Health inspection·November 30, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of Residents #10 and 18's room on 11/28/23 at 11:41 AM revealed the air-conditioned unit had black dirt particles along the vents. Observation of Resident #22's room on 11/28/23 at 11:47 AM revealed the bathroom floor under the sink had thick white dust all over the floor and bathroom cabinet walls. A corner of the bathroom floor, near the toilet, had thick white dusts that was about 2 feet in diameter. The room floor had thick white patches of dust under a chair, around a desk, and near a credenza. The wall near the resident's bed had black spill stains new the lower portion of the wall. There were three large white towels under the air-condition unit, which maintenance advised was due to a small leak under the unit. Observation of Resident #32's room on 11/28/23 at 11:56 AM revealed a lower wall in the corner of the resident's room had deep scrape marks and black drag marks along the wall. The wall also had black stains and marks sprayed all over the wall. Observation of Residents #11 and #26's room on 11/28/23 at 12:14 PM revealed the air-conditioned unit had black dirt particles along the vents. One of the nightstands had a stethoscope and blood pressure monitor sitting on the top of it. Observation of Resident #59's room on 11/28/23 at 12:20 PM revealed, the air-conditioned unit had black dirt particles along the vents. Interview on 11/30/21 at 01:54 PM with the Housekeeping Supervisor, she stated she had been at the facility for over a year. She stated she trained the staff to clean rooms by walking them through everything that needs to be cleaned in the room. She stated staff was to clean everything in the room including the air condition unit and sweep and mop the floor. She stated she checked the rooms and if anything is not done, she would contact the housekeeper to finish it. She stated she had no staffing concerns. She stated the handrails were cleaned every morning . She stated she had advised her staff that if the resident gave them any resistance in cleaning her room, they are to get her, and she would get a nurse involved to get the resident's room cleaned. She stated the risk of not cleaning the residents' rooms thoroughly could result in residents getting sick. Interview on 11/30/23 at 02:13 PM with Housekeeper L, she stated she had just started on 11/26/23. She stated she was trained to clean everything in the room. She stated the Housekeeping Supervisor trained her on what to clean for the first two days. She stated she had experience from previous cleaning jobs. She stated housekeeping are to clean the handrails at least every other day . She was shown pictures of the concerns observed in the residents' rooms and hallways and she stated they are to clean all the areas observed. She stated she had not had a resident on her hall that refused cleaning. She stated she cleans the 200 hall and split the 300 halls. She stated the risk of not cleaning the rooms thoroughly could result in residents getting sick. Interview on 11/30/23 at 03:33 PM with the Administrator, she stated she had been at the facility since June 2023. She stated they completed rounds, which consisted of the key leadership being assigned rooms to conduct daily observations. She stated key leadership consisted of her the DON, ADON, Social Worker, Activity Director, and Maintenance Director. She stated the observations consisted of leadership checking in with the residents see if there were any grievances, check for cleanliness of rooms, and check for any maintenance being required. She stated that that should be done every morning, and findings are discussed during morning meetings. She stated the risk of rooms not being clean could impact their health. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 2 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's policy on Homelike Environment (February 2021) revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 3 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carryout activities of daily living received services to maintain grooming and personal hygiene for 1 of 3 residents (Resident #8) reviewed for quality of life. Residents Affected - Few The facility failed to provide Residents #8 with routine showers. These failures could place residents at risk for and a decreased quality of life. Findings included: 1. Record review of Resident #8's MDS assessment, dated 10/03/23, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included heart failure, renal failure, diabetes, seizure disorder, obesity. Section G of the MDS which described care required for bathing was not completed. Record review of Resident #8's Care Plan, dated 07/09/22, reflected: The resident had an ADL self-care performance deficit related to activity intolerance, impaired balance, and limited mobility. Facility interventions included bathing/showering: The resident required extensive assistance of one staff to bathe/shower 3 times a week and as necessary. Record review of Resident #8's Point of Care ADL Category Report dated 11/02/23 - 11/28/23 indicated the resident received a total of 4 baths/showers. An observation on 11/28/23 at 11:37 AM with Resident #8 revealed she was lying in a bariatric bed. She appeared to be groomed. She