a part-time RECP was hired. She stated the part-time RECP did not last long, and the position had since been vacant. She couldn't recall how long back. She stated she did not believe there was an impact to residents if they were unable to access personal funds as staff could help them purchase something until Monday mornings. Review of Resident Funds Management Service Withdrawal Records reflected petty cash account funds withdrawal is only accessed Monday - Friday: 5/7/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 4/29/2025 - 5/1/2025. 5/12/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 5/6/2025 - 5/9/2025. 5/16/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 5/12/2025 - 5/15/2025. 5/27/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 5/19/2025 - 5/23/2025. 6/6/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 5/27/2025 - 5/30/2025. 6/11/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 6/2/2025 -6/4/2025. 6/12/2025 Petty Cash Account - Petty cash trust fund check logs for week dated 6/9/2025 -6/12/2025. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: r. manages his or her personal funds, or have the facility manage his or her funds (if he or she wishes). Review of facility policy no date noted and titled Resident Trust Policy and Procedures reflected the following: The facility Business Office Manager is responsible for maintaining patient trust accounts and is required to leave a sufficient balance (State Allowance) in the account to cover unforeseen personal needs the resident may request or require in the immediate future (such as hair care, outing expenses, etc.). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 6 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0567 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Note: The nursing home is disputing this citation. Review of facility policy dated 2025 and titled Resident Personal Funds reflected the following: 2. If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: 2. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider, and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents and 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. Review of facility admission Packet dated 9.2022 and titled Statutory Patient's Rights - Statement of Resident's Rights in Texas reflected the following: 13. You have a right to: Access money and property you have deposited with the facility and to an accounting of your money and property that are deposited with the facility and of all financial transactions made with or on behalf of you. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 7 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one of three residents (Resident #7) reviewed for activities. Residents Affected - Few The facility failed to provide Resident #7 in room activities during the months of May and June of 2025. This failure could place residents at risk for boredom, depression, and diminished quality of life. Finding included: Review of Resident #7's face sheet reflected a [AGE] year-old male with an initial admission date of 02/24/2010 and readmitted on [DATE] with diagnoses of spastic hemiplegia (most common type of cerebral palsy) affecting left dominant side, encounter for palliative care (typically involves providing specialized medical care focused on relieving symptoms and improving the quality of life for patients with serious illnesses), cognitive communication deficit (communication difficulties that arise from cognitive impairments), hyperlipidemia, unspecified (high cholesterol), major depressive disorder, single episode, unspecified, depersonalization-derealization syndrome (is a mental health condition characterized by persistent feelings of detachment from one's body or surroundings), pseudobulbar affect (a neurological condition characterized by uncontrollable episodes of inappropriate laughing or crying that do not match the individuals' emotional state), psychophysiologic insomnia (medical term used to describe insomnia linked to excessive worry about sleep). Review of Resident #7's MDS dated [DATE] reflected a BIMS of 99 (resident was unable to complete the interview) indicating severe impairment, and had an active diagnosis, Hemiplegia or Hemiparesis (disorder that affects how you communicate) and taking IV (intravenous) medications. Review of Resident #7's Care Plan dated 4/11/2025 reflected resident had depression and bipolar disorder with anxiety and seizure disorder. Resident also had activity goal to attend at least one activity per week by the next review date. Further review reflected resident had interventions in place to address alternate periods of rest with activity out of bed to prevent respiratory complications, dependent edema (a type of swelling in the lower body due to gravity), flexion deformity (the inability of the knee to fully extend or straighten) and skin pressure areas. Further review Resident #7 will attend (passively at times) 1 cognitive activities including games, trivia, current events, or sensory groups for increase in cognitive abilities or cognitive stimulation. Interventions: Provide me with sensory activities in accordance with past/current interests including music, pet therapy, adapted games/sports, exercise, socials, family visits, being read to, &/or familiar tasks. Review of Resident #7's active orders as of 4/11/2025 reflected resident is currently under services of Hospice with DX: late effect CVA effective 12/3/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 8 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0679 Level of Harm - Minimal harm or potential for actual harm Review of Resident #7's Activities assessment dated [DATE] revealed the resident had an activity-related focus to remain appropriate as per current care plan. Review of Resident #7's active orders as of 7/7/2023 reflected resident had order to participate in activities as tolerated. Residents Affected - Few Review of Resident #7's active orders as of 7/7/2023 reflected resident had order to participate in group and individual activities of choice as tolerated including those involving foods as per current diet order. Review of Resident #7's Activity Participation Record during the month of May from 05/01/2025 to 05/31/2025 reflected Resident #7 did not refuse one-on-one activities or receive one-on-one activities. Review of Resident #7's Activity Participation Record during the month of June from 06/01/2025 to 06/09/2025 and 06/11/2025 to 06/26/2025 reflected Resident #7 did not refuse one-on-one activities or receive one-on-one activities. Observation and interview on 06/24/2025 at 9:00 AM, revealed Resident #7 was sitting in his medical recliner in the television room with four other non-ambulatory residents and the television was turned off. There was no stimulation in the room, and he would not respond to any conversation or questions. Resident #7 was not interviewable. Observation and interview on 06/24/2025 at 11:30 AM revealed Resident #7 was still sitting in his medical recliner in the television room with four other non-ambulatory residents and the television was turned off. There was no stimulation in the room, and he would not respond to any conversation or questions. In a phone interview on 06/25/2025 at 12:46 PM with Resident #7's FM stated overall he was happy with the facility's care and things pop up periodically that need attention. FM stated 90% of the team members pay attention to Resident #7, Resident #7 is very limited on what he can do. FM would like to see Resident #7 involved in more activities and would like staff to pay a little more attention and have Resident #7 engaged in group activities throughout the day. FM stated Resident #7 cannot participate in many activities because of his condition, but FM has discussed in Resident #7's care plan meetings and directly with the AD to spend 30 minutes 2-3 times a week playing music for Resident #7, and FM does not believe this is being done often. FM stated he and another family member visit 5 times per week and very little interaction was observed. Observation and interview on 6/26/2025 at 12:45 PM revealed Resident #7 was sitting in his medical recliner asleep at a dining table with three