Health inspection·March 22, 2024

F 0558 Record review of facility's, undated, policy titled, Call Lights, reflected, staff will ensure the call light is with in reach of of the resident and secured. 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: 676226 If continuation sheet Page 2 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0583 Keep residents' personal and medical records private and confidential. 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 the resident had the right to personal privacy and confidentiality of his or her personal medical records for personal privacy and confidentiality of residents' personal privacy and medical records for 1 of 15 residents (Resident #38) reviewed for residents rights. Residents Affected - Few The facility failed to ensure LVN M closed the door to provide privacy for Resident #38 while adminstering insulin. This deficent practice could place residents at risk of loss of privacy and dignity and decreased quality of life. The findings were: Record review of Resident #38's, undated, face sheet, reflected the resident was admitted to the facility 4/19/24. Resident #38 had diagnoses which included: brain aneurysm( a bulging, weakened area in a blood vessel in the brain), Hypertension (when the pressure in your blood vessels is too high) and diabetes mellitus (disease in which the body's ability to produce or respond to the hormone insulin is impaired). Record Review of Resident #38's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 11, which indicated cognition was moderately impaired. Record Review of Resident #38's Physician orders for March 2024, reflected an order for Humalog 100 unit /ml administer 8 units subcutaneously before meals. Record Review Resident #38's care plan dated, 2/1/24, reflected Care plan hyperglycemia risk for related to diabetes with intervention sliding scale as ordered. Record Review of LVN job description for [Name of Facility], undated, revealed staff is aware and adheres to the Patient [NAME] of Rights and confidentially of patient information, including HIPPA regulations. Observation and Interview on 3/21/24 at 11:04 a.m., LVN M administered 8 units of Humalog to Resident #38 in the abdomen and did not close the door to provide privacy. LVN M stated he forgot to close the door to provide privacy, which could negatively affect residents' dignity. Interview with Resident #38 on 3/21/24 at 11:05 a.m., revealed I would have preferred that nurse asked for my consent before exposing my abdomen . Interview with the ADON on 3/21/24 at 11:30 a.m., revealed LVN M should have closed the door to provide privacy before administering insulin to Resident # 38. Record review of the facility's undated, LVN job description reflected staff is aware and adheres to the Patient [NAME] of Rights and confidentially of patient information, including HIPPA regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 3 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 - Few 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 interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 29 residents (Resident #88) reviewed for care plans. The facility failed to develop a care plan to address Resident #88's smoking behavior. This failure could have placed residents at risk of not having their needs identified and met. The findings were: Record review of Resident #88's face sheet, dated 3/20/24, revealed an admission date of 10/03/2023 with diagnosis that included: unspecified cerebrovascular (a condition in which not enough blood supply was reaching the brain), type 2 diabetes (a condition in which the body's blood sugar was not controlled), and hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Record review of Resident's #88's Quarterly MDS assessment, dated 1/26/24, revealed a BIMS score of 11 which indicated moderately impaired cognition. Record review of Resident #88's Safe Smoking assessment dated [DATE] revealed Resident # 88 was considered a safe smoker. Record review of Resident #88's nursing progress note dated 2/11/2024 revealed the resident's family stated they would be bringing cigarettes to the facility on 2/11/24 for the resident's use. Record review of Resident #88's ongoing care plan initiated on 12/7/23 revealed that the Resident's smoking behavior was not documented in the care plan. During an interview with LVN-MDS-A on 3/20/24 at 10:50a.m., she stated that Resident #88 began smoking on 2/11/24. She stated the current ongoing care plan should have been updated to reflect the smoking behavior in order to provide a complete picture of all of the resident's behaviors. During an interview with the Assistant Director of Nurses (ADON) on 03/20/24 at 11:20am she stated she had completed the resident's safe smoking assessment on 2/9/24. She stated updating the ongoing care plan to include the resident's smoking behavior was necessary for staff to be aware of her care needs. Record review of the facility's undated policy titled Care Plans-Comprehensive revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the resident's comprehensive assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 4 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 was able to carry out activities of daily living and received the necessary services to maintain good nutrition , grooming , personal and oral hygiene for 1 of 15 (Resident #299) reviewed for ADLs, in that: Residents Affected - Few The facility failed to ensure Resident #299 received grooming for her facial hair. This