was alert and oriented but would lose her train of thought. She said she had not been bathed in 2 weeks because the facility did not want to bathe her or were understaffed. She said she was supposed to be bathed on the 2:00 PM - 10:00 PM shift . An interview on 11/20/23 at 10:30 AM with CNA E for Resident #8 revealed she would often bathe the resident but sometimes Resident #8 was not bathed because staff would get confused with which shift was supposed to bathe her. An interview on 11/29/23 at 3:42 PM with the ADON for Resident #8 revealed the resident was supposed to be bathed on Tuesdays, Thursdays, and Saturdays and the resident would fluctuate on the day and evening shift. The ADON said according to her paper shower sheets, Resident #8 received a bath on: 11/2/23 - bath 11/4/23 - bath 11/7/23 - bath (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 4 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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 0677 11/9/23 - bath Level of Harm - Minimal harm or potential for actual harm 11/11/23 - bath 11/14/23 - bath Residents Affected - Few 11/16/23 - bath 11/18/23 - missed bath 11/21/23 - bath 11/23/23 - missed bath 11/25/23 - bath 11/29/23 - bath The ADON said there was no documentation to show the resident was bathed on 11/18/23 and 11/23/23 as scheduled. The ADON said the risk of not receiving baths/showers as scheduled was skin breakdown. Record review of the facility policy, Activities of Daily Living, not dated, reflected: Policy Statement Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 5 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide an environment that was free from accident and hazards to prevent accidents for 1 (Resident #10) of 6 residents reviewed for accidents free of hazards. The facility failed to ensure Resident #10 had a smoking assessment completed since admission to the facility on [DATE]. This failure placed the residents at risk of accidents and hazards. Findings Included: Record review of Resident #10's Face Sheet, dated 11/30/23, revealed she was an 89 -year-old female admitted on [DATE]. Relevant diagnoses included muscle wasting and atrophy, mild cognitive impairment, and lack of coordination. Record review of Resident #10's MDS dated [DATE] revealed the resident's BIM was 05 (Severe Cognitive Impairment). Record Review of the Resident #10's Care Plan dated 10/23/23 revealed the resident was care planned for being a smoker and an intervention included evaluating the resident for safe smoking. Record review on 11/29/30 for Resident #10's smoking assessment in the facility's system of records revealed no smoking assessment on file for the resident. On 11/29/23, a request was made for the facility to provide a smoking assessment for Resident #10 and one was provided showing a completion date of 11/29/23, which required the resident to wear a smoking apron. Interview on 11/30/23 at 12:11 PM with the ADON, she stated smoking assessments were done upon admission by the nurses and the MDS populated when they are due, but she did not recall the frequency of the smoking assessments. She was advised that Resident #10 did not have a smoking assessment on file. She stated she was not sure why the resident had no smoking assessment on file. She stated the charge nurse on duty at the time of the resident's admission should complete the assessment if the resident is identified as a smoker. She stated the risk of the resident not having a smoking assessment could result in resident harming herself. Interview with the Administrator on 11/30/23 at 03:33 PM, she stated she had been at the facility since June 2023. She stated that all residents identified as a smoker must have a smoking assessment completed upon admission into the facility. She stated she was aware Resident #10 was a smoker, but she did not think she really smoked much because of a change in her condition. She stated the charge nurse on duty was responsible for ensuring smoking assessments are completed if needed. She stated the risk of a smoking assessment not being completed could result in the resident injuring herself while attempting to smoke. Record review of facility policy on Smoking Assessments, dated 10/2022, It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 6 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 as being safe for facility smoking privileges. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 7 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents (Resident #13) reviewed for nutrition and hydration. Residents Affected - Few The facility failed to assess Residents #13's weight on a weekly basis per the resident's care plan and the resident experienced an 11% weight loss in a 3-month period. This failure could place resident at risk of experiencing a decline in health due to malnutrition. Findings included: Review of Resident #13's MDS assessment, dated 10/13/23, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE]. Her cognitive status was severely impaired. The resident's diagnoses included anemia, osteoporosis, non-Alzheimer's dementia, and malnutrition. Her weight was 78 pounds and 63 inches tall. The resident was on a pureed diet. Record review of Resident #13's Care plan, revised 07/27/22, reflected the resident had unplanned/unexpected weight loss. Facility interventions included: Alert dietician if consumption is poor for more than 48 hours. Give the resident supplements as ordered. Alert nurse/ dietitian if not consuming on a routine basis. If weight decline persists, contactphysician and dietician immediately. Labs as ordered. Report results to physician and ensure dietician is aware. Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. Monitor and record food intake at each meal. Offer substitutes as requested or indicated. Weigh at same time of day and record: Weekly on Sundays at 8 am. Review of Resident #13's Physician's Orders dated 11/16/23 reflected: Ensure Clear or Boost Breeze 1 carton two times a day as available. Prostat (protein supplement) at bedtime, may add to nectar thick juice or water. Regular diet, Pureed texture, Nectar Thickened consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 8 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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 0692 Record review of Resident #13's Weight Summary reflected: Level of Harm - Minimal harm or potential for actual harm 11/21/23 72.0 lbs Residents Affected - Few Mechanical Lift 11/14/23 72.0 lbs Mechanical Lift 11/8/23 75.4 lbs Wheelchair 11/7/23 72.0 lbs Mechanical Lift 10/24/23 73.0 lbs Mechanical Lift 10/6/23 77.8 lbs Wheelchair 09/5/23 81.0 lbs Wheelchair From 09/05/23 to 11/21/23 on the facility's system of records indicated the resident experienced a 11% weight loss in a 3-month period. Review of a Nutrition nurse notes for Resident #13 reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 9 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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 0692 11/10/2023 11:32 AM /Dietary Note Level of Harm - Minimal harm or potential for actual harm Note Text: Nutrition Progress Note Residents Affected - Few Current diet: Regular, puree textures, nectar thick liquids, large protein portions, additional bread portion. Avg. intake 50-75% of meals. Small spoon. Super cereal at breakfast, encourage 4-8 oz nutrients to limit TID, Arginaid (protein supplement) BID, Prostat 30ml TID, 30 ml HS, snacks BID. Medications: iron-vitamins, probiotic, vitamin C, zinc, multivitamin. Height: 63 inches, weight: 72 lbs 11/7/23, 75.4 lbs 11/8 , BMI 13.4. Significant weight loss of 7.4% for 1 month - October 2023 weight of 77.8 lbs, 9.7% 3 months - August 2023 weight of 79.8 lbs and 15.4% from 6 months - May 2023 weight of 85.2 lbs. Assisted with meals. Recommend: Trial ensure clear or boost breeze twice a day as available - milk free. Monitor weights for stability. Goal: Weight stable: +/- 1-3 lbs/month. Skin: healing/improvement. - Dietician An observation and interview on 11/28/23 at 11:22 AM of Resident #13 revealed she was lying in bed. She was severely thin. She was confused but able to say she was doing ok . An interview with CNA A on 11/20/23 at 9:53 am for Resident #13 revealed she would assist the resident with her meals. CNA A said she thought the resident was losing weight because some days she would not eat regularly, and she would spit out her food or choked on it. CNA A said the resident required supplements when she did not eat . An interview with the WCN on 11/29/23 at 2:46 PM for Resident #13 revealed the resident was difficult to feed. She said the resident had to be fed a certain way or she would throw up her food. She said staff had to be very careful with their spoon sizes. An interview with the ADON on 11/30/23 at 12:22 PM regarding Resident #13 revealed she did not know the resident's care plan indicated she was supposed to be weighed weekly . The ADON said the resident would eat 100% of what she was fed. The ADON said the resident was at risk for deterioration if her weight was not monitored carefully. An interview with the Dietician on 11/30/23 at 3:20 PM regarding Resident #13 revealed she said the resident was losing weight because she was of advanced age, had dementia, and required assistance with meals . The Dietician said she did not know why the resident was not being weighed weekly and that decision was up to the facility. Record review of the facility policy, Weight Management, reviewed on 01/17/23, reflect: Standard: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents . Additionally, the interdisciplinary team will assure that below tasks are accomplished . Care Planning revisions . Ongoing follow-through on resident's status once the interventions have been implemented . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 10 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on record reviews and interviews, the facility failed to employ a certified Dietary Manager or a qualified fulltime dietitian or other clinically qualified nutrition professional for the facility's only kitchen. Residents Affected - Many The facility failed to ensure the Dietary Manager met all required state guidelines or employed a full-time dietician, who also assisted in managing the facility kitchen's daily food and nutrition services. This failure could impact a resident's ability to receive acceptable and appropriated food and nutrition services. Findings include: Record review of the facility's documents for a Qualified Dietary Manager revealed the Dietary Manager had not completed