other residents and three feeding assistants in the dining room. Resident #7 remained asleep for 30 minutes during lunch. Staff did not engage with Resident #7 or make any attempt to wake him up to engage in lunch. In an interview on 6/26/2025 at 3:00 PM SS stated the expectation for residents who are non-ambulatory was to be stimulated with activities and staff should involve residents in individual and group activities. She stated the AD was responsible for providing activities for residents who are non-ambulatory and was not sure as to what was all involved. She stated when residents are not engaged in activities it can be harmful to their mental health. She stated she was familiar with Resident #7's care plan. She stated he was non-ambulatory and believed the AD provided individual activities in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 9 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident's room, but she was not sure. She stated her involvement with Resident #7 was limited and she helped to complete his quarterly assessments/care plans. The SS stated she had only met him a few times, knew his BIMS was at 00 and that he could not do a lot. She stated he needed more care and more assistance than other residents. In an interview on 6/26/2025 at 11:48 AM the AD stated she would stop to talk with non-ambulatory residents who do not want to or who were unable to leave their rooms and were interested in music and social conversation. She stated she would also turn on their [NAME] in their rooms for music. She stated for residents who were non-ambulatory and non-verbal they enjoyed looking out the windows at the birds and yard. The AD stated Resident #7 enjoys being involved in activities. She stated she would have Resident #7 sit and observe the group activities and it would depend on how tired he was and how he was doing during the day. She stated she would provide individual activities for Resident #7 2 -3 times a week and she documented each individual and group activity for him and other residents she provided services to. She stated the potential impact for not including a resident in activities could be detrimental to their mental health and cause them to be isolated. When asked about Resident #7 sitting in the television room with the television off, she stated there were times she was unable to keep an eye on him and other times he was agitated, depending on the activity and would not have him participate. She stated he did participate in daily devotion group even if agitated and she documented all activities each resident engaged in in their electronic medical records. In an interview on 6/26/2025 at 5:50 PM DON stated she has been employed only two weeks at this facility. She stated the activities for non-ambulatory residents whether group or individual was the responsibility of the AD. The expectation was for all residents to be included in activities. Review of In-Service dated 2/16/2025 titled Care for Resident #7 reflected the following: Between meals whether Resident #7 is in the TV room or his room, turn on the TV so he can watch something he enjoys versus sitting in the dark/quiet. Review of facility policy dated 2024 and titled Promoting/Maintaining Resident Dignity reflected the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Review of facility policy dated 2024 and titled Promoting/Maintaining Resident Dignity reflected the following: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Review of facility policy dated 2024 and titled Promoting/Maintaining Resident Dignity reflected the following: 13. Assist residents to participate in activities of choice. Review of facility policy dated 2024 and titled Promoting/Maintaining Resident Dignity reflected the following: 14. Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: 2. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider, and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents and 4. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 10 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. Review of facility policy dated 2025 and titled Activities reflected the following: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. c. Program of Activities -to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend. Event ID: Facility ID: 455917 If continuation sheet Page 11 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #20) of three residents reviewed for quality of care. Residents Affected - Few The facility failed to ensure Resident #20 had his lower extremities wrapped with elastic compression bandages as directed by physician orders. These failures could place residents at risk of not receiving necessary medical care, pain, injury, infection, and hospitalization. Findings included: Review of Resident #20's face sheet revealed an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease (a condition that affects the way the body processes blood sugar that leads to damage to the kidneys that impairs the kidneys from filtering toxins adequately), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder, unspecified (intense and excessive worry and fear), chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral (a long term condition of blood clots in both legs), localized edema (swelling), unsteadiness on feet, cognitive communication deficit (problem with communication caused by cognition rather than a language or speech deficit), need for assistance with personal care, other abnormalities of gait (walking pattern) and mobility. Review of Resident #20's MDS, dated [DATE], reflected Resident #20 had a BIMS score of a 14 indicating his cognition was intact. Further review reflected active diabetes mellitus diagnoses and skin and ulcer/injury care. Review of Resident #20's Comprehensive Care Plan, dated 5/14/2025, reflected Resident #20 had altered skin integrity and interventions included encouraging ambulation if patient was able. Review of Resident #20's active orders as of 4/24/2025 reflected resident had order to apply elastic compression bandage on during day and off at night for BLE edema (bilateral lower extremity) with an order start date of 4/24/2025. Review of Resident #20's Medication Administration Record (MAR) reflected elastic compression bandage on during day and off at night was administered every morning at 8:00 AM from 6/1/2025 to 6/26/2025. Observation and interview on 6/24/2025 at 9:48 AM revealed Resident #20 stated he had cellulitis and in recent and follow up treatment was to have legs wrapped from 8 AM - 8 PM to help with pressure and pain. He stated the last two mornings the nurse forgot and neglected to get it done. He removed his blanket from his legs and his legs were both exposed and the elastic compression bandages were located on his bookshelf out of reach. He stated the nurses did not understand the bandages helped him and he would like them to put them on daily if they could. Observation and interview on 6/24/2025 at 10:55 AM revealed Resident #20 did not have elastic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 12 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few compression bandages placed on his legs. Resident #20 stated he was still waiting for a nurse to wrap his legs. Observation and interview on 6/26/2025 at 12:44 PM revealed Resident #20 did not have elastic compression bandages placed on his legs. Resident #20 was sitting in the dining room eating lunch and he lifted his pant legs and stated he was still waiting for the elastic compression bandage to be placed on his legs and that they were sitting on his bookshelf and a 2nd pair was sitting in his restroom in a small basket. He stated he asked the nurse about the wraps during medication administration and was told they would return and that he continued to wait. In an interview on 6/26/2025 at 2:00 PM RN B stated when there were orders for an elastic compression bandage it would be added in the resident's MAR, nurses were expected to ensure the skin was clean, dry, and intact. They were then expected to wrap the ordered area and notify the doctor and family if skin issues formed. She stated if wraps were ordered and not being applied this could cause skin concerns for the resident. She stated she was