failure could place residents at risk for embarrassment, decreased self-esteem or decrease quality of life at risk for embarrassment and or decreased self-esteem or decreased quality of life. Findings include: Record review of Resident # 299's, undated face sheet, reflected an [AGE] year-old female with an admission date of 2/22/24. Resident # 299 had a diagnosis which included Atrial fibrillation (irregular and often very rapid heart rhythm), Xerosis cutis (Dry skin) and hypertension (is a blood pressure reading of 130/8 or higher). Record Review of Resident #299's admission MDS dated [DATE], reflected a BIMS score of 12, which indicated mild impaired cognition. Record Review of Resident #299's admission MDS, dated [DATE], reflected under section G,0110, ADL, J, Personal Hygiene, one-person physical assist. Record Review of the care plan for Resident #299's, dated 2/22/24, indicated Resident #299 had a self-care performance deficit; required assistance X 1 for Activities of Daily Living. During an observation on 03/19/23 at 10:05 a.m., Resident #299 was sitting in her wheelchair in the room. She had very long hair growing from her chin that was (approximately 1 -1 1/2 cm). During an interview with Resident #299 on 3/19/24 at 10:05 a.m., she stated at home she used to shave her own chin but at facility staff did not let the residents have razors. She stated chin hair made her feel unmanicured as she had requested several staff members to assist her with shaving. During an interview on 03/19/24 at 10:35 a.m., CNA L said she thought nursing was responsible for for shaving hair on residents chin, as CNA's performed all daily activities for residents who could not perform them. During an interview on 03/19/24 at 11:00 a.m., the ADON said the CNAs should assist residents with shaving if requested. The ADON stated residents could be at risk for decreased self-esteem or decreased quality of life if requested shaving was not performed. Record review of the facility's, undated, policy for Activities of Daily Living, reflected, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 5 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director, reviewed for qualifications of activity personnel. Residents Affected - Some The facility failed to ensure the AD was qualified to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings were: Record review of the undated staff roster, provided by the facility revealed the AD was listed as Activities Director. Further review revealed the AD was hired on 02/22/22. During an interview with the Activities Director on 03/21/24 at 3:10 p.m., he stated he was hired on 2/22/22 but became Director of the Activity Department on 10/22/22. He stated he learned the position required an Activity Director certification and did not have the activity director certification. He stated he enrolled in an activity director certification course on 3/5/24. He stated he feels the activity certification would allow him to better understand how to serve residents. During an interview with the Human Resources Coordinator on 3/21/24 at 3:15 p.m., she stated that she thought the Administrator was responsible for ensuring that the activity director was certified. She stated that she believed the activity director certification would allow the activity director to have more access to activity materials that could be used with residents. During an interview with the Administrator on 3/21/24 at 4:00 p.m., he stated that the Administrator was responsible for ensuring the Activity Director was certified. He stated that being certified would allow the activity director to create better activity calendars and better engage the residents in group settings. Review of the Modular Education Program for Activity Professionals, website, https://activityadvisor.org/, on 01/18/2023 revealed the MEPAP course is divided into two parts-MEPAP Part One and MEPAP Part Two. Further review revealed Activity Professional Certified (APC) requires only the MEPAP Part One. Review of National Certification Council for Activity Professionals, website, https://nccap.org/, on 01/18/2023 revealed Certification Renewals: Renewal is required every 2 years. APC: 20 CE (Continuing Education) hours every 2 years. Record review of the facility's policy for Activity Director Qualifications that was undated stated: The facility's activity program will be directed by a qualified professional. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 6 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 4 of 4 residents (Residents #3, #46, #47 and #77) reviewed for respiratory care. Residents Affected - Some 1. The facility failed to ensure the filter in Resident #3's oxygen concentrator was not dirty and the water reservoir attached to oxygen concentrator was not empty and replaced in accordance with the facility's changing schedule. 2. The facility failed to ensure Resident #46 did had handheld nebulizer that was bagged and dated. 3. The facility failed to ensure Resident #47's handheld nebulizer was replaced in accordance with the facility's changing schedule. 