qualified certification course that met the requirement of a qualified nutrition professional . The Dietary Manager and facility produced a college enrollment form for the Dietary Manager courses starting from 03/15/23 and completing on 06/20/24. Interview with the Dietary Manager on 11/30/23 at 02:05 PM, she stated she was a cook at the facility before being promoted to the Dietary Manager in March 2023. She stated she was very familiar with food storage and kitchen sanitation guidelines, and she always trained the kitchen staff on the guidelines as well. She stated she had started a Dietary Manager course in March 2023 and was scheduled to be completed in June 2024. She stated she was aware of the risks of the facility not having a qualified dietary manager could result in residents missing out on proper nutrition services. Interview with the Dietitian on 11/30/23 at 03:20 PM, she stated she had been contracted by the facility since 2020. She stated she was not involved in the management of the facility's only kitchen, and she visited the facility as least quarterly. Interview with the Administrator on 11/30/23 at 03:33 PM, she stated she had been at the facility since June 2023. She stated she was aware that the Dietary Manager was currently not a qualified dietary manager. She stated the facility had enrolled the Dietary Manager into a course to complete her certification and she was scheduled to be completed in June 2024. She stated she works closely with the Dietary Manager to ensure the kitchen was meeting all guidelines; however, she understood that the risk of the facility not having a qualified dietary manager could result in residents missing nutrition services and proper kitchen sanitation. The Administrator stated she had not documents related to qualified dietary manager requirements. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 11 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerators, and freezer were labeled ( labeled identifying items in the container) and dated ( the use by date was not documented) according to guidelines and in a sanitary manner. The facility failed to ensure damaged foods were discarded according to guidelines. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 11/28/23 from 09:15 AM to 09:25 AM in the facility's only kitchen revealed: Six individually wrapped ham and cheese sandwiches were undated in the refrigerator. Five large pitchers of juices were unlabeled and undated in the refrigerator. One large, long tube of ground beef, in its original packaging, in the refrigerator and was undated . Seven small bowls of fruits (miscellaneous) in the refrigerator were exposed to foodborne illnesses, and undated. Four loaves of white bread located in the dry storage area were undated and there were no visible expiration dates. One 6.6 LB. can of spaghetti sauce had a large dent. Interview with the Dietary Manager on 11/30/23 at 02:05 PM, she stated she had been a cook at the facility before being promoted to Dietary Manager in March 2023. She stated she was not a certified Dietary Manager but had started a dietary manager college course in March 2023. She was advised of the finding in the facility's only kitchen of food not being proper labeled and dated, and cans with dents. She stated that everyone in the kitchen is responsible to ensure foods are labeled and dated appropriately. She stated they check for dented cans weekly and somehow missed the one can. She stated she would in-service her staff on the concerns to ensure that the concerns were corrected moving forward. She stated the risk of these concerns not being addressed could result in the residents getting sick . Interviews with the Administrator on 11/30/23 at 03:33 PM, she stated she had been at the facility since June 2023. She stated she had met with her Dietary Manager and was advised of the concerns observed in the kitchen. She stated she and the Dietary Manager had worked together to resolve a lot of the concerns previously observed in the kitchen in the past. She stated she was confident progress was being made and they would focus on the concerns reported. She stated the risk of not addressing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 12 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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 the concerns could result in food contamination and residents getting sick. Level of Harm - Minimal harm or potential for actual harm Record Review of the Facility's policy on Food Storage and Supplies dated October 2022, revealed Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date ). Residents Affected - Some Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 13 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to obtain from hospice the most recent hospice plan of care specific to each patient needs for 1 of 3 residents (Resident #59) reviewed for hospice services. The facility failed to ensure Resident #59's hospice care was care planned. This failure could place residents at risk of needs not being met. Findings include : Record review of Resident #59's Face Sheet, dated 11/30/23, revealed he was a 93 -year-old male admitted on [DATE]. Relevant diagnoses included Permanent Atrial Fibrillation (irregular heartbeat), and Rheumatic Tricuspid