not familiar with Resident #20's care. In an interview on 6/26/2025 at 2:20 PM DON stated the charge nurse that documented Resident #20's Medication Administration Record was sent home due to a verbal altercation with care and inappropriate behavior and would not be available for an interview. In an interview on 6/26/2025 at 5:50 PM DON stated the procedures for the Medication Administration Record was to be documented correctly and accurately by nurses. She stated nurses were to review the orders for a resident, administer the medication or treatment, and document it on the MAR. She stated if there are any medication errors they should be documented, and she should be notified immediately. She stated if orders are to wrap extremities for edema, then this is what needs to be done, there should be no delays in treatment. She stated it could impact the resident by causing an infection and resident can become sick. When Resident #20's MAR was shown to the DON with elastic compression bandage marked as completed for AM she stated the nurses' initials indicate the elastic compression bandages were placed on the resident and the nurse acknowledged completing this. When informed Resident #20's elastic compression bandages not being put on his legs today or several times this week the DON stated this didn't surprise her. She stated the nurses' initials belong to the nurse that was sent home for her behavior on this morning's shift, and she was unavailable to discuss this concern. She stated she would ensure Resident #20 is receiving the care he needed. Review of facility policy dated 2024 and titled Promoting/Maintaining Resident Dignity reflected the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Review of facility policy dated 2024 and titled Promoting/Maintaining Resident Dignity reflected the following: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Review of facility policy dated 2024 and titled Promoting/Maintaining Resident Dignity reflected the following: 14. Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 13 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm 2. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider, and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents and 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 14 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 resident (Resident #15) and 1 of 1 (100-Hall) medication room reviewed for pharmacy services. The facility failed the ensure expired medication, including medication prescribed for Resident #15, and medical supplies were removed from 100-hall medication storage room. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, and/or contamination from expired supplies. Findings included: 1. Record review of Resident #15's admission record, dated 6/26/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #15 had diagnoses which included: chronic obstructive pulmonary disease (a chronic lung disease that limits airflow and causes ongoing respiratory symptoms) and asthma (a chronic lung disease that is caused by inflammation and muscle tightening around the airways, which makes it difficult to breathe). Record review of Resident #15's Quarterly MDS, dated [DATE], reflected a BIMS score of 05, which indicated severe cognitive impairment. Record review of Resident #15's order summary, dated 06/26/2025, reflected Albuterol Sulfate nebulization solution (2.5 mg/3ml) 0.083% 3ml inhale orally via nebulizer every 6 hours as needed for shortness of breath. (Albuterol Sulfate is a medication that is given by breathing in to assist with opening the airway). Record review of Resident #15's care plan, dated 08/23/2024 and last revised on 04/10/2025, reflected no care plan related to respiratory diseases. Observation of 06/26/2025 at 01:53 PM of the 100-hall medication room revealed: Two boxes of Albuterol Sulfate Inhalation Solution 0.083% that belonged to Resident #15 with an expiration date of May 2025. Seven 100-ml bottles of Sterile Water with an expiration date of 05/16/2025 One Catheter Stabilization with an expiration date of 03/28/2025 (a device used to secure a Foley catheter tube to the leg to prevent dislodgement) One Suture removal tray with an expiration date of 12/31/2024 During an interview on 06/26/2025 at 05:23 PM, LVN D stated all the nurses and medication aides were responsible for checking for expired medications/supplies in the medication room. She stated she tried to check it every other day when she had time. LVN D stated she thought the DON followed up to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 15 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ensure all expired medications/supplies were removed. She stated if a resident was to take expired medication, then the medication concentration could be altered, either higher or lower than intended. LVN D stated she was unsure of how residents could be affected if expired supplies were used on the residents. During an interview on 06/26/2025 at 05:30 PM, LVN E stated all the nurses, medication aides, and management were responsible for checking for expired supplies and medications in the medication room monthly. He stated if a resident was to take expired medication, then the medication may not be at the intended dosage. LVN E stated that if expired supplies were used then there was a possibility that the supplies may not be sterile, or the materials could have deteriorated. During an interview on 06/26/2025 at 05:36 PM, MA stated the person in charge of central supply and the medication aides were responsible for checking the medication rooms for expired supplies and medications. He stated he attempted to check the rooms weekly when time allowed. MA stated if expired medications were administered to resident, then the medication may not work like it should or the resident could have an adverse reaction to the medication, like an upset stomach. During an interview on 06/26/2025 at 05:39 PM, LVN F stated the person in charge of central supply and the nurses were responsible for checking the medication rooms for expired supplies and medications. She stated she was unsure of how often the medication rooms were checked or if someone monitored to ensure the medication rooms were being checked. LVN F stated if the expired medications were used for residents, then the resident may not get the right potency of the medication that was ordered. She stated she was unsure how using expired supplies might affect a resident. During an interview on 06/26/2025 at 05:49 PM, the DON stated the medication aide that is responsible for central supply was responsible for checking for expired medications and supplies on a weekly basis. The DON stated that since she had only been at the facility for about 2 weeks, she had not initiated a process to verify the medication rooms were checked for expired medications and supplies yet. She stated that if expired medications were used for residents, then the medication may not work the same as medication that was not expired. During an interview on 06/26/2025 at 06:06 PM, the ADM stated she expected the nurses and medication aides to check the medication rooms for expired supplies and medications. She stated she was unsure of how often the medication rooms were to be checked. The ADM stated the previous DON would conduct audits to ensure the medication rooms were checked but she was unsure how often the audits were being performed. She stated the pharmacy consultant would come in about once a month to audit all medication carts and the medication rooms for expired supplies and medications. The ADM stated she was unsure how using expired medications and supplies on residents might affect a resident. She stated it all depended on the medication or supplies on how it might affect the resident. Record review of the facility's, undated, policy titled Storage of Medications reflected: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 16 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. Residents Affected - Some 1.The pureed kitchen test tray of the lunch meal foods were unappealing and lacked flavor. The pureed kitchen test tray lacked condiments, the food items did not hold their form and ran together, there was no garnishment of the food tray, and the dessert of lemon pie parfait was so thick, gummy, and tasted of food thickener it was inedible. 