Inspection·November 30, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Breakfast consisteds of a regular puree diet. Observation indicated no teeth in her oral cavity. An Aattempt was made to have an interview, but she did not answer. During an interview on 11/29/23 at 1: 00PM, Resident #5 said she wanted to go to bed. She spoke very few words. She said she does not have any teeth and no dentures. Residents Affected - Some Resident #41 Record review of Resident #41's face sheet, dated 11/28/23, revealed [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, unspecified protein-calorie malnutrition, retention of urine, viral pneumonia, covid-19, altered mental status (confusion) , essential hypertension, major depressive disorder, dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and muscle weakness lack of coordination. Record review of Resident # 41's Quarterly MDS assessment dated [DATE] revealed a BIMs score of 3 which indicated severely impaired cognition. Section J for, fall history reflected the section was not coded. This section was left blank. Record review of the facility's 6 months accident and incident history (July 1st through November 20th), indicated Resident #5 had an unwitnessed fall without injury on 06/29/23. Record review of the nurses note dated 9/9/2023 10:48PM, reflected in part-: unwitnessed fall -Vitals: 165/87 P76 R18 T97.6 , head to toe skin check-no new issue pain level 6 .all responsible parties notified . No new orders. Resident # 47 Record review of Resident #47's electronic face sheet, dated 11/28/23, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included, Hip fracture, type 2 diabetes mellitus, essential hypertension, osteoarthritis (bone disease), displaced intertrochanteric fracture of right femur , bipolar disorder, depression, major depressive disorder, recurrent, severe with psychotic symptoms, insomnia (lack of sleep), pain, muscle weakness, cellulitis , abscess of mouth, difficulty in walking and abnormal weight loss. Record review of Resident # 47's significant change MDS dated [DATE] revealed Resident # 47 had a BIMs score of 12 which indicated moderately impaired cognition. Record review of section J for, fall history reflected it was not coded. This section was left blank. = Section L for oral/dental reflected no issue. Record review of Quarterly MDS assessment dated [DATE] revealed a BIMs score of 13 indicated intact cognition. Record review of section J, fall history was not coded. This section was left blank. Record review of Resident #47's care plan dated 10/13/23 reflected in part, potential for impaired chewing r/t poor dental condition abscessed tooth. Goals: Resident will be able to always chew food adequately through next 90day review Date Initiated: 10/13/2023 Revision on: 11/17/2023 Target Date: 02/27/2024. Interventions: Antibiotic as ordered. Date Initiated: Monitor for s/s of oral pain/discomfort such as verbal c/o pain, poor oral intake, inability to chew Obtain order for dental consult. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675556 If continuation sheet Page 2 of 9 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 675556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Woods Care Center 135 1/2 Hospital Dr Angleton, TX 77515 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of facility's accident and incident history from From June 1st through November 25th indicated Resident #47 had falls as followedon 07/21/23 and 11/01/23 had a fall on 09/09/23. Observation on 11/28/23 revealed Resident # 47 was in the dining room for breakfast and her breakfast was a mechanically altered diet. Observation indicated she had some missing teeth. She did not answer too many questions but said she did not have any dentures. She said she had tooth pain on and off but her rResponsible party usually tooktake care of it. During an interview with the MDS Coordinator on 11/30/23 at 3:00PM, she said Resident #5 did not have any teeth in her mouth and did not have any dentures looked at the MDS and said it should have been coded as no natural teeth or edentulous . She said she overlooked the fall assessment and would make an addendum to the indicated MDS. She said inaccurate assessments could prevents from getting the necessary care needed. She said the facility diddoes not have policy on MDS assessments but followeds the resident assessment manual recommended by CMS. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675556 If continuation sheet Page 3 of 9 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 675556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Woods Care Center 135 1/2 Hospital Dr Angleton, TX 77515 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan describing services (Resident #45 was care planned for thickened liquids while receiving thin liquids) that are to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 15 residents, (Resident #45) reviewed for care plan revision and completion. Resident #45's care plan was not revised to accurately reflect his current nutritional needs for fluid intake. Resident #45 was care planned for thickened liquids while receiving thin liquids. This failure placed residents at risk of not receiving appropriate or accurate nutritional needs. Findings include: Record review of Resident #45's admission Record revealed a [AGE] year-old male who admitted on [DATE] and was diagnosed with peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce the flow of blood to the limbs of the body), Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity and slow imprecise movement), hyperlipidemia (abnormally high concentration of fats or lipids in the blood), and cerebral infarction (condition caused by disrupted blood flow to the brain). Record review of Resident #45's Quarterly MDS assessment, dated 10/02/2023, revealed the resident's BIMS score was a 13 out of 15 indicating he was cognitively intact for daily decision making. Further review of Section K -Swallowing/Nutritional Status K0300. Weight Loss . Loss of 5% or more in the last month or loss of 10% or more in the last 6 months, was coded as 2. Yes, not on physician-prescribed weight loss regimen. Record review of Resident #45's undated care plan, revealed the following: Focus .Potential for altered nutritional needs .Goal .Resident will have no significant weight change of > 5% in 1 month, >7.5% in 3 months, or >10% in 6 months .Date Initiated: 07/06/2023 .Target Date: 01/15/2024. Interventions .Diet and food texture provided as tolerated CCD mechanical soft diet, health shakes .nectar thick liquids .Date Initiated 07/06/2023 .Revision on: 08/16/2023. Record review of Resident #45's Medication Review Report dated 11/30/23 revealed the following physician's order: Consistent Carbohydrate (CCD) diet Dysphagia Level 3 Advanced texture. THIN (Regular) 1 consistency, large portion .Order Status .active .Start Date .08/21/2023. Observations of Resident #45 on 11/29/23 at 12:38 pm revealed he was in the main dining room for the lunchtime meal service, drinking thin liquids. His meal ticket attached to his meal tray served reflected: Dysphagia (difficulty or discomfort in swallowing), Level 3 Advanced Texture diet, thin (regular) 1 consistency, large portion. Interview with the DON on 11/29/23 at 1:12 pm, who said that the MDS Coordinator was responsible for both acute, quarterly, and annual care plans. The DON said that nursing staff would complete care plans if the MDS Coordinator was off. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675556 If continuation sheet Page 4 of 9 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 675556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Woods Care Center 135 1/2 Hospital Dr Angleton, TX 77515 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 11/29/23 at 1:17 pm with MDS Coordinator, who said that all the nurses helped complete resident care plans. The MDS Coordinator said that she sometimes completed the acute resident care plans but mostly completed the care plans when she completed the residents scheduled assessments such as quarterly and annual assessments. The MDS Coordinator said that she used the RAI manual as the policy, procedure, and guidance for the completion of all care plans. She said that the undated care plan for Resident #45, she provided on 11/30/23 was the most up to date care plan for Resident #45 and was the revised care plan for Resident #45 because it had the revision date on it. The MDS Coordinator did not know why Resident #45 was still care planned for Nectar thick liquids. The MDS Coordinator said she did not know exactly who was supposed to update the information regarding Resident #45's nectar thick liquids and said that the risk to the resident could be that he would not receive the correct liquids to drink. Record review of undated facility policy and procedure titled Comprehensive Assessments and the Care Delivery Process revealed in part: a. Assess the individual. (1). Gather relevant information from multiple sources, including a). Observation .(d). Resident and family interview; (f). Consultant reports; and (h). Evaluations from other disciplines (for example, dietary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675556 If continuation sheet Page 5 of 9 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 675556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Woods Care Center 135 1/2 Hospital Dr Angleton, TX 77515 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 the professional standards for food service safety and failed to ensure that one of one dish washing machine in the kitchen had a readable hot water gage in 1 of 1 kitchen observed for kitchen sanitation. -The facility failed to ensure that cooking utensils were kept clean and in proper working order. -The facility failed to ensure foods items in the walk-in cooler were properly stored, labeled (missing label identifying items in the bag), and dated (date prepared or date expired). -The facility failed to ensure that expired food products were removed from the walk-in cooler and dry good storage area. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation of the facility's kitchen on 11/28/23 between 6:15AM and 6:50AM with [NAME] A revealed the following: One of one can opener had dark built-up substances around the cutting blade and the blade holder. The vent hood above the stove had grease build up. One of one deep fryer had dark cooking oil and brown floating substances on top of the grease. Observation of the walk-in cooler revealed the following items, and all unlabeled and undated food products were identified by [NAME] A: Half a bag of shredded carrots and purple cabbage were placed together in a plastic bag unlabeled and undated. Leftover uncooked rolls in a plastic bag that was unlabeled and undated. Two cartons, 28 oz of thickened lemon-flavored water had a manufactural stamp date of used by 11/15/23. Observation of the walk-in freezer revealed a 16-inch pan of angel food cake stored underneath the condenser that had ice built up. Observation of the dry goods storage revealed: 3 bottles of 32 oz of foam concentrated lemon juice dated use by 07/14/23. 