4. The facility failed to ensure Resident #77 oxygen humidifier bottle on the oxygen concentrator was not empty and failed to have the handheld nebulizer bagged and dated. These failures could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health. The findings were: 1. Record review of Resident #3's face sheet, undated, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included respiratory failure, cerebrovascular accident (stroke; when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients) and hemiplegia (one-sided paralysis). Record review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS of 15, indicating the resident was cognitively intact. Further review of this MDS revealed in Section O, Special Treatments and Programs, that the resident received oxygen therapy. Resident #3's physician orders for March 2024 revealed the following order: Give O2 @ 3L for O2 saturation less than 90%, DX - Hypoxia to begin on 10/15/2023. Observation on 03/19/2024 at 2:00 PM revealed the filter in Resident #3's oxygen concentrator was covered on one side with gray dust and debris. Observation on 03/22/2024 at 10:10 AM revealed the filter in the oxygen concentrator was still covered with dust and debris, and the water reservoir was empty. The date written in marker on the water reservoir was 03/16/2024. During an interview on 03/22/2024 at 10:12 AM with Resident #3 he stated his nose felt dry. During an interview on 03/22/2024 at 10:15 AM with LVN H he stated the filter on the oxygen concentrator was dirty and the water reservoir was empty and needed to be replaced. LVN H further stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 7 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0695 worked on weekdays only and did not know when filters were cleaned. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/22/2024 at 10:20 AM with the DON she stated the filter on the oxygen concentrator was dirty and the water reservoir was empty and needed to be replaced. The DON further stated she believed Housekeeping was responsible for cleaning or replacing the filters. Residents Affected - Some 2. Record review of Resident #46's, undated face sheet reflected a [AGE] year old female resident who was admitted to the facility on [DATE] with the diagnosis that included: anxiety disorder (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) , dementia(a condition characterized by progressive or persistent loss of intellectual functioning) and spondylitis (type of arthritis that causes stiff, painful joints in your spine). Record review of Resident #46's physician orders for March 2024 reflected an order for Albuterol Sulfate 2.5 mg/3 ml, given one vial per hand-held nebulizer as needed every hour for shortness of breath. Record review of Resident #46's Quarterly MDS dated [DATE] reflected, the BIMS score left blank which indicated Resident #46 was unable to complete the interview. Observation on 3/19/24 at 10:35 a.m. revealed Resident #46 had a hand-held nebulizer at the bedside that was not dated or bagged. During an interview with LVN J on 3/19/24 at 10:55 a.m., revealed the nebulizers were changed and dated by the night shift. 3. Record review of Resident #47's undated face sheet reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident # 47 had diagnosis which included: Hyperlipidemia (high levels of fats in your blood), Anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues) and Type 2 diabetes (body's inability to effectively use insulin). Record review of Resident #47's physician orders for March 2024 reflected an order for Albuterol Sulfate 2.5 mg/ml, to be administered one via per hand-held nebulizer every 4 hours as needed for shortness of breath. Record review of Resident #47's Quarterly MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition. Observation on 3/19/24 at 10:40 a.m. revealed Resident #47 had a hand-held nebulizer at the bedside that was bagged and dated 2/9/24. During an interview with LVN J on 3/19/24 at 10:55 a.m., it was revealed nebulizers were changed and dated by the night shift. 4. Record review of Resident #77's undated, face sheet, reflected a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis that included: Chronic obstructive pulmonary disease (lung disease causing restricted airflow), depression (medical illness that negatively affects how you feel), and Congestive heart failure (long-term condition in which your heart cannot pump blood well enough to meet your body's needs). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 8 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #77's physician orders for March 2024 revealed an order for Budesonide 0.5 mg / 2 ml, administer one vial per handheld nebulizer twice a day, for shortness of breath and congestive heart failure. Record review of Resident #77 physician orders for March 2024 revealed an order for supplemental oxygen at 2 -10 liters per nasal cannula as needed for shortness of breath. Record review of Resident #77's Quarterly MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition. Observation on 3/19/24 at 10:45 a.m. revealed Resident #77 was wearing oxygen per nasal cannula at 2 liters with the humidifier bottle empty and hand-held nebulizer at the bedside that was not dated or bagged. During an interview with LVN J on 3/19/24 at 10:55 a.m., revealed that night shift changed and dated nebulizers to include oxygen humidifier bottles. Interview with the DON on 3/19/24 at 11:00 AM revealed Residents #46, #47, and #77 handheld nebulizers should have been changed by the night shift weekly due to facility using night shift agency nurses, they must have forgotten to do it, which included changing Resident #77's oxygen humidifier bottle weekly. Record review of facility undated policy, Oxygen Administration, reflected: 11. Maintain the water level in the bottle high enough so that the water bubbles as the oxygen goes through it. 19. If disposable humidifier bottles are used, replace when water level falls below the fill line. 21. Filters for oxygen concentrators will be washed weekly unless otherwise indicated by the manufacturer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 9 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 2 of 2 meals reviewed for food and nutrition services: 1. The facility failed to ensure Resident #79 received pureed taco soup with her lunch meal on 03/21/2024. 