Health inspection·December 21, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record review, the facility failed to ensure the resident's right to secure and confidential personal and medical records for one (unknown resident) of 31 residents. The facility failed on 12/20/25 to ensure the privacy of unknown residents by not locking the laptop screen on medication cart (1 of 2), so the residents' information could not be seen and/or accessed by someone walking by. This failure puts residents at risk for confidential health information exposure, psychosocial harm and decreased quality of life. The findings included: Interview and observation on 12/20/25 at 01:12 PM, RN B left her computer screen on her medication cart unlocked and unsupervised with unknown resident information while entering a resident's room during medication pass. She revealed she was supposed to lock her screen for resident privacy. Interview on 12/21/25 at 03:08 PM, the ADM and DON revealed the laptop on the medication cart needed to be locked due to HIPAA and to protect resident's medical information. Record review of facility's policy RESIDENT RIGHTS, undated, reflected Privacy and confidentiality- The resident has a right to personal privacy and confidentiality of his or her personal and medical records. 3. The resident has a right to secure and confidential personal and medical records. Residents Affected - Few Page 1 of 8 675929 675929 12/21/2025 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for three (Resident #1, 3, 4) of eight residents reviewed for pharmaceutical services. 1. The facility failed to ensure that RN D documented that she administered Hydrocodone-Acetaminophen Oral Tablet to Resident #3 on Resident #3's Narcotic Sheet.2. The facility failed to ensure Resident #1's tramadol HCl Oral Tablet was documented as administered on 12/16/25 and 12/17/25 as was reflected on Resident #1's Narcotic Sheet. 3. The facility failed to ensure 1 dose of Resident #4's Lorazepam Oral Tablet was wasted when the blister pack was punctured instead of taping the blister pack. This failure could place the residents at risk for medication errors and drug diversion. The findings included: 1. Record review of Resident #3's admission record, dated 12/21/25, reflected resident was a [AGE] year-old female initially admitted [DATE] and re-admitted [DATE] with diagnoses to include dementia and chronic pain syndrome. Record review of Resident #3's quarterly MDS assessment, dated 10/30/25, reflected Resident #3 had a BIMS score of 11 out of 15, reflecting moderate cognitive impairment. It further reflected that resident experienced pain occasionally in the past 5 days with her pain intensity being 2 out of 10. Record review of Resident #3's Order Summary Report, dated 12/21/25, reflected resident's order summary included Hydrocodone-Acetaminophen Oral Tablet 10-325 MG. Give 1 table by mouth every 6 hours for Pain, with start date 10/15/25. Record review of Resident #3's December MAR, accessed 12/21/25, reflected RN D administered Hydrocodone-Acetaminophen Oral Tablet to Resident #3 on 12/21/25 at 5 AM. Record review of Resident #3's Narcotic Sheet reflected RN D did not document that she administered Hydrocodone-Acetaminophen Oral Tablet at 5 AM. Record review of Resident #3's care plan, undated, reflected Resident has a potential for uncontrolled paid due to chronic pain, initiated 02/20/25, with intervention Give pain medication as ordered by [doctor]., revised 01/31/24. Interview on 12/21/25 at 11:12 AM, RN B revealed she took over the medication cart after RN D's shift. She revealed during shift change they should have caught that Resident #3's narcotic sheet was not updated to reflect that Resident #3 was given her 5AM dose and that the number on the narcotic sheet did not match the number of narcotics in the medication cart. She revealed the narcotic counts on the resident's count sheet needed to be the same as the amount in the medication cart. Interview 12/21/25 at 12:01 PM, RN D revealed she may not have filled out that she administered Hydrocodone to Resident #3 at 5 AM on the narcotic count sheet because sometimes she got too busy to document before she left the facility, but she did reveal that Resident #3 was given her 5AM dose of Hydrocodone. She revealed the number on the narcotic count sheet should match the number of narcotics in the medication cart during shift change, so that narcotics were accounted for. Interview on 12/21/25 at 02:05 PM, Resident #3 revealed she received her pain medication at 5 AM. She revealed she got her medication on time, and her pain was managed appropriately by the facility with no concerns. 