3 cartons of 28 oz of creamy rice dated use by 04/23/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675556 If continuation sheet Page 6 of 9 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 675556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Woods Care Center 135 1/2 Hospital Dr Angleton, TX 77515 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 10 cartons of 28 oz of thickened apple juice dated use by 11/11/23. Level of Harm - Minimal harm or potential for actual harm During an interview with the DM on 11/28/23 at 11:00AM, she said all food in the walk-in refrigerator and the cooler should be dated and labeled. She looked at the expired food products and said she would trash them. She started removing them from the shelves. She said serving expired food products could lead to food poison and sickness. She said the deep fryer grease was supposed to be changed every Sunday, but she did not have enough grease to change the grease in the deep fryer. She did not answer to when the last time the grease was changed. The DM said the oven hood was cleaned last in August of 2023 and was due for cleaning in October of 2023. Record review of the stamped date on the vent 11ood indicated the oven hood should be cleaned every three months. She said the ice built up on the cake was from the condenser because there are always ice buildup in the morning and the staff had to scrape the ice off the door of the walk in-freezer every morning. Residents Affected - Many In an interview with the facility Administrator on 11/28/23 at 1:00PM, he said the contractor that was schedule to clean the oven hood had another job at a local hospital and they were engaged with that job. Observation on 11/29/23 at 2:00PM revealed one of one dishwashing machines in the kitchen was washing at an unknown temperature with a PPM reading of 200. The temperature gage on the dishwashing machine was not readable. Record review of the temperature log dated 11 /01/23 through 11/30/23, indicated the dish washing machine wash and rinse daily at a temperature of 120-degrees Fahrenheit and sanitized at a PPM reading of 200. In an interview with [NAME] B on 11/29/23 at 2:15PM, he said he used the strips to test the water and compared the result with the range. He did not answer the question of how he determined the water temperature. In an interview with [NAME] C on 11/28/23 at 2:20PM, she said the temperature gage did not work and she had told the company representative several times that the temperature gage was bad and needed to be changed. She said the dishwasher was a low temperature machine and was supposed to wash and rinse at 120-140-degrees Fahrenheit. No answer was given about the recorded reading of 120-degrees Fahrenheit. In an interview with the cooperate Manager on 11/29/23 at 2:22PM, he said not knowing the correct temperature could result in the dishes not washing and sanitating correctly. Record review of the facility's food service policy revised 9-2017 reflected in part, .All foodservice equipment will be clean, sanitary, and in proper working order. Procedures: 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675556 If continuation sheet Page 7 of 9 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 675556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Woods Care Center 135 1/2 Hospital Dr Angleton, TX 77515 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 2. Level of Harm - Minimal harm or potential for actual harm All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. Residents Affected - Many All food contact equipment will be cleaned and sanitized after every use. 4. All non-foods contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Dining Services Director will notify the Administrator when repairs are completed. 7. Copies of service repairs and preventative maintenance reports will be submitted monthly. Food label: Guidelines for Labeling and Dating o All foods should be dated upon receipt before being stored. o Food labels must include: o The food item name o The date of preparation/receipt/removal from freezer o The use by date as outlined in the attached guidelines (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675556 If continuation sheet Page 8 of 9 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 675556 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Woods Care Center 135 1/2 Hospital Dr Angleton, TX 77515 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 o Level of Harm - Minimal harm or potential for actual harm Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate use by date as outlined in the Retention Guide attached. (Example: A tube of ground beef). Residents Affected - Many o Leftovers must be labeled and dated with the date they are prepared and the use by date. Record review of the U.S. Public Health Service, Food Code, dated 2022, reflected the following, .3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (D) A date marking system that meets the criteria stated in (A) and (B) of this section may include .(2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (A) of this section; (3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded as specified under (B) of this section. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675556 If continuation sheet Page 9 of 9