2. The facility failed to ensure Resident #62 received health shakes with her lunch meal on 03/22/2024. These failures could place residents at risk for dissatisfaction, poor intake, weight loss, and diminished quality of life. The findings included: 1. Record review of Resident #79's face sheet, dated 03/22/2024, revealed an admission date of 10/15/2022 with diagnoses that included gastroesophageal reflux (a digestive disease where the liquid content of the stomach refluxes into the esophagus), irritable bowel syndrome (a disorder that affects the stomach and intestines causing cramping and pain) and nutritional deficiencies. Record review of Resident #79's quarterly MDS dated [DATE] revealed a BIMS of 8, indicating moderately impaired cognition. Record review of Resident #79's comprehensive person-centered care plan, , reviewed 12/07/2023, revealed the following focus area: Weight loss with risk for continued weight loss related to poor appetite. Interventions included: Weekly weights per protocol; Diet: Pureed texture with nectar thick liquids as tolerated. Record review of Resident #79's physician's orders for March 2024 revealed an order for Diet: Pureed texture, nectar thickened liquids as tolerated with a start date of 12/07/2023. Record review of the lunch menu for 03/21/2024 revealed the menu for the pureed meal was: Pureed taco soup, pureed Spanish rice, pureed cornbread, pureed pineapple salad, milk/water. Observation on 03/21/2024 at 11:40 AM in the kitchen revealed [NAME] D used a ladle to portion pureed taco soup into red plastic bowls for the residents who received a pureed diet. Observation on 03/21/2024 at 12:50 PM in Resident #79's room of the resident's lunch tray revealed there was a plate with one scoop each of pureed rice and cornbread; a gray plastic bowl with pureed pineapple salad, and a red plastic bowl that was empty. The bowl was completely clean as though there had been no food put in the bowl. During an interview on 03/21/2024 at 12:51 PM with Resident #79's family member, who was present in the resident's room during the observation, revealed he did not know why Resident #79 had not received the main entrée for the lunch meal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 10 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 03/21/2024 at 1:30 PM with the administrator he could not explain why Resident #79 did not receive the pureed Taco Soup which was on the menu for residents who received a pureed diet. 2. Record review of Resident #62 revealed the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid), vitamin deficiency (unspecified) and severe protein-calorie malnutrition. Record review of Resident #62's quarterly MDS dated [DATE] revealed a BIMS of 0, indicating severe cognitive impairment. Record review of Resident #62's comprehensive person-centered care plan, , updated 12/07/2023, revealed the following focus area: Weight: Recent weight loss. Interventions: Diet as ordered per M.D. Snacks as ordered. Encourage diet compliance. House shakes to be given BID between meals. Monitor intake and output. Weigh weekly. Offer food alternatives when appropriate for any meal. Record review of Resident #62's physician's orders for March 2024 revealed an order for Diet: Regular Texture, Regular regular liquids. Thin liquids (start date 12/02/2022). House shakes added to be given bid between meals (start date 12/04/2023). House shakes daily with lunch (start date 10/07/2023). Add fortified meal plan all meals (start date 10/07/2023). Offer dietary supplement with each meal (start date 07/01/2023). Record review of the lunch meal for 03/22/2024 for residents on a regular diet, regular texture revealed it was: Fried fish, Parmesan Noodles, Confetti Coleslaw, Dinner roll with margarine, Frosted Lemon Cake and beverage/water. Record review on 03/22/2024 of Resident #62's lunch meal ticket revealed it stated: Puree, Thin. Preferences: House shake, Fortified foods, Hot tea (3/4 cup). Observation on 03/22/2024 at 12:50 PM in the dining room of the lunch tray served to Resident #62 revealed a plate with four scoops of pureed food, a clear plastic cup with a pureed dessert, and a glass of iced tea. There were no house shakes on the tray. During an interview on 03/22/2024 at 12:52 PM with LVN H he stated Resident #62 did not receive house shakes as ordered and he would get them from the kitchen. During an interview on 03/21/2024 at 1:00 PM with CNA I, who fed Resident #62, CNA I stated Resident #62 had a very poor appetite and the shakes were the only thing she consumed because they were sweet. CNA gestured to the two empty containers of chocolate shakes on Resident #62's tray. In an interview on 03/22/2024 at 3:30 PM with the Administrator and DON, they stated they knew Resident #62 was supposed to receive house shakes with her lunch meal and could not explain why they were missing from her lunch tray. Record review of the facility's policy, Diet orders, reviewed and approved 01/03/2024, revealed: Policy: The facility will serve diets as ordered by the physician. Record review of the facility's policy, Fortified Foods, reviewed and approved on 01/03/2024, revealed: Fortified Foods: Description. The Fortified Foods meal plan is designed for those persons (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 11 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0803 requiring increased calories and/or protein that are not able to consume a large volume of food. 