Health inspection·December 1, 2025

F 0804 Level of Harm - Minimal harm or potential for actual harm was still unable to find the directions to puree chicken tenders. Review of the in-service Menus Adequate Nutrition & Thickener dated 06/29/25, reflected in part, Add liquid: Incorporate broth, milk, or juice to adjust thickness as needed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 2 of 4 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 12/01/2025 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 - Some 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. The facility failed to ensure all items were covered and stored properly.The facility failed to label and date all food items in the kitchen.The facility failed to ensure all staff in the kitchen wore hairnets or beard guards. These failures could place residents at risk of foodborne illness.Findings included: An observation on 09/25/25 at 9:58 AM revealed a partially used 50-pound bag of refined sugar, open and undated, on a shelf in the storage room. An observation on 09/25/25 at 9:59 AM revealed a large bag of enriched flour, open and undated on a shelf in the storage room. An observation on 09/25/25 at 9:59 AM revealed a large plastic storage bin labeled Flour 07/22. The lid was not secure on the storage bin. An observation on 09/25/25 at 10:01 AM revealed a brownish-orange pudding like substance in a plastic container in the walk-in refrigerator. The container was not dated or labeled. An observation on 09/25/25 at 10:02 AM revealed an unidentified brownish substance in a plastic container in the walk-in refrigerator. The container was not dated or labeled. An observation on 09/25/25 at10:02 AM revealed an open package of sliced honey ham with juices in an unsealed plastic bag stored in the same bin as unsealed bags of shredded cheese. During an interview on 09/25/25 at 10:22 AM, the DM stated all food was dated when opened and everything was kept in a sealed container. She stated it did not meet her expectations that the large flour and sugar bags were not sealed. She stated bugs or animals could get into open containers and cause food-borne illness. She stated it did not meet her expectations that the ham and cheese were in unsealed bags and in the same bin. An observation on 09/25/25 at 10:30 AM revealed the MS with facial hair, without a hairnet or a beard guard, walked through the food prep area and clean dish area to the dishwasher. During an interview on 09/25/25 at 10:42 AM, the MS stated he was aware that hairnets and beard guards were required in the kitchen. He stated he got in a hurry and forgot. The MS stated not wearing the hairnet or beard guard could have caused contamination or hair to get in food. During an interview on 09/25/25 at 12:29 PM, the DM stated she was responsible for training the dietary staff. She stated the dietitian was in the facility frequently and observed staff and educated as needed. During an interview on 09/25/25 at 2:15 PM, the CK stated everything in the pantry was dated and was good for three days once opened. She stated everything had to be in sealed containers. She stated bugs could get into open containers. She stated the open ham should not have been stored in bin with open containers of cheese. She stated staff were required to wear hairnets in the kitchen because the hair can get in the food or fly everywhere. During an interview on 09/26/26 at 3:45 PM, the ADM stated it was her expectation that food was stored in the right place and dated properly. She stated a package, once opened was dated then kept in a sealed container. She stated if food were not stored properly, it could cause everyone to get sick. The ADM stated it was her expectation that hairnets or beard guards were worn any time staff were near a food prep area. The ADM stated the DM was responsible for training the dietary staff. Review of the in-service titled Labeling and Dating provided by the DM and dated 07/28/25, reflected, Label all non-identifiable food items. Date all Open / Prepped / Leftover food items. Date LEFTOVER items as follows: Open or prep date / 3 Day DC date. Example: [NAME] Beans P: 05/16/18 / D: 05/18/18. Note: Dressings / Cheese / Mayo - Open Date / DC + 1 month. Review of the Food Receiving and Storage policy, revised November 2022, reflected in part, Dry Food Storage 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Refrigerated/Frozen Storage 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 3 of 4 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 12/01/2025 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 frozen, or discarded. Review of the Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices Policy, dated October 2017, reflected in part, 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455917 If continuation sheet Page 4 of 4