Health inspection·September 20, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few immune system destroys the pancreas' insulin-producing cells), spinal stenosis (condition that occurs when the spinal canal narrows), and hypokalemia (condition where the level of potassium in your blood is lower than normal). Review of Resident #2's physician orders dated from 09/28/2023 to 09/20/2024 revealed no orders for self-administration of medications or for Triad Hydrophilic wound dressing cream. Review of Resident #2's care plan dated 5/8/2024 revealed an intervention to administer medications as ordered. Observation and interview on 09/20/2024 at 11:34 AM, revealed Resident #2 had clinical anti-fungal powder and Triad Hydrophilic wound dressing in her room at bedside. Resident #2 stated that the anti-fungal power is for under her breast and that the staff put it on after her showers and the hydrophilic wound dress is not currently utilized. She stated that she usually just kept the powder in her room. During an interview on 09/20/2024 at 10:44 AM, LVN A stated all medications are required to have an order and that this included over the counter medications like throat lozenges. LVN A was not aware of any residents whose medications are at bedside. During an interview on 09/20/2024 at 12:24 PM, the NP stated she expected any medications in the facility, which included over the counter medications, had an order. The NP stated that she included throat lozenges and anti-fungal powders in this expectation. The NP stated that she expected medications to have an order and not be stored in the resident's room so that the facility is aware of what is being taken incase something changes or needed to be added. She stated that the facility had to know what the resident was taken to ensure any treatment decisions are the right ones. During an interview on 09/20/2024 at 1:13 PM, CNA B stated that residents were not supposed to have medications in their rooms. CNA B stated that if she saw medication in the room, she would have let the nurse know. During an interview on 09/20/2024 at 1:19 PM, CNA C stated residents were not supposed to have mediations in their rooms. She stated that if she were to see medications, she would let the nurse know. During an interview on 09/20/2024 at 1:36 PM, LVN D stated that residents could have medications at bedside if they have been checked off and had an order. She stated that she was not aware of any residents who had been approved to have medications at bedside. LVN D stated that all medications required an order even if they were over the counter medications. She stated that if staff found medications, they would need to reach out to the MD or NP to determine if they needed an order. LVN D stated that the medication would not have been a necessity because the MD would have already prescribed it. During an interview on 09/20/2024 at 1:55 PM, the DON stated that she was not aware of any residents who were able to store medications in their room or self-administer. She stated that if they are able to store medications in their room, there would have been an order. She stated the medication would have also needed to be properly stored. The DON stated that there is an order needed for any medication the residents took and this included over the counter medications. She stated that there is potential harm to patient and other residents if they were to wander into that resident's room, they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 2 of 6 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 09/20/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few could ingest it. She stated if medication is found in the room it may have been removed to staff may get an order if needed. During an interview on 09/20/2024 at 2:50 PM, the ADM stated that medication was allowed to be at bedside if there was an order. The ADM stated it was his expectation that any medications being taken by a resident had an order. He stated the risk ranged from little risk to life threatening and included death which depended on the type of medication and resident. He stated that by policy the facility should be administering medications to the residents unless they have been assessed to do so on their own. The ADM stated that anyone could have come into contact with the medications which was why they needed to be secured if kept at bedside and why they should not be there. Review of undated facility policy titled Medication Administration Schedule revealed that medications shall be administered according to established schedules. Review of undated facility policy titled Medications - Storage revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Further review revealed medications should be locked when not in use and not be left unattended if open or otherwise potentially available to others. Review or undated facility policy titled Orders - Medications revealed medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Review revealed no drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribed for and treat human illnesses. Drugs and biological orders must be recorded on the physician's order sheet in the resident's chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 3 of 6 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 09/20/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments inaccessible to unauthorized staff, visitors, and residents for 2 of 4 residents (Resident #1 and Resident #2) reviewed for medication storage. The facility failed to ensure Resident #1 and Resident #2 did not have medications stored at the bedside. This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences. Findings included: Review of Resident #1's face sheet revealed an [AGE] year-old woman admitted on [DATE] with diagnoses of Parkinson's disease (brain disorder that causes variety of symptoms including uncontrollable movements), repeated falls, dysarthria, and anarthria (slurred and slowed speech). Review of Resident #1's physician orders dated from 12/27/2022 to 09/20/2024 revealed no orders for Chloraseptic throat lozenges, medicated chest rub, or self-administration of medications. Review of Resident #1 care plan dated 09/20/2024 revealed resident had altered cognitive with BIMS of 09 which indicated moderate cognitive impairment. Further review included intervention to