Insufficiency (heart valve complications ). Record review of Resident #59's records in the facility's system of records indicated the resident was moved to hospice services on 10/12/23 . Review of Resident #59's Comprehensive Care Plan revised on 08/24/2023 reflected no care plan for hospice care. Interview on 11/30/23 at 11:45 AM with Social Services, she stated she that it was primarily the MDS Nurse's responsibility to enter data such as a resident receiving hospice care, and she was the backup. She stated that Resident #59 was on hospice, and he should have been care planned for it. She stated that they were still working on a process to ensure care plans are updated timely and appropriately. She stated the risk of the resident not being care planned for hospice could result in missed care. Interview on 11/30/23 at 12:11 PM with the ADON, she stated she had been the ADON for a year. She stated Resident #59 was receiving hospice care and it should be care planned. She stated that she was unsure how it was overlooked during their care plan meetings, and she stated that it was the responsibility of the MDS Nurse to update any changes to the care plan. She stated the risk of the resident not having the hospice services could result in the resident not receiving all of the care hospice provided. Interview on 11/30/23 at 01:00 PM with the MDS Nurse, she stated she was not aware that Resident #59 was on hospice and was just made aware of this on 11/29/23. She stated she did not know how the resident was overlooked. She stated they usually received communication from the business office that the resident had been placed into hospice and then they are notified, and the hospice is care planned. She stated she had updated the resident's care plan to reflect the hospice care. She stated the risk of the resident not having hospice services care planned it that the resident may miss out of services he should be receiving. Record review of facility's policy on Care Planning, dated January 2023, stated The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 14 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #20 and Resident #39) of 4 residents reviewed for incontinence care. Residents Affected - Some 1. The facility failed to ensure CNA B performed hand hygiene while providing incontinence care to Resident #20. 2. The facility failed to ensure CNA C performed hand hygiene while providing incontinence care to Resident #39. This failure could place residents at risk of cross-contamination resulting in infections. Findings include: 1. Review of Resident #20's MDS assessment, dated 09/14/23, reflected the resident was a [AGE] year old female admitted to the facility on [DATE]. Her cognitive status was severely impaired. She was always incontinent of bladder and bowel. Her diagnoses included diabetes and Alzheimer's disease. An observation and interview on 11/29/23 at 2:28 PM revealed CNA B was preparing to perform incontinence care for Resident #20. CNA B cleaned the peri-area that had stool, grabbed a new brief, turned the resident to her side, cleansed buttocks of stool, and put the new brief in place. The WCN was in the room and asked CNA B if she was going to perform hand hygiene and CNA B said yes, and washed her hands. CNA B said she did not perform hand hygiene because she was in a hurry and did not get to get all of her supplies needed for incontinence care beforehand. CNA B said hand hygiene was important to prevent infection. 2. Review of Resident #39's MDS assessment, dated 09/14/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. She was frequently incontinent of bladder and bowel. Her diagnoses included heart failure, diabetes, and non-Alzheimer's dementia. An observation and interview on 11/30/23 at 01:09 PM with CNA C revealed she was prepared to perform incontinence care for Resident #39. CNA C cleaned the resident's peri-area, performed hand hygiene, and put on new gloves. The resident was rolled to her right side and CNA C cleansed urine off the resident's buttocks. CNA C did not perform hand hygiene. CNA C placed a new brief on the resident. CNA C said she did not realize she did not perform hand hygiene when going from dirty to clean but had been trained to. She said hand hygiene was important for infection control. An interview with the ADON on 11/29/23 at 3:33 PM regarding Resident #20 and Resident #39 revealed hand hygiene was supposed to be performed when going from a dirty area to a clean area and hand hygiene was important to prevent infections. Record review of the facility policy, Infection Prevention and Control Program, reviewed 2023, reflected: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 15 of 16 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 455930 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Ridge Rehabilitation and Healthcare Center 1700 N Washington Pilot Point, TX 76258 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Policy Statement Level of Harm - Minimal harm or potential for actual harm An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection . Residents Affected - Some Employee Training on Infection Control . a. Standard precautions, including hand hygiene . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455930 If continuation sheet Page 16 of 16