Health inspection·April 17, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some who was admitted to the facility on [DATE]. Resident #30 had diagnoses which included heart failure, muscle weakness, anemia (not enough healthy red blood cells), lack of coordination, abnormality of gait and mobility, hypertensive heart disease with heart failure (damage to heart and heart failure due to chronic high blood pressure), type 2 diabetes mellitus with hyperglycemia (high blood sugar), cognitive communication deficit (problems with communication), repeated falls, pain in right shoulder, pain in left shoulder, nausea with vomiting, and dementia (memory, thinking, difficulty). Record review of Resident #30's Quarterly MDS assessment, dated 11/24/2024, revealed Resident #30 had a BIMS score of 03, which indicated severe cognitive impairment. 3. Record review of Resident #33's face sheet, dated 04/16/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #33 had diagnoses which included insomnia (difficulty sleeping), nausea, history of falling, acute pain, dysphagia (difficulty swallowing), COVID 19 , difficulty walking, attention and concentration deficit, kidney disease, muscle wasting, abnormality of gait and mobility, obesity, unsteadiness on feet, pain in right shoulder, major depressive disorder , and vitamin D deficiency. Record review of Resident #33's Quarterly MDS assessment, dated 11/24/2024, revealed Resident #33 had a BIMS score of 12, which indicated moderate impairment. 4. Record review of Resident #82's face sheet, dated 04/16/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #82 had diagnoses which included insomnia (difficulty sleeping), burn of third degree of shoulder and upper limb, nausea, constipation, heart failure, vitamin deficiency, Severe Sepsis without septic shock (life threating condition where the bodies overwhelming response to an infection leads to organ damage), hyperlipidemia (high cholesterol), acquired absence of right leg below the knee, and pain. Record review of Resident #82's Quarterly MDS assessment, dated 11/24/2024, revealed Resident #82 had a BIMS score of 11, which indicated moderate impairment. Observation on 04/15/2025 at 11:10 a.m., revealed the MAIN walked into Resident #30's room without knocking to check the bathroom. Resident #30 was in the bathroom when the MAIN walked in her room and opened the bathroom door. Observation on 04/15/2025 at 9:05 a.m., revealed LVN A walked into Resident #33 and Resident #82's room without knocking. Observation on 04/15/2025 at 10:02 a.m., revealed LVN A walked into Resident #33 and Resident #82's room without knocking. Observation on 4/16/2025 at 5:30 p.m. revealed CNA T feeding Resident #23 in the assisted dining room. CNA T was observed sitting beside Resident #23 feeding her. When she received a text message, she put down the utensils she was using to feed Resident #23 and pulled out her cell phone and began reading a message and laughing. She was observed on her personal phone for 3 minutes. Once CNA T observed Surveyor in the doorway, she put her cell phone away and returned to feeding Resident #23. During an interview with Resident #33 on 04/17/2025 at 8:40 a.m., revealed staff did not always knock on his door. He said staff did not knock on his door a lot. He said he would like for them to knock all the time. He said it did not upset him when staff did not knock . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 2 of 33 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 04/17/2025 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview with Resident #83 on 04/17/2025 at 8:42 a.m., revealed staff did not always knock. He said he would like for staff to knock all the time. He said he did not know how he felt about staff not knocking on his door. He said he did not know how often the staff did not knock on his door. During an attempted interview with Resident #30 on 04/17/2025 8:33 a.m., she said she did not know if staff always knocked before entering her room. She said she did not care if the staff knocked or not. She also said she did not know if she got upset when staff did not knock. She said she was not sure how often staff did not knock. An interview with LVN A on 04/17/2025 at 8:34 a.m., revealed he was trained on resident rights. He said the policy was staff were to knock on the door and wait for the resident to respond. He said staff were to knock except if it was an emergency such as the resident not breathing. He said if a resident did not want someone in their room they could get upset. He said everyone was responsible for monitoring to ensure staff were knocking. He said knocking on the door was monitored by doing observations. He said he was just in a hurry and did not think about knocking on the resident's door. An interview with the MAIN on 04/17/2025 at 9:15 a.m., revealed he was trained on resident rights. He said the policy was staff were to knock on the door and wait for the resident to say it was okay to come in. He said he was not sure of anytime the staff did not have to knock. He said every resident had a room and that was their private space. He said it was a violation of the resident's right and it was not nice to be obnoxious by not knocking. He said everyone should monitor to ensure staff were knocking. He also said staff monitored each other by observation. He said he did not recall going into Resident #30's room without knocking and opening the bathroom door while she was in the bathroom. An interview with the ADM on 04/17/2025 at 11:38 a.m., revealed she and staff were trained on resident rights. She said the policy was to knock on the door and inform the resident what they were there to do. She said all staff were supposed to knock before entering the residents' room. She said some residents did not care if staff knocked. She said regardless of if the resident did not care staff should be knocking. She said management monitored knocking by observation of the halls. She said she thought the staff got complacent and did not knock. An interview with the DON on 04/17/2025 at 12:19 p.m., revealed she and staff were trained on resident rights. She said she was not sure what the policy was that staff were to knock on the door. She said staff were expected to knock whenever they wanted to go into the room. She said if staff did not knock the resident may feel as if the facility was not his/her home. She said all staff were supposed to knock anytime they wanted to enter the resident's rooms. She said everyone was responsible for monitoring to ensure staff were knocking. She said knocking on the door was monitored by doing observations. She said she did not know why the staff did not knock. In an attempted interview on 04/17/2025 at 1:20 p.m. Resident #23 was nonverbal. Resident would not say anything she would just look at surveyor. In an interview on 04/17/2025 at 1:26 p.m. CNA H stated that she had been trained on resident rights. She stated not treating a resident with respect and providing privacy would affect them negatively and make them feel worthless or unimportant. She stated the facility's cell phone policy was to not have cell phones out on the floor, near personal information, around resident or in their room, it must be put away. She stated cell phones were not allowed to be used if tasked with feeding a resident. She stated if phones were out when assisting a resident with feeding this can cause them to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 3 of 33 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 04/17/2025 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 0550 feel unimportant and they were being paid to pay attention to the resident to avoid them from choking. Level of Harm - Minimal harm or potential for actual harm In an interview on 04/17/2025 at 1:43 p.m. RN D stated that she had been trained on resident rights and privacy and dignity was important to residents as they can be affected negatively if not treated with respect and dignity. She stated the cell policy was to not have them out unless on break or work related. She stated the facility allows for the use of personal cell phones. She stated she does assist with feeding residents as there were many feeders, and as a wound care nurse nutrition was a big part of wound care, and everybody shares this responsibility. She stated it would not be appropriate to feed a resident and use cell phone. She stated she has personally witnessed staff using their personal cell phones while assisting a resident with feeding. She stated that residents could choke if they were not being supervised or assisted correctly. She stated CNAs were less likely to communicate work items on cell phones and sees no need for them to be out. She stated she was unsure how staff communicate between each other and may require their personal cell phones. Residents Affected - Some In an interview on 4/17/2025 at 2:54 p.m. the DON stated the facility's cell phone policy was that staff can have it on their person. She stated with patient care staff should not be on their phones especially when assisting a resident with feeding. She stated cell phones were allowed and if an emergency staff can step away and go and use in the breakroom. In an interview on 4/17/2025 at 2:54 p.m. RN E stated managers have a cell phone, communication between staff was allowed on phone. She stated she does text staff members and states phones were becoming more common in the facility. She stated nurses can communicate with practitioners at the desk and phone was allowed if it was work related. She stated no staff should be using their cell phone when providing direct services in person. RN E stated the cell phone policy was provided to each new hire during onboarding as it can affect HIPAA, resident's privacy. She stated if a severe problem with cell phones he would put a stop to it immediately and provide all staff in-service on cell phones. In an interview on 4/17/2025 at 2:54 p.m. RN E stated the assisted dining was for the residents that require assistance with feeding. She stated feeding a resident while on a personal cell phone could impact a resident's dignity as they were not receiving the attention they need to be fed. RN E stated being focused on their task at hand was necessary whenever working on direct services with any resident. Record review of the Resident Rights: 5. Respect and dignity: Resident Rights Policy, not dated, reflected The resident has a right to be treated with respect and dignity. 