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: 676226 If continuation sheet Page 12 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interviews, and record reviews, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 6 of 6 residents (Residents #22, #51, #72, #76, #79 and #248) reviewed for food and nutrition services. The facility failed to ensure food prepared for residents who received a pureed diet was in the proper consistency. This deficient practice could place residents who received pureed meals at risk of dissatisfaction, poor intake, choking, and/or weight loss. The findings included: Record review of Resident #22's face sheet dated 03/22/2024 revealed an admission date of 09/28/2022 with diagnoses that included dysphagia (difficulty swallowing food or liquid) and mild protein-calorie malnutrition. Record review of Resident #51's face sheet, dated 03/22/2024, revealed an admission date of 05/17/2022 with diagnoses that included dysphagia. Record review of Resident #72's face sheet, dated 03/22/2024, revealed an admission date of 09/23/2021 with diagnoses that included dysphagia and protein-calorie malnutrition. Record review of Resident #76's face sheet, dated 03/22/2024, revealed an admission date of 04/11/2022 with diagnoses that included dysphagia and mild protein-calorie malnutrition. Record review of Resident #79's face sheet, dated 03/22/2024, revealed an admission date of 10/15/2022 with diagnoses that included gastroesophageal reflux (a digestive disease where the liquid content of the stomach refluxes into the esophagus), irritable bowel syndrome (a disorder that affects the stomach and intestines causing cramping and pain) and nutritional deficiencies. Record review of Resident #248's face sheet, dated 03/22/2024, revealed an admission date of 02/29/2024 with diagnoses that included dysphagia and protein-calorie malnutrition. Record review of the physician's orders for Residents #22, #51, #72, #76, #79 and #248 revealed all the residents had orders for a regular diet, pureed texture. Record review of the lunch menu for 03/21/2024 revealed the menu for the pureed meal was: Pureed Taco Soup, pureed Spanish Rice, pureed Cornbread, pureed Pineapple Salad, milk/water. Observation on 03/21/2024 at 10:50 AM of the steam table revealed a 1/3 pan, 6 deep, of pureed Taco Soup intended for residents on a pureed diet. Further observation revealed the soup was grainy and had the consistency of a thick liquid. Further observation revealed when the DM used a ladle to scoop a portion of the soup, the soup poured out of the ladle and was not of a smooth, pudding-like consistency. During an interview on 03/21/2024 at 10:51 AM with the DM he stated [NAME] D put the soup on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 13 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some steam table to keep it hot but would thicken it prior to service. The DM further stated the recipe for the pureed soup was in there somewhere (gestured toward the kitchen) and asked if he should print it or have it available on his computer screen. During an interview on 03/21/2024 at 11:30 AM with [NAME] D she stated she did not follow any recipes when she prepared the pureed menu items. Observation on 03/21/2024 at 11:35 AM revealed [NAME] D served the Taco Soup intended for residents on a pureed diet in a plastic bowl. Observation on 03/21/2024 at 12:36 PM in the dining room revealed CNA E fed Resident #76, CNA F fed Resident #51 and CNA G fed Resident #248. All three CNAs stated the consistency of the soup was different from the consistency as the pureed rice, pureed cornbread and pureed pineapple salad. CNAs E and F mixed a small portion of the soup with either the pureed rice or pureed bread to feed Residents #76 and #51. CNA G attempted to feed Resident #248 but the resident did not want to eat the meal. Observation on 03/21/2024 at 1:00 PM of the test tray received from the kitchen revealed the Taco Soup was served in a bowl and the survey team concurred it remained in a thick liquid form and did not have proper smooth, mashed potato/pudding-like consistency. During an interview on 03/21/2024 at 1:30 PM with the administrator and DON, the administrator and the DON stated they observed Taco Soup was served in a bowl and the consistency of the soup was different from that of the pureed cornbread and pureed rice. Record review of the recipe for the preparation of the Taco Soup for pureed diets revealed: Portion size: #6 Scoop. Serving utensil: #6 Scoop. 1. [NAME] beef and onions in a large pan. Drain off fat. 2. Add remaining ingredients and simmer for approximately one hour. Internal temperature must reach 165 degrees Fahrenheit for 15 seconds. 3. Process until smooth adding 1 TBSP thickener per serving. 