2. The regular texture kitchen test tray of the lunch foods were unappealing and lacked flavor. The regular texture kitchen test tray lacked condiments, the food items of roast pork loin was dried out, Harvard beet juice had run into the rice pilaf, the dessert of lemon pie parfait was not a full serving size of ½ cup, and there was no garnishment of the food tray. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included: Observation on 6/25/25 at 10:30 AM of lunch meal puree preparation revealed CK K was pureeing pork loin. CK K was observed pouring food thickener from thickener container into puree machine with pork loin and broth. CK K did not measure food thickener just poured straight from container on 3 different occasions while pureeing pork loin. Further observation revealed CK K did not taste the pork loin after the pureed process was complete. Observation on 6/25/25 at 1:13 PM of Pureed texture lunch kitchen test tray revealed the test tray did not have any condiments on the tray, the food items of (roast pork loin, Harvard beets, rice pilaf, and dinner roll) did not hold their form and ran together. There was no garnishment on the meal tray. The dessert of lemon pie parfait was so thick, gummy, and tasted of food thickener it was inedible. The pureed foods items were unappealing in appearance and lacked flavor. Observation on 6/25/25 at 1:13 PM of the Regular texture lunch kitchen test tray revealed the test tray did not have any condiments on the tray, the food items of roast pork loin was dried out and had no gravy or sauce to give any moisture, Harvard beet juice had ran all over the plate and got into the rice pilaf, and the dessert of lemon pie parfait was not a full serving size of ½ cup (per diet spreadsheet and recipe), and there was no garnishment for the food tray. Observation on 6/26/25 at 10:05 AM of lunch meal puree preparation revealed CK K was pureeing Salisbury steak, carrots, dinner rolls, and strawberries. CK K stated the food thickener scoop was missing from the container and proceeded to use a table cutlery teaspoon to measure food thickener for each of the food items prepared. CK K visually looked at each food item to ensure desired consistency was achieved. CK K did not taste any of the food items prepared after the puree process was complete. During a confidential resident council interview on 6/25/25 at 2:03 PM it was revealed that several concerns and complaints were made of the food being inedible and being told when asking for alternatives that none are available. Ombudsman present at resident council meeting confirmed food concerns (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 17 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some have been brought up for the last several months at the resident council meetings with no resolution being provided. Interview on 6/25/25 at 3:24 PM with CK J revealed CK J stated when pureeing foods, you need to start with 2 oz of liquid then add more as needed. CK J stated the next step is to use the spoon test to see if the desired consistency has been achieved and add food thickener as needed until the desired consistency is reached. CK J stated you always need to use the least amount of liquid and food thickener as possible so as not to compromise the flavor or nutrients of the food. Interview on 6/26/25 at 10:33 AM with CK K revealed CK K stated she had received 1 month of training from the DM. CK K stated the method she used was to start the puree machine, count 30 seconds, then check the consistency of the food item to see if food thickener needs to be added. CK K stated, I add 1 tsp at a time if the scoop is missing from the thickener container, I just use a regular teaspoon that the residents receive on their trays. CK K stated you visually check the food item, and you also taste the food items. CK K could not explain or give an answer as to why she had not tasted any of the food items when she completed the puree process. Interview on 6/26/25 at 10:50 AM with RD revealed the RD stated she expected the meals served to be attractive and palatable to the residents. When shown photos of the pureed texture test tray, RD stated the foods are not supposed to run together and the food items should hold their form. RD stated the dessert item lemon pie parfait should not be as thick as it appeared in the photo. RD stated all food items should have the flavor of the food item and not just the flavor of food thickener. When shown photos of the regular texture test tray, RD stated the Harvard beets could have been drained better before plating so the juices did not run into the other food items. RD stated she was unsure if the dessert item of lemon pie parfait was the correct serving size as it was hard to tell from a photo. When asked if the RD watched the tray line process RD responded, yes. When asked if the RD felt the dessert items were of the correct serving size, RD stated she was unsure as she had not specifically looked at the dessert items. When asked if condiments were supposed to be on the meal trays RD stated, Yes condiments should be on the meal trays. RD stated she was unsure about the cook training specifics, RD stated she knew the DM had trained the cook. RD stated if she sees a concern when she is present then she works with the staff member in the moment and alerts the DM for further training and or follow up. RD stated she was unsure if the diet spreadsheet and recipes address the pureed texture diets. Telephone interview on 6/26/25 at 1:49 PM with DM revealed the DM stated the cooks were trained on how to prepare pureed foods from the corporate office. DM stated corporate had a trainer come to the facility and train and that the ADM had a copy of the in-service training provided. DM stated he was aware that the pureed recipes were not in the diet spreadsheet binder. DM stated he had contacted the food service company that the facility used to request these recipes be sent to him to add to the diet binder. DM stated he had not received a reply from the food service company at this time. DM stated he expected the meal trays to be attractive and palatable to the residents. Interview on 6/26/25 at 5:26 PM with the DON revealed she expected the meal tray to be clean, meal ticket to be correct with all the information needed, and the meal to be presentable and appealing. DON stated she was unsure if there should be recipes for the pureed foods in the diet spreadsheet binder. DON stated she was unsure how the cooks were trained about how to puree foods. DON stated she had only been employed at the facility for a couple of weeks and she was still unsure about several of the processes, but she felt the DM was responsible for the kitchen and the kitchen staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 18 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 6/26/25 at 6:00 PM with ADM revealed the cooks work with the DM for a minimum of 3 days of training and that the RD and speech therapist both assist as needed for training and coaching the staff. ADM stated recipes for pureed foods were not necessarily needed to be in the diet spreadsheet binder as the cooks should be visually looking at the food items to see if the desired consistency has been achieved and tasting all the foods items to ensure the desired flavor was present. ADM stated the cooks had received training on the puree process from the corporate office. ADM further stated that the cooks were to be using the least amount of food thickener as possible to achieve the desired consistency and taste. ADM stated she expected the tray appearance to be appetizing for the regular texture and for the pureed texture she expected those trays to also be appetizing in appearance and for the food to hold its consistency. Record review of diet spreadsheet binder reflected no recipes available for pureed food items. Record review of food thickener container listed specific thickener mixing chart instructions depending on desired consistency of food item. Pureed fruits 4 oz drained use 3/4-1 1/2 tsp thickener Pureed vegetables 4 oz drained uses ¾-1 