2. Record review of Resident #1's admission record, dated 12/21/25, reflected resident was a [AGE] year-old female admitted [DATE] with diagnoses to include pain, chronic obstructive pulmonary disease (lung condition caused by damage to the lungs), malignant neoplasm (a cancerous tumor) of right female breast, secondary malignant neoplasm of right lung, and malignant neoplasm of upper lobe, left bronchus or lung. Record review of Resident #1's quarterly MDS assessment, dated 12/02/25, reflected Resident #1 had a BIMS score of 12 out of 15, reflecting moderate cognitive impairment. It further reflected that resident experienced pain frequently in the past 5 days with her pain intensity being a 4 out of 10. Record review of Resident #1's Order Summary Report, 675929 Page 2 of 8 675929 12/21/2025 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated 12/20/25, reflected resident's order summary included tramadol HCl Oral Tablet 50 MG. Give 1 tablet by mouth every evening shift related to chronic obstructive pulmonary disease, with start dated 12/05/25, and tramadol HCl Oral Tablet 50 MG. Give 50 MG by mouth every 6 hours as needed for Pain Record review of Resident #1's care plan, undated, reflected Resident requires hospice as evidenced by terminal illness: Malignant Neoplasm of Right breast, Secondary malignant Neoplasm of Right Lung and Malignant Neoplasm of upper lobe, left Bronchus or lung, initiated 12/05/25, with intervention 1. Monitor for [signs and symptoms] of increased pain, discomfort-give meds/tx. monitor for relief, revised 12/11/25. Record review of Resident #1's December MAR (accessed 12/20/25) when compared to Resident #1's narcotic sheet reflected tramadol HCl Oral Tablet 50 MG was administered on 12/16/25 at 8AM and 12/17/25 at 8AM on her narcotic sheet by LVN C, but was not reflected in her December MAR. Interview on 12/21/25 at 12:59 PM, LVN C revealed she forgot to document medications given in a residents' MAR. LVN C was unable to confirm blanks in Resident #1's MAR as she did not have access to Resident #1's medical record. LVN C revealed she sometimes will write down that she gave medication but did not get to document in MAR as the facility's workload got busy at times. LVN C further revealed it was important to document residents' administration records to keep track of what medication was administered, what time a medication was last given, and to not overdo any medication. 3. Record review of Resident #4's admission record, dated 12/21/25, reflected resident was an [AGE] year-old male admitted [DATE] with diagnoses to include anxiety disorder. Record review of Resident #4's annual MDS assessment, dated 12/05/25, reflected Resident #4 had a BIMS score of 6 out of 15, reflecting severe cognitive impairment. Record review of Resident #4's Order Summary Report, dated 12/21/25, reflected resident's order summary did not include Lorazepam. Record review of Resident #4's December MAR, dated 12/21/25, reflected Resident #4 stopped taking Lorazepam Oral tablet 0.5 MG. Give 1 tablet by mouth every 12 hours as needed for anxiety for 14 days. Record review of Resident #4's care plan, undated, reflected Resident has a mood problem r/t DX of Anxiety, initiated 07/22/25, with intervention Administer medications as ordered., dated 07/22/25. Record review and observation on 12/21/25 at 10:51 AM revealed Resident #4's blister pack covering the 30th tab of Lorazepam 1 MG was punctured with 1/2 tablet in the pack, but the blister pack was taped shut. It was revealed the order on the narcotic control sheet was: Take 1/2 tablet (0.5 MG) by mouth twice daily as needed for anxiety. It was further revealed that Resident #4's narcotic count sheet matched the number of narcotics in the medication cart and the blister pack in the medication cart was received on 10/03/25 and not used. Interview and observation on 12/21/25 at 11:12 AM, RN B revealed she was not sure if it was okay to tape a blister pack for narcotics after it was punctured. LVN E walked by this medication cart and revealed if the blister pack was punctured, they would not tape it shut as was observed with Resident #4's blister pack, but they would do a drug destruction because they did not want nurses to be taking these medications and it will also be considered taking the resident's money as the residents pay for these medications. LVN E further revealed they needed 2 nurses to witness and sign off when this happened. It was further observed that LVN E and RN B were wasting (disposing of) Lorazepam 0.5 MG tablet that was in the 30th slot of Resident #4's blister pack. Interview on 12/21/25 at 03:08 PM, the DON and ADM regarding Resident #1, the DON revealed it was important for nurses to update the residents' MARs so that nurses knew how much medication was given to residents to prevent over medication. Regarding Resident #3, the DON revealed the numbers on the residents' narcotics sheets needed to match the number of medications in the medication carts because controlled substances needed to be accounted for and she expected nurses to ensure these were updated before they leave after their shift. She further revealed nurses would be able to catch these discrepancies at shift change. 675929 Page 3 of 8 675929 12/21/2025 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Regarding Resident #4, the DON revealed blister packs for narcotics should not be taped. She revealed that if the blister pack was punctured, the narcotic should be wasted and witnessed by 2 nurses. The DON revealed this was important to ensure all narcotics were accounted for. Record review of facility's policy, Medication Administration and General Guidelines, dated 2025, reflected . 