4. Reheat to a minimum temperature of 165 degrees Fahrenheit. Hold at minimum required temperature or higher for service. NOTES: Amount of thickener required may vary relative to liquid content of cooked product. For best results, alternate adding thickener with processing. Check product consistency periodically. Record review of the facility policy, Diet orders, reviewed and approved 01/03/2024, revealed: Pureed Diets: The pureed diet is used for residents who have difficulty chewing and/or swallowing. Foods are processed in a food processor. Procedures have been developed to puree food to provide correct and adequate portions equivalent to portions used on regular diets. Record review of the facility policy, Dietary In-Service, reviewed and approved 01/03/2024, revealed: Policy: Educational programs designed to develop and improve skill and knowledge of employees with respect to the needs of the residents will be planned on a yearly basis by the dietitian and/or Dietary Manager. Procedure: 2. Content on in-services will vary but must include at least one yearly in-service on: d. Modified diet patterns served by the facility. Record review of the IDDSI Pureed Adult Consumer Handout revealed: Level 4 - Pureed Foods: - Are usually eaten with a spoon; Do not require chewing; Have a smooth texture with no lumps; Hold shape on a spoon; Fall off a spoon in a single spoonful when tilted; are not sticky; Liquid (like sauces) must not separate from solids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 14 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0805 https://iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 15 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for one of 8 residents (Resident #62) reviewed for food and nutrition services. The facility failed to ensure Resident #62 had a physician's order for a pureed diet. The resident was prescribed a regular diet and was provided a pureed diet. This deficient practice could place residents who are provided a modified texture diet at risk poor intake, and weight loss and diminished quality of life. The findings were: Record review of Resident #62's face sheet, undated, revealed the resident was admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing food or liquid), vitamin deficiency (unspecified) and severe protein-calorie malnutrition. Record review of Resident #62's quarterly MDS dated [DATE] revealed a BIMS of 0, indicating severe cognitive impairment. Further review of this MDS revealed there was no check in Section K indicating the resident was receiving a mechanically altered or therapeutic diet. Record review of Resident #62's physician's orders for March 2024 revealed the following diet order: Diet: Regular texture: Regular Liquids: Thin Liquids (start date 12/02/2022). House shakes added to be given BID between meals (start date 12/04/2023). House shake daily with lunch (start date 10/07/2023). Add Fortified Meal Plan all meals (start date 10/07/2023). Record review of Resident #62's comprehensive person-centered care plan, updated 12/07/2023, revealed the following focus area: Weight: Recent weight loss. Interventions: Diet as ordered per M.D. Snacks as ordered. Encourage diet compliance. House shakes to be given BID between meals. Monitor intake and output. Weigh weekly. Offer food alternatives when appropriate for any meal. Record review of Resident #62's lunch meal ticket revealed it stated: Puree, Thin. Preferences: House shake, Fortified foods, Hot tea (3/4 cup). Observations on 03/21/2024 and 03/22/2024 from 12:00 to 12:00 PM of Resident #62's lunch trays in the dining room during the lunch meal revealed the resident was served a pureed diet. During an interview on 03/21/2024 at 1:00 PM with CNA I, who fed Resident #62 the lunch meal on this day, CNA I stated Resident #62 had a very poor appetite. CNA I further stated Resident #62 preferred to feed herself and she did not like pureed food. During an interview on 03/22/2024 at 12:27 PM with the ADON she stated she believed Resident #62 should be on a pureed diet and was ordered one but could not find such a diet order. The ADON stated the only diet order she found in Resident #62's EHR as ordered by her physician was a regular diet. During an interview on 03/22/2024 at 2:00 PM with the DON she stated that Resident #62 was on hospice services, and the resident's hospice doctor and her facility doctor are supposed to work together (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 16 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with regard to the resident's orders. The DON further stated that a review of the resident's hospice orders did not reveal an order for a pureed diet. During an interview on 03/22/2024 at 2:30 PM with Resident #62's NP she stated it was her intention to change Resident #62's diet order to a pureed diet in the past but it appeared neither she nor the resident's physician put in the order. The NP further stated she would change Resident #62's diet order to a pureed diet that day and would order a swallow study for Resident #62 to see if a regular diet was the best diet for her, since the resident did not care for pureed food and a regular diet may improve her intake. Record review of the facility's policy, Diet orders, reviewed and approved 01/03/2024, revealed: Policy: The facility will serve diets as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 17 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 1 of 1 kitchen reviewed for kitchen sanitation. 1. There were three opened bags of shredded Mozzarella cheese in the walk-in cooler past their use-by date. 2. There were three containers of sour cream in the walk-in cooler past their use-by date. 3. There was a plastic bag of salad mix in the walk-in cooler that contained pieces that were brown. 