1/2 tsp thickener Pureed meats 3 oz uses 1 oz meat broth slurry. Meat broth slurry =4 oz meat broth thickened with 1 Tbsp. thickener Record review of Menus and Adequate Nutrition policy undated reflected under heading policy: The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines. Under heading policy explanation and compliance guidelines: 5. Menus shall reflect input from residents and resident groups. a. Resident preferences, including likes and dislikes will be documented in the resident's chart, and shall be reviewed when planning menus. i. Alternatives shall be immediately available if the primary menu or selections for a particular meal is not to a resident's liking. ii. Each resident's plan of care will reflect interventions to accommodate nutritional needs. when his/her preferences exclude a food group (i.e. vegetarian, does not eat dairy). b. The resident council will be included periodically in menu planning, and efforts will be made. to accommodate requests. The facility shall make the final decision on all menus. Record review of IDDSI implementation in-service training log dated 5/20/21 reflected DM, CK J, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 19 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0804 CK K had attended the training. Level of Harm - Minimal harm or potential for actual harm Record review of pureed recipes provided by ADM reflected: 1. Residents Affected - Some Prepare food item according to regular recipe. 2. Prepare slurry. 3. Process until smooth adding 1oz slurry per portion. Notes: 1. Amount of thickener required may vary relative to liquid content of cooked product. For best results alternate thickener and processing checking product consistency periodically. Record review of always available menu posted on bottom of daily menu reflected options of cottage cheese w/fruit, baked potato (butter, cheese, and sour cream), and sandwich (ham, turkey, chicken salad, tuna salad, peanut butter & jelly). Record review of grievance binder reflected 10 grievances filed since 1/2025 concerning food preferences no grievances had resolution part of grievance form completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 20 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on observation, interview, and record review, the facility failed to ensure that residents had suitable, nourishing meals and snacks outside of scheduled meal service times for 2 of 2 halls (100 and 200 halls) and 2 of 2 refrigerators in 2 of 2 nourishment rooms (100 hall and 200 hall) reviewed for evening snack. The facility failed to ensure residents were offered snacks at bedtime on the 100 and 200 halls. The facility failed to have reserves of snacks for after dinner and at bedtime in 2 of 2 refrigerators in the nourishment rooms. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for unplanned weight loss, side effects from medication given without food, and diminished quality of life. Finding included: Observation on 6/24/2025 at 9:39 AM of hall 200 nourishment room revealed health shakes, cartons of milk, and containers of yogurt in refrigerator. One peanut butter and jelly sandwich on nourishment room shelf dated 6/23 and several packages of peanut butter crackers. Further observation revealed no temperature monitoring log on nourishment room refrigerator. Observation on 6/24/2025 at 12:52 PM of hall 100 nourishment room revealed no refrigerator in nourishment room. Further observation revealed no snacks on shelving in nourishment room. Nourishment room contained ice chest with ice in it and a coffee maker with a tray of mugs. Observation on 6/26/2025 at 4:41 PM of hall 200 nourishment room revealed health shakes, 2 cartons of milk, 1 container of thickened milk, 11 bottles of Boost supplement drink and a thermometer. No resident snacks available in refrigerator. On nourishment room shelving revealed to have 5 packages of peanut butter crackers, and a supermarket bag with 3 packages of pudding cups. Observation on 6/26/2025 at 4:44 PM of hall 100 nourishment room revealed nourishment room now has a refrigerator. Refrigerator only has a thermometer and a jar of picante sauce with a resident name labeled on it. During a Resident Council meeting on 6/25/2025 at 2:00 PM, 16 anonymous residents stated snacks were not offered and were not aware they could ask for them. Some residents stated they have asked for a snack during bedtime and have been informed they do not have any or are told they will come back with one and the staff does not return. Interview on 6/26/2025 at 10:50 AM with RD revealed RD stated she was unsure about what the daily snack rotation was. RD stated she did not know the snack policy or procedure for this facility specifically but stated that generally snacks are offered 3 times a day. RD stated she knew the snacks were delivered to the nursing station on each hall by the dietary staff. Interview on 6/26/2025 at 1:49 PM with DM revealed DM stated the dietary staff deliver a tray of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 21 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some snacks and health shakes to the nursing station in the morning and then the nurses are responsible for storage and passing of snacks. DM stated the one tray of snacks supplies for the entire day. DM states the snacks consist of half sandwiches, cookies, peanut butter crackers, yogurt, and health shakes. Interview on 6/26/2025 at 4:35 PM with RN I revealed the dietary staff deliver the morning snacks consisting of yogurt, sandwiches, cookies, and peanut butter crackers which are brought with the morning coffee and the nursing staff pass the snacks to the residents. RN I stated any snacks left are placed into the nourishment room refrigerator. RN I stated she was unsure of who was responsible for cleaning the nourishment room refrigerator and has asked that since she started working at the facility and has not received an answer yet. Interview on 6/26/2025 at 4:38 PM with LVN F revealed there were never any snacks brought to the nurse station for residents. If a resident requested a snack, then the nurse needed to go to the kitchen and ask for something. LVN F stated if the kitchen was already closed for the day, then the nurse needed to go into the kitchen and find some options for the resident as a snack. LVN F stated the only option usually available to the residents was peanut butter crackers. Interview on 6/26/2025 at 5:26 PM with DON revealed she was unsure of the facility snack process as she had just started at the facility a couple of weeks ago. Interview on 6/26/2025 at 6:00 PM with ADM revealed the nursing staff had resident snacks available in the nourishment room on each station. ADM stated typically the morning dietary staff deliver a tray of snacks to cover the entire day. ADM stated the snack rotation consists of sandwiches, peanut butter crackers, cookies, and yogurt. Policy regarding snacks was requested on 6/26/2025 at 3:41 PM. Email correspondence from ADM on 6/26/2025 at 3:45 PM revealed the facility did not have a snack policy. Review of facility policy dated Quarter 3, 2022 and titled Resident Rights reflected the following: 2. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider, and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents and 4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 22 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1.The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning the juice machine dispenser, cleaning the inside of the microwave, covering lemonade and iced tea drink receptacles to ensure they remain free of contamination, storing the ice scoop in an ice scoop receptacle that had a lid and that was free from standing water accumulation and free from food debris buildup, ensuring staff utilize hair restraints while in the kitchen, ensuring trash receptacles in the kitchen had lids secured covering contents, cleaning the walk in refrigerator unit shelving and walls to ensure they are free of mold and debris, sweeping the kitchen prep area floors to be free of debris and crumbs, and cleaning the kitchen prep area shelving to be free of debris and crumbs) 2.The facility failed to ensure cleaning logs were being completed. 