11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to property care for its residents. Record review of the Dining Rooms: Dietary Policy, not dated, reflected 2. Nursing assistance will assist the resident as needed, i.e., cutting meat, buttering bread, unwrapping food items, etc. Record review of the Resident Rights, not dated, revealed residents have the right to be treated with respect and dignity. Residents have the right to personal privacy and confidentiality. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 4 of 33 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 04/17/2025 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 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation , interview and record review the facility failed to ensure residents were provided with a private space, and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for residents' monthly council meetings and the confidential resident group meeting during the survey for 8 of 8 residents reviewed for confidential resident council meeting. Residents Affected - Some The facility failed to provide a private space for resident council meetings. This failure could place residents at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings Include: Observation on 04/15/2025 at 10:35 AM, revealed staff walked in on the resident council meeting, and the residents told the staff they were having a meeting . Observation on 04/15/2025 at 10:41 AM, revealed staff just walked in to the resident council meeting, and the residents told the staff they were having a meeting. The meeting was held in the assisted dining room Observation on 04/15/2025 at 10:56 AM, revealed a family member interrupted the resident council meeting in the assisted dining room. Observation on 04/15/2025 at 11:13 AM revealed a staff member interrupted the meeting to bring a resident into the room for lunch in the assisted dining room . During an interview on 04/15/2025 at 9:20 AM, with the Administrator revealed a meeting was already scheduled for 10:30 AM, in the main dining room. She said they always had the meeting in the main dining room. She said they could move it to the assisted dining room to be more private . During an interview with a confidential resident revealed resident council always met in the dining room. He said staff would come in and out of the dining room while the meeting was in session. He also said even if the door was closed staff still opened it and came in. He said he would tell them they were having a meeting and for the staff not to come in, but they still came in. He said the resident council did not get the privacy they wanted. He said he talked to the ADM about staff coming in and out. He said the ADM told him there was nothing the facility could do. During an interview with the AD on 04/17/2025 at 11:14 AM revealed she had been trained on resident rights. She said the resident council was supposed to have a private meeting area. She also said they had the right to privacy and could say if staff could join or not. She said she was responsible for ensuring the resident council had a private area to meet. She said the resident council asked for a private area to meet so that was why she moved it to the small dining room. She also said this was the first time they had met in the small dining room. She said she did not consider the small dining room a private area after the meeting on 04/15/2025. She said it was not a private area due to all the interruptions that had happened. She also said that if they did not have a private area it could make the residents not want to speak freely about issues. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 5 of 33 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 04/17/2025 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 0565 Level of Harm - Minimal harm or potential for actual harm During an interview with the ADM on 04/17/25 at 11:26 AM revealed her and staff were trained on resident rights. She said the resident council must have a private place to meet. She said She said the AD was responsible for ensuring the resident council had a private place to meet. She said she was not aware they asked for a private area. She said the resident council was supposed to be a secure environment and if not secure then the residents may not feel comfortable talking about their concerns about staff. Residents Affected - Some During an interview with the DON on 04/17/2025 at 12:16 PM revealed she had been trained on resident rights. She said the resident council must have a private place to meet. She said she said the AD and administration were responsible for ensuring the resident council had a private place to meet. She said she had not heard the resident council wanted a more private place to meet. She said if the resident council did not have a private meeting space the residents may not feel they could speak freely about staff or the facility. Record review of the facility's, undated, Resident Council Meetings Policy revealed the facility will provide the Resident Council with a private space to meet and take reasonable steps, with the approval of the group to make residents aware of upcoming meetings in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 6 of 33 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 04/17/2025 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 resident rights for personal privacy for 3 of 8 residents (Resident #75, Resident #39, and Resident #26) reviewed for resident rights. Residents Affected - Some The facility failed to ensure Resident #75, Resident #39, and Resident #26 were provided privacy and confidentiality when personal care and treatment signs were hung up in their rooms. The failure could place residents at risk of feeling like their privacy is being invaded or the facility is not their home. Findings included: Resident #75 Review of Resident #75's face sheet dated 4/17/2025 reflected [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Hemiplegia (severe paralysis on one side of the body), Hemiparesis (weakness on one side of the body), Cerebrovascular disease (affect blood flow to the brain), muscle weakness, repeated falls, and Type 2 diabetes (insulin resistance and high blood sugar levels). Review of Resident #75's MDS quarterly assessment dated [DATE] reflected a BIMS score of 08 indicating moderate impairment. MDS further reflected Resident #75 has symptoms presence of feeling down, depressed, or hopeless. Review of Resident #75's care plan, dated 03/24/2025 reflected Resident #75 was dependent on staff for meeting emotional, intellectual, physical, and social needs. Observation of Resident #75's room on 4/16/2025 at 8:48 AM revealed personal care and medical treatment signage, PLEASE APPLY BARRIER CREAM IN BETWEEN BRIEF CHANGES AND PRN and Reminder to all Staff! When in bed. Kindly position the cushion provided under right leg to prevent pressure sore and further contracture. It stated she declines the cushion under her right leg hanging on the wall behind Resident #75's bed. In an interview on 4/17/2025 at 8:57 AM Resident #75 stated the personal care and medical treatment signage hanging directly behind her was meant for staff providing her daily personal care. She stated the signage was uncomfortable, but she was used to them being there. She stated she has discussed concern with staff, but they stated it was meant to help them and in return helps her. Resident #39 Review of Resident #39's face sheet dated 04/17/2027 reflected [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Venous insufficiency (flow of blood through the veins is impaired), muscle weakness, Muscle atrophy (wasting or thinning of muscle mass), Unspecified lack of coordination (poor muscle control), and cognitive communication deficit (communication difficulties). Review of Resident #39's MDS quarterly assessment dated [DATE] reflected a BIMS score of 11 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 7 of 33 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 04/17/2025 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 indicating moderate impairment. Level of Harm - Minimal harm or potential for actual harm Review of Resident #39's care plan, dated 3/25/2025 reflected Resident #39 was confirmed to bed. Residents Affected - Some Observation of Resident #39's room on 4/16/2025 at 9:20 AM revealed personal care and medical treatment signage, please apply barrier cream in between brief changes hanging on the wall behind Resident #39's bed. In an interview on 4/17/2025 at 8:57 AM Resident #39 stated she would prefer if the personal care signage was not up and for staff to know what to do with her daily personal care. She stated she doesn't stay anything about the signage as staff have stated it helps them. Resident #26 Review of Resident #26's face sheet dated 4/17/2025 reflected [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Non-ST-Elevation Myocardial (heart attack that usually happens when your heart's need for oxygen can't be met), acute kidney failure (sudden loss of kidney function), muscle weakness, lack of coordination, repeated falls, Dysphagia (difficulty in swallowing food or liquid), and cognitive communication deficit (communication difficulties). Review of Resident #26's MDS quarterly assessment