9. Except for single unit dose packet distribution systems, only the licensed or legally authorized personnel who prepare a medication may administer it. This person then records the administration on the residents MAR at the time the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.Record review of facility's policy, Medication Storage in the Facility, dated 2025, reflected .13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists. (sp) Record review of facility's policy Medication Administration Procedures, dated 2003, reflected . If a controlled medication is wasted it must be documented on the controlled accountability sheet for the medication and witnessed by nurses. Both staff members must sign on the accountability sheet verifying the drug was wasted. 675929 Page 4 of 8 675929 12/21/2025 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 8 residents (Resident #2). The facility failed to ensure RN B did not leave Resident #2's medications inside the resident's room for the resident to take unsupervised on 12/20/25. This deficient practice could affect residents who received medications for treatments and could result in less potent or an adverse effects and drug diversion. The findings included: Record review of Resident #2's admission Record, dated 12/21/25, reflected resident was a [AGE] year-old male initially admitted [DATE] and re-admitted [DATE] with diagnoses to include dementia (group of symptoms affecting memory, thinking, and social abilities, which interfere with daily life) and cortical age-related cataract (an area of the lens of the eye loses transparency). Record review of Resident #2's quarterly MDS assessment, dated 10/10/25, reflected Resident #2 had a BIMS score of 11 out of 15, reflecting moderate cognitive impairment. Record review of Resident #2's Order Summary Report, dated 12/21/25, reflected resident's order summary included Prolensa Opthalmic Solution 0.07% . Instill 1 drop in left eye one time a day for CATARACT SURGERY. With start date 12/08/25. Record review of Resident #2's care plan, undated, reflected Resident has impaired visual function, has DX of cataracts, resident wears glasses, initiated 05/29/24, with intervention to include Review medications for side effects which affect vision. PRN, revised 07/19/24. Interview and observation on 12/20/25 at 01:12 PM, RN B revealed Resident #2 had his prescribed eye drop medication at bedside. RN B revealed Resident #2 was not supposed to have his eye drops at bedside even though he may be able to administer them himself. RN B further revealed it could be possible that a resident could overdo their eye drops medication but this resident was aware so this would not happen. Interview on 12/21/25 at 03:08 PM, the DON and ADM revealed they were not aware if Resident #2 could self-administer his medications. (It was asked if they could find this care planned or if there was an assessment that he could self-administer his medications, but no records were identified.) The DON revealed if Resident #2 could not self-administer his medication, they needed to keep these medications on the medication carts and doctor's orders needed to be followed. Record review of facility's policy, Medication Administration and General Guidelines, dated 2025, reflected . 9. Except for single unit dose packet distribution systems, only the licensed or legally authorized personnel who prepare a medication may administer it. This person then records the administration on the residents MAR at the time the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. 675929 Page 5 of 8 675929 12/21/2025 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

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 for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to document temperatures that were taken from: 12/12/25 to 12/18/25 for Breakfast, Lunch, and Dinner and 12/10/25 to 12/11/25 for Lunch and Dinner.2. The facility failed to label discard dates on containers of jalapeno peppers, ketchup, and tartar sauce.3. The facility failed to clean the air conditioner vent in the kitchen. 4. The facility failed to store raw protein food items below fully cooked foods in the freezer. These failures could place residents at risk for food borne illness. The findings included: 1. Record review of HACCP Production Sheet-All Dining Locations, dated 12/12/25 to 12/18/25 for Breakfast, Lunch, and Dinner and 12/10/25 to 12/11/25 for Lunch and Dinner, reflected no temperatures of foods were documented for the foods served to residents. Interview on 12/20/25 at 05:25PM, the CDM revealed there were a few days where the temperatures were missing from the temperature logs for foods prior to meal service. He revealed this was the cook's responsibility, but he oversaw this task and was not aware the temperatures were not being taken prior to meal service. 