3.The facility failed to ensure all items were covered and stored properly. 4.The facility failed to label and date all food items in the kitchen. 5. The facility failed to ensure all flooring was free from cracks and breakage and ice buildup and not a fall hazard. These failures could place residents at risk of foodborne illness. Findings included: Observation on 6/24/25 at 9:11 AM of 55-gallon trash can without a lid near 3 compartments sink area. Observation on 6/24/25 at 9:12 AM of broken kitchen floor tiles in speed rack / cart storage area near ovens. Observation on 6/24/25 at 9:15 AM of juice dispenser machine revealed the underside of the nozzle dispensing area to be covered in orange and red sticky buildup with fuzzy mold appearing substance on dispensing nozzles. Observation on 6/24/25 at 9:16 AM of 1 5-gallon container of lemonade and 2 5-gallon containers of iced tea without a lid or covering to prevent debris or containment from falling in. Observation on 6/24/25 at 9:17 AM of 55-gallon trash can near ice machine without lid. Observation on 6/24/25 at 9:18 AM of ice machine revealed mineral deposit buildup on outside of machine all around door and seal. Further observation revealed black and brown mold appearing substance and a pink and reddish slime appearing substance on the interior of the ice machine on the ice guard, door, door seal, and interior wall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 23 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 6/24/25 at 9:20 AM of the microwave revealed the interior of the microwave to have dried food debris on the interior top and in the corners. Observation on 6/24/25 at 9:22 AM of the kitchen dry goods pantry revealed a package of dry jello mix unsealed, dated 7/5, unsure if that is receipt date, open date, or use by date. Further observation revealed an undated, opened but securely sealed package of penne pasta. Observation on 6/24/25 at 9:26 AM of walk-in refrigerator unit revealed dunnage racks where crates of milk were being stored to be covered in a gray black mold appearing substance. Further observation revealed shelving and walls to have gray and black mold appearing substance on underside and tops of shelving and on walls behind shelving. Observation on 6/24/25 at 9:28 AM of walk-in freezer unit revealed ice buildup on floor of unit. Observation on 6/24/25 at 9:30 AM of kitchen prep area shelving to have crumbs and food debris on lower level. Observation on 6/24/25 at 9:33 Am of kitchen floor revealed crumbs and food debris on flooring. Observation on 6/25/25 at 12:11 PM of floor dolly where dish machine racks were stored with drinking glasses to have black and brown mold appearing substance on it. Observation on 6/26/25 at 10:15 AM of MS entering kitchen without hairnet or beard guard wearing ball cap. MS walked over to ice machine to perform checks on it. MS walked to back of kitchen to chemical storage closet and back to front of kitchen near DM office before exiting thru side door of kitchen. Interview on 6/26/25 at 10:50 AM with RD revealed the evening shift staff complete the cleaning logs. RD stated she was unsure of what the monthly ice machine cleaning entailed, and she was unsure of the specifics of the cleaning logs in general. RD stated she was unsure how often the walk-in refrigerator was supposed to be cleaned. RD stated all staff were to wear hair restraints while in the kitchen. RD stated she just consulted for the facility and was at the facility 1-2 times a week. RD stated the day to day running of the kitchen was the responsibility of the DM who was currently on vacation. RD stated if the kitchen sanitation was not maintained, and hair restraints were not worn then the residents have the potential for food borne illness and food contaminants. Interview on 6/26/25 at 11:10 AM with MS revealed he services the ice machine quarterly and deep cleans it twice a year. MS stated when he cleans and services the ice machine it was for the internal electrical and plumbing components of the machine not the interior or exterior cleaning of the machine. MS stated a hair restraint is to be always worn in the kitchen unless a ball cap was worn then that would count as a hair restraint and a beard guard was required for any facial hair more than 1 inch long. MS stated this was to prevent hair getting into the food and the food being contaminated. Interview on 6/26/25 at 1:49 PM with DM revealed it was expectation of the staff to follow the cleaning logs concerning the kitchen sanitation. DM stated he was unaware of the issues with the ice machine mold, juice machine buildup and mold, and walk-in refrigerator buildup and mold. DM stated he was also unaware of the food debris and crumbs on the kitchen prep area lower shelving and floors. DM stated it was his expectation that all food items were to be labeled, dated, and sealed properly. DM stated he was unaware of the broken floor tiles near the oven and the ice buildup in the freezer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 24 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many DM stated all staff were to be wearing hair restraints while in the kitchen including beard guards if they have facial hair. DM stated it was his responsibility to ensure staff are completing the kitchen cleaning logs and to be monitoring the kitchen for proper sanitation practices. DM stated the kitchen staff needs to ensure proper sanitation practices, so the residents do not become sick. Interview on 6/26/25 at 5:26 PM with DON revealed it was her expectation that the kitchen be kept clean, and everything should be labeled, dated, and organized. DON stated she expected the staff to be following appropriate hand hygiene and hair restraint practices. DON stated it was the responsibility of the DM to ensure kitchen sanitation. DON stated if the kitchen sanitation is not maintained it can negatively affect the residents with the potential of food borne illness. Interview on 6/26/25 at 6:00 PM with ADM revealed she expected the kitchen staff were following a cleaning schedule and maintaining it. ADM stated it was her expectation that the staff were following policy concerning hair restraints. ADM stated it was the responsibility of the DM and the ADM to ensure kitchen sanitation was maintained. ADM stated it could potentially negatively affect the residents if kitchen sanitation was not maintained by food borne illness. ADM stated if hair restraints were not worn there was potential for contamination of food from hair. Record review of cleaning logs revealed there to gaps in completion in the logs from 2/25, 3/25, 4/25, 5/25, and 6/25. Attempted record review of kitchen sanitation policy was unsuccessful as the policy was requested on 6/26/25 at 1:33 pm with response from ADM on 6/26/25 at 3:48 pm that the facility does not have a kitchen sanitation policy. Record review of Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy undated reflected under policy interpretation and implementation: 12. Hair nets or caps and / or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 25 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to adequately equip residents the ability to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, from the bathroom for 56 of 61 resident rooms reviewed for resident call systems. Residents Affected - Some Note: The nursing home is disputing this citation. The facility failed to ensure resident bathrooms had a pull string attached to the push button call light switch making the call light button inaccessible if the resident was lying on the floor in their bathrooms in rooms: 1) 100 2) 102 3) 103 4) 105 5) 106 6) 107 7) 110 8) 111 9) 113 10) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 26 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 115 Level of Harm - Minimal harm or potential for actual harm 11) 116 Residents Affected - Some 12) Note: The nursing home is disputing this citation. 117 13) 118 14) 119 15) 120 16) 121 17) 122 18) 123 19) 124 20) 125 21) 126 22) 127 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 27 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 23) Level of Harm - Minimal harm or potential for actual harm 128 24) Residents Affected - Some 129 Note: The nursing home is disputing this citation. 