dated [DATE] reflected a BIMS score of 04 indicating severe cognitive impairment. Review of Resident #26's care plan, dated 4/8/2025 reflected Resident #26 was having symptoms of depression. Observation of Resident #26's room on 4/15/2025 at 10:34 AM revealed personal care and medical treatment signage, please apply barrier cream in between brief changes hanging on the wall behind Resident #26's bed. In an interview on 4/17/2025 at 9:13 AM Resident #26 stated the personal care signage was not welcomed and she hates it. She stated she feels like she wasn't important, but it was for staff, and she can't do anything about it. She stated issue has been discussed with staff, but they reassure here it was necessary. In an interview on 4/17/2025 at 9:02 AM CNA S stated that she had been trained on resident rights and privacy and how dignity was important for residents. She stated residents could be affected negatively and feel unsafe, scared, and angry if not treated with dignity and provided privacy. She stated that all staff should be professional with all residents. She stated that the personal care and medical treatment signage behind Resident #26, Resident #39, and Resident #75's bed along with all other residents with similar personal care and medical treatment signage was helpful to staff providing care. She stated as she and other staff do not work at the facility daily the signage helps to remind them of specific personal care and medical treatment needed for the resident. She stated she has not received complaints about the personal care and medical treatment signage from residents and doesn't believe it provides personal information. In an interview on 04/17/2025 at 1:26 PM CNA stated that he had been trained on resident rights. He stated not treating a resident with respect and dignity and providing them privacy would affect them negatively and make them feel worthless or unimportant. He stated the personal care and medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 8 of 33 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 04/17/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some treatment signage hanging behind their bed was to remind facility staff of what to do daily for the resident. He stated that he was not familiar with specific personal care or medical treatment signage behind Resident #26, Resident #39, and Resident #75's bed along with all other residents with similar signage and stated that he was aware that some residents do not like the signs up. He stated he understands the signage could cause the resident embarrassment and, in his opinion, he doesn't believe they feel comfortable and if he were the resident he wouldn't want them up either. In an interview on 04/17/2025 at 1:43 PM RN D stated that she had been trained on resident rights and privacy and dignity was important to residents as they can be affected. She stated privacy in a single room was provided by shutting the door and if there were roommates the resident can pull curtain shut for privacy. She stated another option for privacy was to ask the roommate to step out. She stated the signage listing daily care for residents was for communication for all staff members. She stated she was familiar with a few residents having personal care and medical treatment signage up for daily care, but was not familiar with signage behind Resident #26, Resident #39, and Resident #75's beds specifically. RN D stated that she can see how personal care and medical treatment signage technically would cross the boundaries of privacy. She stated privacy and dignity was affected, but has not heard complaints, that would oversee any privacy concerns. In an interview on 4/17/2025 at 2:54 PM RN E stated that she had been trained on resident rights and privacy and understands the negative effects that can be imposed on a resident if not provided these rights. She stated she provides facility staff with regular in-services on HIPAA and resident privacy. RN E stated that the residents need to communicate with facility staff as to what they need or what they don't like. She stated that personal care and medical treatment signage for residents was to provide personal care information to staff and doors were usually closed when staff were assisting a resident. She stated that the personal care and medical treatment signage listing resident's care hanging in the rooms could be seen as a privacy issue, but stated she was familiar with a few residents having signage up for daily care directions for staff but was not familiar with personal care and medical treatment signage behind Resident #26, Resident #39, and Resident #75's bed specifically. She stated she has not received or heard complaints regarding privacy concerns. Record review of Resident Rights Policy: Explanation and Compliance Guidelines, not dated, reflected 1. Prior to or upon admission, the social service designee, or another designated staff member, will inform the resident and/or the resident's representative of the resident's rights and responsibilities. 2. Information about resident rights and responsibilities will be given to the resident both orally and in writing. Record review of Resident Rights Policy, not dated, reflected, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Record review of Resident Rights: 5. Respect and dignity: Resident Rights Policy, not dated, reflected The resident has a right to be treated with respect and dignity. 11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Record review of Resident Rights: 6. Self-Determination: Resident Rights Policy, not dated, reflected b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 8. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. A. Personal privacy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 9 of 33 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 04/17/2025 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 includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups. 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 10 of 33 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 04/17/2025 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 who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 8 residents (Resident #18) reviewed for ADL care. Residents Affected - Few The facility failed to ensure Resident #18 was provided fingernail care. This failure could place residents at risk for not receiving adequate care and services to prevent infection, injury, and a diminished quality of life. Findings include: Record review of Resident #18's face sheet, dated 04/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #18 had diagnoses which included: Cerebral Infarction (a stroke occurs when blood flow to the brain is cut off), speech impairment related to stroke, Parkinson's disease (a chronic and progressive movement disorder that causes tremors, stiffness, or slowing of movement) with dyskinesia (uncontrolled, involuntary movements), hemiplegia (paralysis) and hemiparesis (weakness) affecting left side, and diabetes mellitus (a disease that affects how the body uses blood sugar). Record review of Resident #18's Quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #18 had impaired vision. Section E-Behavior reflected Resident #18 did not resist ADL care that was necessary to achieve the resident's goals for health and wellbeing. Section GG-Functional Abilities and Goals reflected Resident #18 needed substantial/maximal assistance with bathing and toileting hygiene, Resident #18 required partial/moderate assistance for personal hygiene. Record review of Resident #18's Comprehension Care Plan, revised on 04/16/2025, reflected she had limited physical mobility due to hemiplegia on left dominant side due to stroke. Interventions included, passive range of motion during ADL care daily, hand roll in left hand as tolerated, provide supportive care and assistance with mobility as needed. The care plan did not address nail care. Care plan reflected Resident #18 was resistant to nail care. Record review of Resident #18's task list for in PCC reflected nail care was scheduled to be provided by licensed nurse twice a week. Between 03/18/2025 through 04/15/2025, one refusal was documented on 04/01/2025. Record review of Resident #18's order summary did not reflect any order for nail care. Observation and interview on 04/15/2025 at 10:43 AM revealed Resident #18 was sitting in a wheelchair in her room watching television. Her left hand was closed in a fist, contracted, and she could not open it. Her left thumb nail was long and had rough edges. The resident stated she would like someone to trim her nails. In an interview on 04/15/2025 at 10:55 AM, CNA G stated Resident #18's nails on her left hand were really long. CNA G stated she could feel the long nails on the left hand when she gave Resident #18 showers and put soap into resident's left hand. CNA G stated Resident #18 could not open her left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 11 of 33 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 04/17/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hand due to the contracture and moving it caused the resident pain. She was not aware of anyone trimming the resident's nails. CNA G stated she could not trim Resident #18 nails because the resident was diabetic and nail care was provided by the nurse. Observation and interview on 04/15/2025 at 03:16 PM revealed Resident #18's left thumb nail was long and had rough edges. Resident #18 stated she would like someone to trim her nails and she had not refused nail care, and no one provided nail care on 04/15/2025. Interview on 04/16/2025 at 03:57 PM, LVN B stated he was familiar with Resident #18 and her left hand was contracted. LVN B stated fingernails needed to be trimmed to avoid self-injury, skin issue and infection. LVN B stated he, the treatment nurse, or ADON could provide nail care. LVN