2., 3., 4. Interview and observation on 12/20/25 at 10:42 AM reflected there was a container of jalapenos in the refrigerator dated 12/9 with no discard date and ketchup and tartar sauce dated 12/12/25 with no discard date. The CDM revealed the cook (unnamed) oversaw labeling, but he was supposed to make sure this task was done. The CDM revealed he was looking to hire another cook, but he was taking over the cook position in the meantime. It was observed that the air conditioner vent above closed cereal containers had black substances on it. The CDM revealed this needed to be cleaned but he was not sure who oversaw this. He revealed he would find out and get this cleaned. The CDM further revealed he had not been able to catch up with the cook's duties. Interview on 12/20/25 at 05:25PM, the CDM revealed there was uncooked chicken stored above pizza dough and cookie dough and uncooked proteins should not be above fully cooked products. Interview on 12/21/25 at 10:37 AM, [NAME] A revealed she was trained to take temperatures before meal service to prevent food poisoning, but it helped to get re-educated to refresh her knowledge. She revealed she needed to ensure raw proteins were not stored on top of fully cooked food products, because the juices could leak onto fully cooked food products and cause food poisoning. She revealed foods needed to be labeled with discard dates because food could smell good, but it could be bad to serve to residents and cause food poisoning. She revealed kitchen areas needed to be clean to prevent cross contamination. She revealed cold food products needed to be less than 41 degrees Fahrenheit to prevent food poisoning. She further revealed she had been in-serviced on all of this but sometimes they get in-serviced as needed. Interview on 12/21/25 at 10:42 AM, the CDM revealed since the air conditioning vent was in the kitchen he could ensure this was clean to prevent cross contamination. He revealed to prevent food poisoning he would need to ensure all temperatures were within recommended temperature range per policy. He further revealed raw proteins needed to not be stored above fully cooked foods to prevent food poisoning and cross contamination. He revealed he would make sure discard dates were on his food products, but that staff knew to throw out food after 3 days or depending on what the food is. The CDM revealed he needed to in-service his staff on all these concerns as a refresher, but all his staff were already educated on this. Interview on 12/21/25 at 03:08 PM, the DON revealed there was no pattern for any gastrointestinal issues for residents in the facility's infection control surveillance in the last 6 months. Record review of facility's policy Cleaning Schedules, dated 2012, reflected The dietary department and all equipment in the dietary department will be cleaned on a regular scheduled basis. Record Review of facility's policy 675929 Page 6 of 8 675929 12/21/2025 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Daily Food Temperature Control, dated 2012, reflected Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges. Record Review of facility's policy Food Storage and Supplies, dated 2012, did not reflect dating food products with an expiration date as was reflected in the FDA Food Code 2022. Record Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of the FDA Food Code 2022 reflected, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3- 403.11(E) may be held at a temperature of 54 C (130 F) or above; or (2) At 5 C (41 F) or less. Record review of the FDA Food Code 2022 reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and. Record review of the FDA Food Code 2022 reflected, 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from:. (d) Frozen, commercially processed and packaged raw animal FOOD may be stored or displayed with or above frozen, commercially processed and packaged, ready-to-eat food. 675929 Page 7 of 8 675929 12/21/2025 Cedar Creek Nursing and Rehabilitation Center 159 Montague Ave Bandera, TX 78003

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. 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 enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 1 resident reviewed, in that: The facility failed to maintain the temperature of Resident #1's personal refrigerator was at or below 41 degrees F 12/1/25 to 12/4/25 and was documented 12/5/25 to 12/19/25. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included:Record review of Resident #1's admission record, dated 12/21/25, reflected resident was a [AGE] year-old female admitted [DATE] with diagnoses to include constipation, protein-calorie malnutrition, and nausea. Record review of Resident #1's quarterly MDS assessment, dated 12/02/25, reflected Resident #1 had a BIMS score of 12 out of 15, reflecting moderate cognitive impairment. Interview and record review on 12/20/25 at 03:55 PM revealed Resident #1's Refrigerator Temperature log, dated December 2025, reflected temperatures on days 1 to 4 were 43 degrees Fahrenheit and temperatures for days 5 to 19 were not documented. Resident #1 revealed she had never gotten sick from her foods in her refrigerator. Interview on 12/20/25 at 05:20PM, the ADM and the CDM revealed the ADM instructed the ambassadors (persons in management that visited residents every morning and checked the temperatures of their refrigerators, about ensuring the residents' refrigerator temperatures should be 41 degrees Fahrenheit or less. They revealed the ambassadors will be doing a sweep on Monday of all the refrigerators to ensure all the refrigerators are within the appropriate temperature range. Record Review of facility's policy Personal Refrigerators Policy, dated 2012, reflected The refrigerator compartment should be maintained at a temperature of 35-41 degrees (Fahrenheit). Residents Affected - Few 675929 Page 8 of 8