25) 130 26) 131 27) 200 28) 201 29) 202 30) 203 31) 204 32) 205 33) 206 34) 207 35) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 28 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 208 Level of Harm - Minimal harm or potential for actual harm 36) 209 Residents Affected - Some 37) Note: The nursing home is disputing this citation. 210 38) 211 39) 212 40) 213 41) 214 42) 215 43) 217 44) 219 45) 221 46) 222 47) 223 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 29 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 48) Level of Harm - Minimal harm or potential for actual harm 224 49) Residents Affected - Some 225 Note: The nursing home is disputing this citation. 50) 226 51) 227 52) 228 53) 229 54) 230 55) 231 56) 232 This failure could place residents at risk of harm by not being able to call for help when needed and at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Observations on 06/24/2025 by the survey team during the initial pool screening of residents' rooms in the 100 and 200 halls from 9:30 AM to 4:30 PM revealed most bathrooms (56 rooms in total) had a push button call light system next to the toilet on the wall. There were no strings attached to the push call light buttons that extended to the floor. In an interview on 06/25/2025 at 02:50 PM RN G stated she was familiar with the facility's call light policy. Call lights must be within reach of the resident. In the bathroom, RN G stated she did not know exactly where the placement should be, but the current push button call light system in room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 30 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Note: The nursing home is disputing this citation. [ROOM NUMBER], and many other rooms, would not be within reach if a resident was lying on the floor and that could potentially cause harm if the resident fell and could not call for help. RN G stated that help could be delayed due to the resident not being able to reach the call light. RN G stated she thought the call light system should have a pull string cord. In an interview on 06/25/2025 at 03:04 PM CNA H stated he was aware of the facility's call light policy. He stated the call light policy was for the call light to be within reach of the resident and he would clip the call light bedroom call light to the resident or the bedding. In the bathroom, CNA H stated he did not know exactly where the placement should be, but the current push button call light system in room [ROOM NUMBER], and many other rooms, would not be within reach if the resident was lying on the floor and that could potentially cause harm if the resident fell and could not call for help. He stated help would be delayed due to the resident not being able to reach the call light. CNA H stated he thought the call light should have a pull string, which is the new system and easier for the residents to use as it took less effort and force on the resident's part. The old system call light system was the push button. In an interview on 06/25/2025 at 03:22 PM the Maintenance Director stated he was responsible for repairing call lights. He stated that their policy was that call lights needed to be within reach if the resident was lying on the floor. He stated he did not know why some bathrooms had pull string cords vs. push buttons but stated that a resident could not reach the push call button if they were on the floor and that could cause a delay in staff's response to provide care, which would not be good for the resident. During observations and an interview on 06/26/2025 at 08:31 AM the Maintenance Director measured the distance from the floor to the push call light button in three random rooms (205, 211, and 223) using a standard hard tape measure. The push button call lights were 41 inches from the base of floor to the push button. The Maintenance Director stated 41 inches was the standard placement and it should be the same in all rooms. The State Surveyor also measured with own tape measuring device and got the same measurement of 41 inches from the base of floor to the push button call light. All these rooms also have a shower in them, and it would not be accessible from the shower area as the call light is on the opposite wall of the shower, next to the toilet. The Maintenance Director stated the push call lights could not be reached by a resident lying on the floor. In an interview on 06/26/2025 at 09:20 AM the DON stated she did not know what the policy said about call light placement because she has only been at the facility for two weeks. The DON stated there were some pull lights with strings and some push buttons call lights in bathrooms and she had not had any complaints about the call light system. The DON stated she did not think either pull string or push button would be accessible to a resident lying on the floor. The DON stated it was important for a resident to be able to reach the call light and if they could not, they might try to get up by themselves and fall. Also, not being able to reach the call light could cause a delay in response time by staff. In an interview on 06/26/2025 at 10:12 AM the ADM stated that their policy for call lights placement in the bathrooms were to be accessible to a resident lying on the floor. The ADM stated she was not sure if a resident lying on the floor could reach the call push button or not. She stated she was not sure if a resident on the floor could reach a pull cord string call light either. The ADM stated those push button call lights were old and had been in the facility for years. The pull string system was new. She thought there were 55 rooms with the old push button call light system. The ADM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 31 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Level of Harm - Minimal harm or potential for actual harm stated it was important for a resident to be able to call for assistance so their needs can be met timely and not being able to reach the call light could cause a delay in care, which could result in potential harm depending on the situation. The ADM stated she did not believe any residents had fallen in the bathrooms and had tried to use the call lights. The ADM stated that when residents fell, they usually do not use the call lights because they were on the floor. Residents Affected - Some The ADM stated this was a list of rooms with push buttons for call lights in the bathrooms: Note: The nursing home is disputing this citation. 100 102 103 105 106 107 110 111 113 115 116 117 118 119 120 121 122 123 124 125 126 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 32 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 127 Level of Harm - Minimal harm or potential for actual harm 128 129 Residents Affected - Some 130 Note: The nursing home is disputing this citation. 131 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 217 219 221 222 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 33 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 223 Level of Harm - Minimal harm or potential for actual harm 224 225 Residents Affected - Some 226 Note: The nursing home is disputing this citation. 227 228 229 230 231 232 Review of the facility policy Call lights: Accessibility and Timely Response, undated, reflected: Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 7. The call system must be accessible to the resident at each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 34 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. 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 review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility reviewed for pests. Residents Affected - Some 1. The facility failed to ensure resident rooms were free from flies for Resident #58. 