B stated he had not provided nail care for Resident #18 because the resident was not his resident, and he was not aware Resident #18 needed nail care. LVN B stated he checked the residents' nails about once a week, but he didn't know how often he should be checking the residents' nails. He was not familiar with the policy or schedule of required nail care. Interview on 04/17/2025 at 10:07 AM, CNA F stated she was familiar with Resident #18 and she gave Resident #18 a shower this morning and noticed the resident's nails were long. Resident #18 left hand was contracted, and she required assistance with showers. CNA F stated CNAs could not provide nail care to Resident #18 because the resident was diabetic. She stated she would report her concern to the nurse on shift and ask them to cut the nails because the resident could hurt herself, cut her skin, or cause an injury to herself due to the long nails. Observation and interview on 04/17/2025 at 10:13 AM revealed Resident #18's left thumb nail was long and had rough edges. Resident #18 stated she would like someone to trim her nails and she had not refused nail care, and no one provided nail care on 04/17/2025. Interview on 04/17/2025 at 10:26 AM and 11:27 AM, RN E stated nail care was performed by any licensed nurse according to the tasks in the resident's chart. Normally, LVN C provided nail care to Resident #18, but she was unavailable to interview as she was in clinicals. RN E stated LVN C told her she trimmed Resident #18's nails a few weeks ago and forgot to sign off as task completed in PCC. RN E stated there was an error in the task function in PCC, which had been corrected. The check marks the state surveyor had observed were made by CNAs and they could not perform nail care on Resident #18 because she was diabetic. She stated Resident #18 was scheduled for nail care on 04/18/2025. RN E stated residents fingernails needed to be trimmed for the comfort, dignity, appearance and cleanliness. Also to avoid the risk of scratching self, skin wounds or digging into the palm of the hand due to the contracture on the left hand. RN E stated there was a policy that provided guidance on the frequency of nail care, but she did not know the details. All nursing staff were responsible for checking residents' nails, especially the CNAs. RN E stated CNAs needed to check nails to ensure they were clean and report to nurses any concerns with nails if they needed to be trimmed. Her expectation would be the nurse would provide nail care same shift/same day as nurse was notified nail care was needed. RN E viewed the photo of Resident #18's nails and that resident needed nail care and this would not meet her expectations. Interview on 04/17/2025 at 11:47 AM, RN D stated she was a wound care nurse and provided nail care to residents on Sundays but did not document nail care anywhere in PCC because she did not know where to document. RN D stated nurses and CNAs were supposed to be checking residents' nails once a week or every other week but did not know what the schedule for nail care was. RN D stated it was important to check residents' nails to avoid residents causing skin tears, self-injury, or infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 12 of 33 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 04/17/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few concerns due to touching feces. RN D stated there was a policy about nail care, but she did not know the details. RN D stated she would provide nail care same day/as soon as possible if a staff member informed her of a concern with a resident's nails. RN D viewed a photo of Resident #18's nails and RN D stated residents needed nail care to avoid injury to self. Interview on 04/17/2025 at 12:02 PM the DON stated it was important for residents to receive nail care on Tuesdays and Fridays to keep nails short, clean, and avoid a skin issue. If a resident was diabetic, then any nurse or treatment nurse could provide nail care, otherwise, CNAs could trim nails, which was documented in the tasks in PCC. The DON stated CNAs and nurses were responsible for checking residents' nails and her expectation would be that nail care occurred the same day the nurse was notified or became aware that nail care was needed. The DON viewed a photo of Resident #18's nails and stated resident's nails needed to be trimmed immediately and this would not meet her expectation. Interview on 04/17/2025 at 12:06 PM the ADON stated that any nurse could provide nail care to residents with diabetes. The ADON stated nurses were responsible for checking residents' nails once a week and they should be documenting nail care in PCC under tasks. Nurses get alerts for residents scheduled for nail care in PCC and nurses should be checking those residents twice a week. The ADON would expect nurses' to trim nails if they were long, even if it was not the resident's scheduled day for nail trimming to avoid infection control issues. The ADON viewed a photo of Resident #18's nails and stated residents nails needed to be trimmed immediately and this would not meet her expectation. Interview on 04/17/2025 at 02:01 PM, the ADM stated she just became aware of the nail care concern when the state surveyor started asking questions. Before this, she thought Sunday was reserved for nail care for all residents. The ADM sated CNAs were responsible for checking residents' nails to ensure they were clean and to trim as needed or let the charge nurse know if they could not trim the nails. The ADM stated she just learned today once the state surveyor started asking questions that diabetic residents were different, and those residents needed to be handled by the nurses, not the CNAs. The ADM stated she knew diabetic residents had to have a podiatrist trim their toenails, but she never thought about residents' fingernails. The ADM stated the treatment nurse should be checking for nail care when doing skin rounds weekly. The ADM didn't know if their nail care policy required nail checking at a certain frequency, but she thought it should be done twice a week. The ADM stated it was important to check and trim nails as needed so the residents didn't get infections or scratch themselves. The ADM stated her expectation was the charge nurse would complete nail care the same day they become aware the resident needed nail care. The ADM stated long nails could dig into the palm of a resident who had contractures and could cause a wound or pain. Record review of the facility's, undated, policy titled Nail Care reflected: Policy: The purpose of this policy is to provide guidelines for the provision of care lo a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: 1. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 2. Routine nail care, to include trimming and filing, will be provided by nurse on a regular (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 13 of 33 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 04/17/2025 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 schedule per care plan unless contraindicated. Nail care will be provided between scheduled occasions as the need arises. Level of Harm - Minimal harm or potential for actual harm 3. Principles of nail care: Residents Affected - Few a. Nails should be kept smooth to avoid skin injury. b. Only licensed nurses shall trim or file fingernails of residents with diabetes Record review of the facility's, undated, policy titled Activities of Daily Living reflected the following: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 14 of 33 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 04/17/2025 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 - 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, to meet the needs of each resident for 3 of 3 (Resident #22, Resident #33 and Resident #71) residents, 2 of 2 medication carts (400-hall and 500-hall), and 1 of 1 medication storage room reviewed for pharmaceutical services. 1. The facility failed to ensure Resident #33 took their medication prior to LVN A leaving the room. 2. The facility failed to ensure expired medications and supplies were removed from the 400-hall and 500-hall medication carts and the medication storage room. These failures could place residents at risk for not receiving a therapeutic dosage or another resident taking medications that were not administered to them. Findings include: 1. Record review of Resident #22's admission record, dated 04/17/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #22 had diagnoses which included: diabetes mellitus type II (a condition that affects how the body uses sugar as a fuel), cerebral infarction (a condition when the blood flow to the brain is impaired), hypertension (high blood pressure), and atrial fibrillation (an irregular and often rapid heart rhythm). Record review of Resident #22's admission MDS, dated [DATE], reflected a BIMS score of 12, which indicated mild cognitive impairment. Section N: Medication reflected resident received insulin 1 day out of the previous 7 days to the assessment. Record review of Resident #22's order summary, dated 04/17/2025, reflected Insulin Lispro Injection Solution 100 unit/ml Inject as per sliding scale. If 150 - 199 = 1; 200 - 249 = 2; 250 - 299 = 3; 300 - 349 = 4; 350 - 399 = 5 Greater than 399 = 6 units and notify provider, Okay to administer if patient is NPO, subcutaneously (under the skin) before meals and at bedtime, related to type 2 diabetes mellitus with unspecified complications. Record review of Resident #22's care plan, dated 03/04/2025, reflected Focus: The resident has Diabetes Mellitus with Interventions that included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. 