4. There was a plastic bag of ground food in walk-in cooler that did not have a label identifying the food or the use-by date. 5. There was a bag of pork patties that was open in the walk-in freezer. 6. There was a bag of spaghetti in the dry storage room that was open not properly sealed. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 03/19/2024 at 9:50 AM in the walk-in cooler revealed two 5 lb. bags of shredded Mozzarella cheese. Both bags had been opened; one bag was approximately 50% full and dated 3/8/24. The other bag was approximately 10% full and dated 3/12/24. During an interview on 03/19/2024 at 9:51 AM with the DM he stated these were the use-by dates for the bags of cheese and both bags should have been discarded by those dates. The DM further stated the dietary aide or cook storing food in the cooler was responsible for labeling and dating stored food in the cooler. 2. Observation on 03/19/2024 at 9:55 AM in the walk-in cooler revealed three 5-lb. containers of sour cream that had been opened. All three containers were labeled 1/22. One container had approximately 50% left in the container and there were multiple black spots that resembled mold on the inside of the lid and the rim of the container. The other two containers had one large scoop removed from each container. During an interview on 03/19/2024 at 9:56 AM with the DM he stated 1/22 was the use-by date for all three containers of sour cream and they should all have been discarded by that date. 3. Observation on 03/19/2024 at 9:57 AM in the walk-in cooler revealed one clear plastic bag approximately gallon-sized of salad mix sealed with a knot. The bag was marked with the date 3/10 and approximately 1/3 of the salad mix was brown or in a decaying state and unfit for service. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 18 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 During an interview on 03/19/2024 at 9:58 AM with the DM he stated the bag of salad should be discarded. Level of Harm - Minimal harm or potential for actual harm 4. Observation on 03/19/2024 at 9:58AM in the walk-in cooler revealed one clear gallon-sized plastic bag filled almost halfway with ground food that was beige in color. There was no label on the bag identifying the food or a use-by date. Residents Affected - Some Interview on 03/19/2024 at 9:58 AM with the DM revealed the food in the bag was ground turkey and it had been stored in the cooler that morning. The DM stated the bag should have been labeled with the name of the food and use-by date. 5. Observation on 03/19/2024 at 9:59 AM in the walk-in freezer revealed a 10 lb. case of cooked pork patties. The patties were stored in a bag inside the case and the bag was open, exposing the patties to the ambient air in the freezer and to potential deterioration in quality from freezer burn. Interview on 03/19/2024 at 10:00 AM with the DM revealed the bag inside the case should have been properly sealed to prevent deterioration in product quality. 6. Observation on 03/19/2024 at 10:01 AM in the dry storage room revealed a 1 lb. bag of spaghetti pasta that had been opened and was loosely wrapped with plastic wrap. The spaghetti was not placed in a sealed container or bag to prevent deterioration and potential contamination from insects, pests and debris. Interview on 03/19/2024 at 10:02 AM with the DM revealed the spaghetti should have been placed in a sealed container or bag. The DM further stated that he trains his staff upon hire and both he and the consultant dietitian provide training to dietary staff on a monthly basis. Record review of facility policy Storage: Dry Food reviewed and approved on 01/03/2024 revealed, 2. Keep all containers tightly closed from insect, rodents and dust. Dry foods can be contaminated, even if they don't need refrigeration. Record review of facility policy, Storage: Freezer reviewed and approved on 01/03/2024 revealed, 2. Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (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: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 3-305.11, revealed: Preventing Contamination from the Premises - Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 19 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 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 Based on interviews and record reviews, the facility failed have 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 one of one facility reviewed for personal food policy. Residents Affected - Some The facility failed to ensure the policy regarding use and storage of food brought to residents and family and visitors addressed: Ensuring facility staff assists the resident in accessing and consuming the food if the resident is unable to do so on his or her own; responsibility for storing food brought in by family/visitors in a way separate or easily distinguishable from facility food; and the responsibility to help family and visitors understand safe food handling practices. The facility also failed to provide this policy to family/and or visitors who brought food to residents. This failure could place residents who received food from outside sources at risk for foodborne illnesses. The findings were: Record review of the facility policy, Food Brought By Visitors, reviewed and approved on 01/03/2024, revealed it stated the following: Policy Statement: Liberalized diets will be permitted as much as possible; staff should be aware of, and approve, foods (s) brought to a resident by family/visitors. 