2. The facility failed to ensure the facility was free of gnats and flies throughout the facility including dining rooms, hallways, and kitchen. This failure placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life. The findings included: 1. Record review of Resident #58's admission record, dated 06/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #58 had diagnoses which included: chronic obstructive pulmonary disease (a chronic lung disease that limits airflow and causes ongoing respiratory symptoms), chronic kidney disease (a disease that impairs the kidney's ability to filter toxins), unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), and generalized anxiety disorder (a condition characterized by persistent and excessive worry about various everyday issues). Record review of Resident #58's Quarterly MDS, dated [DATE], reflected a BIMS score of 12, which indicated moderate cognitive impairment. 2. Record review of Resident #3's admission record, dated 06/26/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had diagnoses which included: chronic obstructive pulmonary disease (a chronic lung disease that limits airflow and causes ongoing respiratory symptoms), essential hypertension (high blood pressure), chronic kidney disease (a disease that impairs the kidney's ability to filter toxins), and type 2 diabetes mellitus - (a condition that affects the way the body processes blood sugar). Record review of Resident #3's Quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. During an observation and interview on 06/24/2025 at 12:34 PM a fly landed on Resident #58's meal tray in the dining room during lunch meal service. Resident #58 stated, The fly is always here, and it bothers me. During an observation and interview on 06/24/2025 at 03:42 PM 2 flies were observed on Resident #3's wheelchair and 1 fly was observed on Resident #3's plant on the windowsill. Resident #3 stated the flies were frequently in her room and they bothered her. During an observation on 06/25/2025 at 10:30 AM of the pureed lunch meal preparation process, a gnat and 2 flies were buzzing around and landed near the puree station. Further observation revealed a bug light plugged in with sticky catch pad covered in flying insects. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 35 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 06/26/2025 at 10:20 AM of the pureed lunch meal preparation process revealed 3 flies and a gnat flew all around the area and landed on various items in the kitchen. During an interview on 06/26/2025 at 10:50 AM the RD stated she was unsure of the specifics of the pest control policy, procedures, and interventions. The RD stated she knew maintenance handled the pest control. During an interview on 06/26/2025 at 11:10 AM the MS stated he had not seen any pests, including flies and gnats, in the building recently. He stated the facility had a contract with a local pest company to come and treat the building (spray the perimeter and change the bait) once a month for insects and rodents. The MS stated there were bug lights in the kitchen and dining room to help prevent flying insects. He stated there were air-curtains at 3 of the exterior doors to prevent flying insects. The MS stated it was his expectation that there would not be insects or rodents in the kitchen or dining room. The MS stated the presence of insects and/or rodents could potentially cause the residents to become sick. During an interview on 06/26/2025 at 01:49 PM the DM stated he felt the pest control services were adequate as the pest control company came out monthly to spray, the kitchen had a blue bug light, and a blower at the back door to blow insects away from the door when it was opened. The DM could not explain as to why flies and gnats were observed in the kitchen. The DM stated that he was aware that insects could affect the residents negatively by biting them and possibly making them sick. During an interview on 06/26/2025 at 05:21 PM CNA C stated she had seen flies in the facility every once in a while. She stated she primarily saw the flies in the staff break room. CNA C stated that she told the DON and pest control responded by spraying around the facility. She stated flies could affect the residents negatively by laying eggs on the residents and spreading infection. During an interview on 06/26/2025 at 05:23 PM LVN D stated she had occasionally seen flies and/or gnats all over random areas of the facility. She stated the policy was to write the observation of any pests in the pest control book for the exterminator to review when he was in the facility. LVN D stated she was unsure how having pests in the facility could negatively affect residents. During an interview and observation on 06/26/2025 at 05:30 PM in the dining room with LVN E, he stated he had seen pests in the facility in the past. He stated he had seen ants in the hallways near the resident's room doors. LVN E stated he had previously seen flies in some of the resident's rooms because the resident had taken food into their room. He stated the policy was to notify the ADM and she would ensure it was addressed by the exterminator. LVN E stated that insects could negatively affect residents by landing in their food and that is not hygienic. During the interview, a fly was observed flying around the dining room then landed on the table next to LVN E. During an interview on 06/26/2025 at 05:26 PM the DON stated she was unsure what the facility's current policy was concerning pest control as she had only been at this facility for a couple of weeks. The DON stated that at prior facilities her expectation concerning pest control was that the facility would be free of pests and that all pests would be reported to the appropriate contacts and that the policy and procedure were followed. The DON stated she felt like the MS would be responsible for pest control. The DON stated she had not seen any pests in the facility. The DON stated that it could negatively affect a resident if pests were present because the residents could be bitten or become sick. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 36 of 37 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 455917 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Deer Creek Nursing and Rehabilitation 555 Ranch Rd 3237 Wimberley, TX 78676 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 06/26/2025 at 05:36 PM the MA stated he had not seen any pests in the facility. He stated if he were to see any pests, then he would notify the nurse and the MS. The MA stated flies and/or gnats could negatively impact a resident by landing in their food, laying eggs, and spreading infection. During an interview on 06/26/2025 at 05:39 PM LVN F stated she had seen pests in the facility pretty much everywhere. She stated when she saw pests in the facility, she reported it to the MS through their computerized tracking system and then follow up with verbally telling him. LVN F stated pests in the facility could negatively impact a resident by spreading infection, or the pest could get into the residents' mouth, nose, or even their food. During an interview on 06/26/2025 at 06:00 PM the ADM stated that her expectation concerning pest control was that the facility had and maintained the pest control program. The ADM stated the MS was responsible for overseeing the pest control program. The ADM stated the facility had a contract with a pest control company that came and serviced the building. The ADM stated she had occasionally seen flies in her office and toward the front entrance to the facility. She stated that she expected staff to log any observations of pests in the pest control binder. The ADM stated it could negatively affect the residents if pests were present in the facility by the residents possibly getting bitten or becoming sick. Record review of pest control service log reflected documentation on 01/14/2025 of roach spotted in room [ROOM NUMBER] restroom with no documentation of service completed, 02/10/2025 of ants in room [ROOM NUMBER] B windowsill with documentation of service completed, 04/16/2025 of rat no location listed with documentation of service completed, 06/19/2025 of roach in room [ROOM NUMBER] A & B with no documentation of service completed. Further review reflected pest control company documents coming to facility bi-monthly to service facility. Record review of facility policy titled Pest Control Program, dated 2025, reflected: Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents . Policy Explanation and Compliance Guidelines: 3.Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 37 of 37