2. Record review of Resident #33's admission record, dated 04/17/2025, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: pain, dysphagia (difficulty swallowing), apraxia (difficulty with coordination), chronic kidney disease (a condition in which the kidneys could not adequately filter waste), dysarthria (difficulty with speaking), diabetes mellitus type 2 (a condition that affects how the body uses sugar as a fuel), vascular dementia (difficulty with thought processes and memory due to an injury to the brain affecting blood flow), hypertension (high blood pressure), cerebral infarction (a condition when the blood flow to the brain is impaired), and hypertensive heart failure (damage to the heart due to prolonged high blood pressure). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 15 of 33 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 04/17/2025 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 Record review of Resident #33's annual comprehensive MDS, dated [DATE], reflected a BIMS score of 12, which indicated mild cognitive impairment. Record review of Resident #33's medical chart, on 04/17/2025, reflected Resident #33 did not have a self-administer medication evaluation. Residents Affected - Some Record review of Resident #33's care plan, dated 03/24/2025, reflected there was not a care plan for Resident #33 to self-administer his own medications. 3. Record review of Resident #71's admission record, dated 04/17/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #71 had diagnoses which included: diabetes mellitus type 2 (a condition that affects how the body uses sugar as a fuel), unspecified dementia (difficulty with thought processes, memory and social functioning), hyperlipidemia (high cholesterol), anxiety (a feeling characterized by fear, tension or worry in response to real or perceived threats), transient ischemic attack (a brief blockage of blood flow to the brain), and hypertensive heart failure (damage to the heart due to prolonged high blood pressure). Record review of Resident #71's quarterly MDS, dated [DATE], reflected a BIMS score of 04, which indicated severe cognitive impairment. Section N: Medications reflected Resident #71 received insulin for 7 of the 7 days prior to the assessment. Record review of Resident #71's care plan, dated 02/27/2025, reflected Focus: The resident has Diabetes Mellitus with Interventions that included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Humalog with sliding scale. Lantus. Sitagliptin. Record review of Resident #71's order summary, dated 04/17/2025, reflected Insulin Glargine Soln Pen-Injector 100 Unit/ml Inject 35 unit subcutaneously one time a day related to type 2 diabetes mellitus. Observation on 04/15/2025 at 09:04 AM revealed Resident #33 in his room with a medication cup with nine unidentified pills in it. There were not any staff members in sight at that time. Observation on 04/16/2025 at 04:27 PM of the 400-hall medication cart revealed: One Humalog (Insulin Lispro) pen that belonged to Resident #22 with an opened date of 03/05/2025 written on a sticker under Discard after 28 days One Lantus (Insulin Glargine) pen that belonged to Resident #71 with an opened date of 03/18/2025 written on a sticker under Discard after 28 days One box of bisacodyl 10mg suppositories with an expiration date of 01/2025 Three single use packets of lubricating jelly with an expiration date of 11/30/2024 Observation on 04/16/2025 at 05:30 PM of the medication storage room revealed: One bottle of melatonin 3mg with an expiration date of 11/30/2024 One CVC dressing change tray with an expiration date of 01/31/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 16 of 33 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 04/17/2025 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 One box of glucose control solution with an expiration date of 08/15/2024 Level of Harm - Minimal harm or potential for actual harm One bag of 0.9% Sodium Chloride Intravenous Solution 1000mL with an expiration date of 08/2024 Residents Affected - Some Six packages of albuterol sulfate inhalation solution 2.5mg/3ml packaged with a prescription label for someone that was not a resident at the time of the survey. The expiration date was 11/2024. Observation on 04/17/2025 at 01:35 PM of the 500-hall medication cart revealed: Five 27g x 1.5 hypodermic needles with an expiration date of 03/31/2025 Five 23g x 1 hypodermic needles with an expiration date of 08/2021 One bottle of Zinc 50mg with an expiration date of 03/2025 Twenty-one peri-stoma (the skin around a surgical opening created to allow waste to exit the body) cleaner and adhesive remover wipes individually wrapped with an expiration date of 11/10/2024. During an interview on 04/15/2025 at 09:04 AM with Resident #33, he stated staff usually left medication in a cup with him for him to take without watching him take the medication. During an interview and observation on 04/15/2025 at 09:06 AM with LVN A, he stated he didn't normally leave medication for the resident in a cup at the bedside, but he left the room to go get batteries for Resident #33's remote control. He stated doing so could place a resident at risk of choking, aspiration (when something that was swallowed entered the airway or lungs), or the resident could not take the medication. Observed LVN A return to Resident #33's room and picked up the cup of medication from the bedside table, LVN A told Resident #33 I have medicine for you then told the state surveyor I will be here for a while. During an interview on 04/16/2025 at 05:42 PM, LVN R stated all the nurses were responsible for checking for expired medications/supplies on their own cart every shift. She stated if a resident was to take expired medication, then the medicine may not be as effective. She stated the policy for medication administration was to ensure residents took their medication completely before leaving the room because they could choke or someone else could take the medication. During an interview on 04/16/2025 at 05:46 PM with the ADON, she stated she, the DON, and the pharmacist were responsible for checking for expired medication and supplies in the medication room weekly. She stated using expired medication or supplies could affect the resident differently depending on what it was. She stated she would have to look each individual item up to determine the potential effect to the resident. She stated each nurse was responsible for ensuring their cart was locked anytime it was left unattended. The ADON stated not securing the cart could leave it where residents could open the drawer and take anything inside. During an interview on 04/17/2025 at 01:33 PM with LVN A, he stated the nurses were responsible for checking their own cart for expired or discontinued medication. He stated medications and supplies may lose effectiveness or may cause adverse reactions if utilized after the expiration date. During an interview on 04/17/2025 at 2:18 PM with the DON, she stated she expected the nurses to check their carts for expired and discontinued medications and supplies daily. She stated all expired (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 17 of 33 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 04/17/2025 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 - Some medications and supplies were to be removed from the carts and placed in the destruction bin. The DON stated the weekend RN was responsible for auditing the medication carts on the weekends. She stated the ADON, the pharmacist and she spot checked the carts for expired medication/supplies. She stated the ADON was responsible for ensuring all expired supplies and medications were removed from the medication storage room and the DON spot checked the medication room once a month. She stated if used after the expiration date, then medications or supplies may not be as effective. The DON stated the nurses were responsible for ensuring their medication cart was secured at all times. She stated leaving a medication cart unsecured could place residents at risk because they could get into a drawer and grab something potentially. She stated she does daily spot checks and has done in-services on securing the medication cart. The DON stated her expectations for medication administration was to ensure the resident takes their medications completely before leaving their side. She stated not doing could lead to the resident not taking their medication and getting the needed benefits. During an interview on 04/17/2025 at 02:38 PM with the ADM, she stated she expected all expired medication and supplies to be removed from the medication carts and room. She stated the nurses were responsible for ensuring this was done on their carts and the ADON was responsible for ensuring this was done in the medication storage room. She stated having expired medications available lead to a potential for the resident to take the expired medication but was unsure how that might affect the resident. She stated she relied on the DON and the pharmacist to audit the carts and medication room weekly to ensure expired medication and supplies were removed. The ADM stated the nurses were responsible for ensuring their medication carts were secured. She stated leaving a medication cart unsecured could allow a resident access to the drawers and take something not meant for them and it could be detrimental. She stated administrative staff did frequent rounding to ensure medication carts were locked. The ADM stated she expected the nurses to remain with the resident until they took all their medication. She stated if medication was left in a room, then another resident would have access to the medication and could take some medication that wasn't prescribed to them, or the resident could not take their medication and not receive the intended therapeutic benefits. Record review of the facility's, undated, policy titled Medications-Storage reflected: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Record review of the facility's, undated, policy titled Medications - Administering reflected: Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 3. Medications must be administered in accordance with the orders, including any required time frame . 