administer medications as ordered. Observation and interview on 09/20/2024 at 10:28 AM, reveled Resident #1 had two medications at bedside, Chloraseptic lozenges and medicated vapor rub. Resident #1 stated that she keeps medication in her room for her throat in case she needs them but does not take them every day. During an interview with Resident #1's family member on 09/20/2024 at 10:29 AM, they stated that resident usually keeps that in her room in case she needs it. 2. Review of Resident #2's face sheet revealed an [AGE] year old woman admitted on [DATE] with diagnoses of Type 1 diabetes mellitus with diabetic nephropathy (chronic autoimmune disease when the body's immune system destroys the pancreas' insulin-producing cells), spinal stenosis (condition that occurs when the spinal canal narrows), and hypokalemia (condition where the level of potassium in your blood is lower than normal). Review of Resident #2's physician orders dated from 09/28/2023 to 09/20/2024 revealed no orders for self-administration of medications or for Triad Hydrophilic wound dressing cream. Further review revealed order for Antifungal Powder with start date of 02/01/2024 to apply under breast when red. Review of Resident #2's care plan dated 5/8/2024 revealed an intervention to administer medications as ordered. Observation and interview on 09/20/2024 at 11:34 AM, revealed Resident #2 had clinical anti-fungal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 4 of 6 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 09/20/2024 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some powder and Triad Hydrophilic wound dressing in her room at bedside. Resident #2 stated that the anti-fungal power is for under her breast and that the staff put it on after her showers and the hydrophilic wound dress is not currently utilized. She stated that she usually just kept the powder in her room. During an interview on 09/20/2024 at 10:44 AM, LVN A stated all medications are required to have an order and that this included over the counter medications like throat lozenges. LVN A was not aware of any residents whose medications are at bedside. During an interview on 09/20/2024 at 12:24 PM, the NP stated she expected any medications in the facility, which included over the counter medications, had an order. The NP stated that she included throat lozenges and anti-fungal powders in this expectation as well. The NP stated that she expected medications to have an order and not be stored in the resident's room so that the facility is aware of what is being taken incase something changes or needed to be added. She stated that the facility had to know what the resident was taken to ensure any treatment decisions are the right ones. During an interview on 09/20/2024 at 1:13 PM, CNA B stated that residents were not supposed to have medications in their rooms. CNA B stated that if she saw medication in the room, she would have let the nurse know. During an interview on 09/20/2024 at 1:19 PM, CNA C stated residents were not supposed to have mediations in their rooms. She stated that if she were to see medications she would let the nurse know. During an interview on 09/20/2024 at 1:36 PM, LVN D stated that residents could have medications at bedside if they have been checked off and had an order. She stated that she was not aware of any residents who had been approved to have medications at bedside. LVN D stated that all medications required an order even if they were over the counter medications. She stated that if staff found medications, they would need to reach out to the MD or NP to determine if they needed an order. LVN D stated that the medication would not have been a necessity because the MD would have already prescribed it. During an interview on 09/20/2024 at 1:55 PM, the DON stated that she was not aware of any residents who were able to store medications in their room or self-administer. She stated that if they are able to store medications in their room, there would have been an order. She stated the medication would have also needed to be properly stored. The DON stated that there is an order needed for any medication the residents took and this included over the counter medications. She stated that there is potential harm to patient and other residents if they were to wander into that resident's room, they could ingest it. She stated if medication is found in the room it may have been removed to staff may get an order if needed. During an interview on 09/20/2024 at 2:50 PM, the ADM stated that medication was allowed to be at bedside if there was an order. The ADM stated it was his expectation that any medications being taken by a resident had an order. He stated the risk ranged from little risk to life threatening and included death which depended on the type of medication and resident. He stated that by policy the facility should be administering medications to the residents unless they have been assessed to do so on their own. The ADM stated that anyone could have come into contact with the medications which was why they needed to be secured if kept at bedside and why they should not be there. Review of facility in-service dated 08/13/2024 revealed staff should stay with resident for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 5 of 6 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 09/20/2024 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 0761 medication pass until medications were taken. Level of Harm - Minimal harm or potential for actual harm Review of undated facility policy titled Medication Administration Schedule revealed that medications shall be administered according to established schedules. Residents Affected - Some Review of undated facility policy titled Medications - Storage revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Further review revealed medications should be locked when not in use and not be left unattended if open or otherwise potentially available to others. Review or undated facility policy titled Orders - Medications revealed medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Review revealed no drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribed for and treat human illnesses. Drugs and biological orders must be recorded on the physician's order sheet in the resident's chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 6 of 6