1. Family members should inform nursing of their desire to bring foods into the facility. The Dietitian or nurse supervisor should assure the food is not in conflict with the resident's diet plan. 2. If necessary, nursing staff will discuss with the physician whether a diet can be liberalized. 3. The Dietitian will counsel residents or families about requests that conflict with the resident's dietary restrictions and whenever diets cannot be liberalized. 4. The Dietitian or a nurse will document any such discussion in the resident's medical records. 5. Non-perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. 7. The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). 8. Foods that present a choking hazard for residents with impaired cognitive function or swallowing difficulty will be taken from the resident and returned to the family member or visitor. 9. Home prepared and home-preserved foods may not be shared or distributed to other residents. 10. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded. During an interview on 03/21/2024 at 1:15 PM with Resident #79's family member he stated he routinely brought food for the resident. The family member further stated he never received a policy from the facility regarding use and storage of food he brought and safe food handling practices were never explained to him. The family member further stated he had stored shakes for Resident #79 in a refrigerator next to the nurses' station but stopped doing so because they would frequently disappear so he began storing them in the resident's room. During an interview on 03/21/2024 at 2:10 PM with the Administrator and the DON, the Administrator stated he would review the facility's policy and the required components for the policy as specified in the State Operations Manual Appendix PP. During an interview on 03/22/2024 at 11:45 AM with CNAs B and C, the CNAs stated they frequently (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 20 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0813 Level of Harm - Minimal harm or potential for actual harm observed family members bringing food for residents. CNA B further stated she did not think there was any policy regarding families bringing in food for residents as long as the food complied with their diet restrictions and had never provided any family member with such a policy. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 21 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices , medical records were maintained on each resident that were accurately documented for 1 of 4 residents ( Resident #97 ) reviewed for accuracy of medical records. The facility failed to ensure documentation of assessments for Resident #97 was stopped after the resident was discharged from the facility on 1/05/24, LVN N continued to document assessments for 1/7/24 and 1/8/24 This failure could place residents at risk of receiving improper care. Findiings include : Record review of Resident #97 face sheet undated revealed an [AGE] year-old female admitted to the facility on [DATE] with the diagnosis that included: Dementia (disease that affects memory and thinking), Hypertension (blood pressure that is higher than normal), Post-traumatic stress disorder (disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event). Record review of Resident #97 admission MDS, dated [DATE], reflected a BIMS score of 0, which indicated severe cognitive impairment. Record review of the closed medical record for Resident #97 reflected LVN N, documented progress notes on 1/7/24 and 1/8/24. The medical record reflected Resident #97 was discharged from the facility on 1/5/24. Interview with the ADON on 3/22/24 at 10:15 a.m., revealed LVN N was not employed with the facility at this time. The ADON stated she was unaware LVN N documented on a discharged resident for two days. Interview attempt with LVN N on 3/22/24 at 10:35 a.m., was unsuccessful. Record review of the facility's undated licensed staff job responsibilities, revealed responsibilities, assures there is accurate and timely documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 22 of 23 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 676226 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Healthcare and Rehabilitation Center 1351 Sadler San Marcos, TX 78666 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and comfortable living environment in 1 (Resident Hall 100 Shower Room) of 3 shower rooms reviewed, in that: Residents Affected - Some The Resident Hall 100 Shower Room contained razors and hazardous cleaning materials which were not secured. This deficient practice could result in injury for residents who come into contact with sharp implements or hazardous materials. The findings were: Observation on 03/19/2024 at 10:45 a.m. in Resident Hall 100 Shower Room revealed a box of approximately 25 razors and two 32 once spray bottles of cleaning fluid labeled, Danger and Keep Out of Reach of Children. During an interview with the Administrator on 03/19/2024 at 11:07 a.m., the Administrator confirmed the presence of the razors and cleaning fluid and confirmed the items should have been secure so that residents could not access them and possibly be injured by them. The Administrator stated it was the responsibility of staff who utilized the shower rooms to ensure they were clean and safe for resident use. Record review of the facility policy, Homelike Environment, undated, revealed, .ensuring that the resident can receive care and services safely . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 23 of 23