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 18 of 33 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 04/17/2025 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 properly store, label, and/or secure medications and biologicals for 2 of 2 medication carts and 1 of 1 medication storage room reviewed for drug storage. 1. The facility failed to ensure the medication cart for 500 hall was locked when unattended by LVN A on [DATE] at 9:04 AM. 2. The facility failed to ensure glucose control solution was dated with an opened-on date for the 500-hall medication cart. 3. The facility failed to ensure medication were secured in their original packaging. The medication cart for 400-hall had three and a half loose pills. The medication cart for 500-hall had one loose pill. 4. The facility failed to ensure medications that required a prescription were labeled with the appropriate information including the resident's name in the medication storage room and the 500-hall medication cart. These failures could place residents at risk of harm due to unauthorized access and potential ingestion of medication, needles, and other biologicals. These failures could also place residents at risk of not receiving the appropriate medications and not reaching the intended therapeutic dose and possible exacerbation of health conditions. Findings included: Observation on [DATE] at 09:04 AM revealed a medication cart unlocked and unattended at the nurses' station at the end of 500-hall. RN A was at the other end of 500-hall in a room. Observation on [DATE] at 04:25 PM of the medication cart for 400-hall revealed two beige oval pills with UL125 on one side and blank on the other side, one yellow oval pill with HH on one side and 343 on the other side, and one-half white pill with unidentifiable markings. Observation on [DATE] at 05:39 PM in the medication storage room revealed a large clear baggie with 100 individually wrapped ondansetron orally disintegrating tablets (a prescription medication used to treat nausea). No resident or prescription label was observed on the bag. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 19 of 33 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 04/17/2025 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 Observation on [DATE] at 01:35 PM revealed two bottles of glucose control solution with the plastic seal removed and two unopened unlabeled packages of Budesonide 0.5mg/2mL (a prescription medication used to treat inflammation), one oval blue pill with H on one side and 87 on the other side in the medication cart for 500-hall. No handwritten dates observed on either bottle or box of the glucose control solution. The side of the box containing both bottles of glucose control solution stated, Discard after 3 months from opening date. The packages of Budesonide stated Rx only, but no prescription label was on the packaging. During an interview on [DATE] at 09:06 AM with LVN A, he stated he was responsible for locking the medication cart anytime he walked away from it. He stated he thought he had locked the medication cart for 500-hall before he walked away. He stated if the cart was left unlocked then residents could get into the cart and take the medications inside. During an interview on [DATE] at 05:42 PM with LVN R, she stated she had worked at the facility since [DATE]. She stated that she has not ever noticed pills in the bottom of the drawer. She stated all nurses were responsible for checking their cart for loose pills. She stated all prescribed medications were required to have a prescription label on it unless it was removed from the emergency medication supply and given immediately to the resident. She stated if a prescribed medication was not labeled properly then it could possibly be administered to a resident with whom it wasn't intended for, or a resident could miss a dose of scheduled medication. During an interview on [DATE] at 05:46 PM with the ADON, she stated that ondansetron should have a prescription label with a resident's name on it. She stated she, the DON and the pharmacist check the medication room weekly to ensure all expired and invalid medications are removed. She stated she didn't know what the effect to the resident might be for a prescribed medication that wasn't labeled properly. During an interview on [DATE] at 01:33 PM with LVN A, he stated he had worked at the facility for about the last two and a half years. He stated that budesonide should have had a prescription label on it because it was a prescribed medication. He stated the glucose control solution should have been labeled with an opened-on date by the nurse who opened it. He stated not having a date on the glucose control solution could lead to altered results on the blood glucose monitor due to invalid calibration. During an interview on [DATE] at 2:18 PM with the DON, she stated that all medications that required a prescription needed a label on it from the pharmacy. She stated the nurses were responsible for keeping their cart clean. She stated loose pills in the medication cart could mean a resident might have missed a dose of medication. She stated the ADON was responsible for checking the medications in the medication room. The DON stated the glucose control solution should be dated by the nurse who opened the box. She stated not doing so could potentially affect the accuracy of blood glucose monitoring. She stated the nurses were responsible for locking their medication cart when they walk away from it. The DON stated if a cart was left unlocked, then residents could get in the drawer and potentially grab something and take it. She stated she did daily spot checks and monthly in servicing on securing medications properly. During an interview on [DATE] at 02:38 PM with the ADM, she stated all medication that required a prescription should have a prescription label on it. She stated if it didn't have a label then the resident might miss getting the medication. She stated the nurses were responsible for ensuring their carts were clean and locked when the cart was unattended. She stated the pharmacist, DON and ADON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 20 of 33 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 04/17/2025 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 were responsible for auditing the cart to ensure no loose medications. She stated if the carts were left unlocked then a resident could have access to medication that is not for them, and it could be detrimental. The ADM stated she did frequent rounding and in-services to ensure the carts remained secured. Review of undated facility policy title Medications-Storage reflected: Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 2. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 21 of 33 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 04/17/2025 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 - Some 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. Based on observation, interview, and record review the facility failed to serve a menu to the meet the nutritional needs of residents in accordance with established national guidelines including a subsitution for the main entree for one of one menu reviewed. The facility failed to document resident acceptance or refusal of meal substitutions as per the facility policy. These failures could decrease intake and cause weight loss and functional decline. Findings included: Observation on 04/15/2025 at 9:00 AM during the brief tour of kitchen revealed the following: Mealtime schedule posted in the dining room noted lunch was served at 11:30 AM. The walk-in refrigerator contained a large, unlabeled, and uncovered produce box of 8 lettuce heads with black leaves that indicated rotting. The walk-in refrigerator contained unlabeled and open bag of lettuce mix. Observation on 4/15/2025 at 11:30 AM first meal service revealed old menus dated 03/05/2025 were posted in the dining room. Observation of cook, [NAME] L preparing puree foods on 4/16/2025 at 10:51 AM revealed he used water as the liquid to puree cornbread muffin. He was not following a specific recipe. Observation on 4/16/2025 at 1:09 PM of the survey test tray revealed the following: Regular diet chili temperature reading was 110 degrees and taste of test tray by surveyor found it was flavorless. Regular diet corn temperature reading was 109 degrees and taste of test tray by surveyor found it was tasteless. Puree chili temperature reading was 109 degrees and taste of test tray by surveyor found it was flavorless. Puree corn temperature reading was 95 degrees and taste of test tray by surveyor found it was tasteless. In an interview on 4/15/2025 at 9:31 AM the DM stated the residents were not enjoying the facility meals because they were not feeling the Louisiana menu he was currently using to prepare foods from. He stated the company he procures product for provides a Louisiana menu and he was working on making the switch to a local, Texas procurement company. He stated there were contracts being worked on which will transition the facility over to a Texas menu beginning May 1, 2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 22 of 33 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 04/17/2025 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 - Some In an interview on 4/15/2025 at 10:48 AM Resident #67 stated he doesn't care for the meals being served from the kitchen and prefers the alternate choices of hamburgers, hotdogs, corndogs, and pizza. He stated 1-2 times per week he will choose the alternate meal because he was tired of constantly eating rice and beans and would prefer other options like chicken with mashed potatoes and carrots. In an interview on 4/15/2025 at 12:37 PM Resident #73 stated, she hates the lunch, she hasn't eaten the facility food in so long, roughly two years. She stated she used to eat the meats served for protein, but the food has become cardboard, really tough, and flavorless. She stated the alternative grilled cheese sandwiches were a joke, the food was cold, smells horrible at times and the flavor was poor. In an interview on 4/15/2025 at 12:10 PM Resident #56 stated she normally doesn't eat because she doesn't like the meals that were served. She said she was not happy with meals. She stated she doesn't like the alternatives because they were not cooked well. She stated she would rather eat cereal than to eat the food being served. She stated she likes fruit, but it doesn't look appetizing. In an interview on 4/16/2025 at 9:20 AM Resident #39 stated food was mediocre. The resident stated mashed potatoes are served practically every day , the seasoning is very poor, and boring. She can ask for alternative of some sort of sandwich if she doesn't care for the food. In an interview on 4/16/2025 at 9:57 AM Resident #64 stated his eggs were burnt, this morning and he didn't care for the breakfast. In an interview on 4/16/2025 at 9:10 AM Resident #46 stated he did not like breakfast, the food has no taste to it, meat was dry, and cold. He stated he eats in the dining room and will be provided a substitute meal when he doesn't like what was being served. He stated he will usually ask for cereal, [NAME] Krispies. In an interview on 4/17/2025 at 2:21 PM the DM stated the Dietician provides him training on preparing menus, hand sanitation, food procurement, following recipes, diets, and puree preparation and in turn he trains the dietary staff. Surveyor asked DM for in-service logs during this interview, and he stated he doesn't complete his own in-service logs and the ADM would have in-service logs. He stated he would reach out to the ADM and obtain logs for surveyor (logs not provided prior to exiting). He stated the protocol for pureeing foods was to use milk, butter, gravy, broth, and thickening powder, if necessary, but to not use water. He stated he was unsure why [NAME] L would use water when pureeing foods as he knows it has no nutritional value. He stated he has the supplies needed to puree foods. He stated he was expected to follow the menus and understands he can add to the menu just not remove items or seasonings. He stated he will typically taste the food and believes it was good quality and flavorful and would eat it himself and he doesn't have concerns serving to the residents. He stated he was aware several residents were declining the meal trays, and he has instructed aids to notify him so he may offer a substitute. He stated he does not have substitutions documented. He stated he has been informed by aids and residents the food lacks flavor and would like other foods and he stated he wants to provide the residents with flavorful, edible, and presentable food so they would want to eat it. He stated the 8 lettuce heads in the walk-in refrigerator have been in there for four weeks now pending company picking up and he would have to follow-up with the company. He stated he did not inspect the food quality at delivery, and he had some items that was returning. He wasn't aware he needed to label it. He stated the black ripe bananas were kept in the kitchen for residents who require soft foods for consumption. He stated the expectation was for cooks to begin meal prep no more than two house prior to meal service. He discussed that he was not aware that [NAME] L (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 23 of 33 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 04/17/2025 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 was preparing lunch as early as 9:00 am on 4/15/2025 and that this can cause concerns for residents. Level of Harm - Minimal harm or potential for actual harm In an interview on 4/17/2025 at 2:54 PM the ADM stated the DM receives in-services directly from the Dietician. The ADM stated the expectation was for the food to be warm and appetizing, that it tastes good, right temperature, and nutritious. The ADM stated she was aware of a few residents not liking the meals and being offered alternatives, which they decline as they were provided meals by their family. Surveyor requested in-service logs for all dietary staff (not provided to surveyor prior to exiting). Residents Affected - Some In an interview on 4/17/2025 at 2:54 PM the DON stated she was aware that some residents don't like the type of food that was being prepared by the kitchen and were offered alternatives. She stated some residents have notified her that the food was sometimes cold, but this wasn't often. Record Review of Storage Freezer: Dietary Policy, no date revealed 2. Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. 2. Label and date all items. Record Review of Storage: Refrigerator: Dietary Policy, no date revealed 7. Keep refrigerated foods wrapped or covered and in sanitary containers. Record Review of Dietary Daily Functions: Dish machine: Dietary Policy, no date revealed Monitor and record temperatures and sanitizer solution at each meal. Record Review of Meal Delivery: Dining Rooms: Dietary Policy, no date revealed 3. Service must be prompt and efficient so that food will remain at the appropriate temperatures for consumption. 5. If the resident refuses any food item, the kitchen will supply a substitute of similar nutritive value. Acceptance or refusal of such substitution should be documented. Record Review of Menu Planning: Dietary Policy, no date revealed Menus will be posted and clearly visible to residents. Record Review of Dietary General Policies: Organizational Goals: Dietary Policy, no date revealed Provide the best quality food and food service for the residents within the budget as predetermined by the administration and according to established guidelines of all other regulatory agencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 24 of 33 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 04/17/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance in the facility's only kitchen. Residents Affected - Some The facility failed to ensure [NAME] L were preparing meals within two hours or less of meal service. The facility failed to ensure regular diet and puree test trays rendered a proper serving temperature and had flavor. These failures could compromise and destroy nutritive value of food and prevent residents who ate food from the kitchen at risk of recovery from illness or injury. Findings included: Observation on 04/15/2025 at 9:00 AM during the brief tour of kitchen revealed the following: Mealtime schedule posted in the dining room noted lunch was served at 11:30 AM. The walk-in refrigerator contained a large, unlabeled, and uncovered produce box of 8 lettuce heads with black leaves that indicated rotting. The walk-in refrigerator contained unlabeled and open bag of lettuce mix. Observation on 4/15/2025 at 11:30 AM first meal service revealed old menus dated 03/05/2025 were posted in the dining room. Observation of cook, [NAME] L preparing puree foods on 4/16/2025 at 10:51 AM revealed he used water as the liquid to puree cornbread muffin. He was not following a specific recipe. Observation on 4/16/2025 at 1:09 PM of the survey test tray revealed the following: Regular diet chili temperature reading was 110 degrees and taste of test tray by surveyor found it was flavorless. Regular diet corn temperature reading was 109 degrees and taste of test tray by surveyor found it was tasteless. Puree chili temperature reading was 109 degrees and taste of test tray by surveyor found it was flavorless. Puree corn temperature reading was 95 degrees and taste of test tray by surveyor found it was tasteless. In an interview on 4/15/2025 at 9:31 AM the DM stated the residents were not enjoying the facility meals because they were not feeling the Louisiana menu he was currently using to prepare foods from. He stated the company he procures product for provides a Louisiana menu and he was working on making the switch to a local, Texas procurement company. He stated there were contracts being worked on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 25 of 33 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 (X3) DATE SURVEY COMPLETED A. Building 04/17/2025 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 0804 which will transition the facility over to a Texas menu beginning May 1, 2025. Level of Harm - Minimal harm or potential for actual harm In an interview on 4/15/2025 at 10:48 AM Resident #67 stated he doesn't care for the meals being served from the kitchen and prefers the alternate choices of hamburgers, hotdogs, corndogs, and pizza. He stated 1-2 times per week he will choose the alternate meal because he was tired of constantly eating rice and beans and would prefer other options like chicken with mashed potatoes and carrots. Residents Affected - Some In an interview on 4/15/2025 at 12:37 PM Resident #73 stated, she hates the lunch, she hasn't eaten the facility food in so long, roughly two years. She stated she used to eat the meats served for protein, but the food has become cardboard, really tough, and flavorless. She stated the alternative grilled cheese sandwiches were a joke, the food was cold, smells horrible at times and the flavor was poor. In an interview on 4/15/2025 at 12:10 PM Resident #56 stated she normally doesn't eat because she doesn't like the meals that were served. She said she was not happy with meals. She stated she doesn't like the alternatives because they were not cooked well. She stated she would rather eat cereal than to eat the food being served. She stated she likes fruit, but it doesn't look appetizing. In an interview on 4/16/2025 at 9:20 AM Resident #39 stated food was mediocre. The resident stated mashed potatoes are served practically every day , the seasoning is very poor, and boring. She can ask for alternative of some sort of sandwich if she doesn't care for the food. In an interview on 4/16/2025 at 9:57 AM Resident #64 stated his eggs were burnt, this morning and he didn't care for the breakfast. In an interview on 4/16/2025 at 9:10 AM Resident #46 stated he did not like breakfast, the food has no taste to it, meat was dry, and cold. He stated he eats in the dining room and will be provided a substitute meal when he doesn't like what was being served. He stated he will usually ask for cereal, [NAME] Krispies. In an interview on 4/17/2025 at 2:21 PM the DM stated the Dietician provides him training on preparing menus, hand sanitation, food procurement, following recipes, diets, and puree preparation and in turn he trains the dietary staff. Surveyor asked DM for in-service logs during this interview, and he stated he doesn't complete his own in-service logs and the ADM would have in-service logs. He stated he would reach out to the ADM and obtain logs for surveyor (logs not provided prior to exiting). He stated the protocol for pureeing foods was to use milk, butter, gravy, broth, and thickening powder, if necessary, but to not use water. He stated he was unsure why [NAME] L would use water when pureeing foods as he knows it has no nutritional value. He stated he has the supplies needed to puree foods. He stated he was expected to follow the menus and understands he can add to the menu just not remove items or seasonings. He stated he will typically taste the food and believes it was good quality and flavorful and would eat it himself and he doesn't have concerns serving to the residents. He stated he was aware several residents were declining the meal trays, and he has instructed aids to notify him so he may offer a substitute. He stated he does not have substitutions documented. He stated he has been informed by aids and residents the food lacks flavor and would like other foods and he stated he wants to provide the residents with flavorful, edible, and presentable food so they would want to eat it. He stated the 8 lettuce heads in the walk-in refrigerator have been in there for four weeks now pending company picking up and he would have to follow-up with the company. He stated he did not inspect the food quality at delivery, and he had some items that was returning. He wasn't aware he needed to label it. He stated the black ripe bananas were kept in the kitchen for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 26 of 33 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 04/17/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents who require soft foods for consumption. He stated the expectation was for cooks to begin meal prep no more than two house prior to meal service. He discussed that he was not aware that [NAME] L was preparing lunch as early as 9:00 am on 4/15/2025 and that this can cause concerns for residents. In an interview on 4/17/2025 at 2:54 PM the ADM stated the DM receives in-services directly from the Dietician. The ADM stated the expectation was for the food to be warm and appetizing, that it tastes good, right temperature, and nutritious. The ADM stated she was aware of a few residents not liking the meals and being offered alternatives, which they decline as they were provided meals by their family. Surveyor requested in-service logs for all dietary staff (not provided to surveyor prior to exiting). In an interview on 4/17/2025 at 2:54 PM the DON stated she was aware that some residents don't like the type of food that was being prepared by the kitchen and were offered alternatives. She stated some residents have notified her that the food was sometimes cold, but this wasn't often. Record Review of Storage Freezer: Dietary Policy, no date revealed 2. Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. 2. Label and date all items. Record Review of Storage: Refrigerator: Dietary Policy, no date revealed 7. Keep refrigerated foods wrapped or covered and in sanitary containers. Record Review of Dietary Daily Functions: Dish machine: Dietary Policy, no date revealed Monitor and record temperatures and sanitizer solution at each meal. Record Review of Meal Delivery: Dining Rooms: Dietary Policy, no date revealed 3. Service must be prompt and efficient so that food will remain at the appropriate temperatures for consumption. 5. If the resident refuses any food item, the kitchen will supply a substitute of similar nutritive value. Acceptance or refusal of such substitution should be documented. Record Review of Menu Planning: Dietary Policy, no date revealed Menus will be posted and clearly visible to residents. Record Review of Dietary General Policies: Organizational Goals: Dietary Policy, no date revealed Provide the best quality food and food service for the residents within the budget as predetermined by the administration and according to established guidelines of all other regulatory agencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 27 of 33 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 04/17/2025 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 - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, interview, and record review the facility failed to serve each resident receives and the facility provides food prepared in a form to meet individual needs for one of one pureed food preparation. The facility failed to ensure [NAME] L prepared puree foods with adequate and appropriate liquids. These failures could result in choking hazards, decreased nutrient intake and weight loss. Findings included: Observation of cook, [NAME] L preparing puree foods on 4/16/2025 at 10:51 AM revealed he used water as the liquid to puree cornbread muffin. He was not following a specific recipe. In an interview on 4/15/2025 at 9:31 AM the DM stated the residents were not enjoying the facility meals because they were not feeling the Louisiana menu he was currently using to prepare foods from. He stated the company he procures product for provides a Louisiana menu and he was working on making the switch to a local, Texas procurement company. He stated there were contracts being worked on which will transition the facility over to a Texas menu beginning May 1, 2025. In an interview on 4/15/2025 at 10:48 AM Resident #67 stated he doesn't care for the meals being served from the kitchen and prefers the alternate choices of hamburgers, hotdogs, corndogs, and pizza. He stated 1-2 times per week he will choose the alternate meal because he was tired of constantly eating rice and beans and would prefer other options like chicken with mashed potatoes and carrots. In an interview on 4/15/2025 at 12:37 PM Resident #73 stated, she hates the lunch, she hasn't eaten the facility food in so long, roughly two years. She stated she used to eat the meats served for protein, but the food has become cardboard, really tough, and flavorless. She stated the alternative grilled cheese sandwiches were a joke, the food was cold, smells horrible at times and the flavor was poor. In an interview on 4/15/2025 at 12:10 PM Resident #56 stated she normally doesn't eat because she doesn't like the meals that were served. She said she was not happy with meals. She stated she doesn't like the alternatives because they were not cooked well. She stated she would rather eat cereal than to eat the food being served. She stated she likes fruit, but it doesn't look appetizing. In an interview on 4/16/2025 at 9:20 AM Resident #39 stated food was mediocre. The resident stated mashed potatoes are served practically every day , the seasoning is very poor, and boring. She can ask for alternative of some sort of sandwich if she doesn't care for the food. In an interview on 4/16/2025 at 9:57 AM Resident #64 stated his eggs were burnt, this morning and he didn't care for the breakfast. In an interview on 4/16/2025 at 9:10 AM Resident #46 stated he did not like breakfast, the food has no taste to it, meat was dry, and cold. He stated he eats in the dining room and will be provided a substitute meal when he doesn't like what was being served. He stated he will usually ask for cereal, [NAME] Krispies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 28 of 33 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 04/17/2025 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 - Few In an interview on 4/17/2025 at 2:21 PM the DM stated the Dietician provides him training on preparing menus, hand sanitation, food procurement, following recipes, diets, and puree preparation and in turn he trains the dietary staff. Surveyor asked DM for in-service logs during this interview, and he stated he doesn't complete his own in-service logs and the ADM would have in-service logs. He stated he would reach out to the ADM and obtain logs for surveyor (logs not provided prior to exiting). He stated the protocol for pureeing foods was to use milk, butter, gravy, broth, and thickening powder, if necessary, but to not use water. He stated he was unsure why [NAME] L would use water when pureeing foods as he knows it has no nutritional value. He stated he has the supplies needed to puree foods. He stated he was expected to follow the menus and understands he can add to the menu just not remove items or seasonings. He stated he will typically taste the food and believes it was good quality and flavorful and would eat it himself and he doesn't have concerns serving to the residents. He stated he was aware several residents were declining the meal trays, and he has instructed aids to notify him so he may offer a substitute. He stated he does not have substitutions documented. He stated he has been informed by aids and residents the food lacks flavor and would like other foods and he stated he wants to provide the residents with flavorful, edible, and presentable food so they would want to eat it. He stated the 8 lettuce heads in the walk-in refrigerator have been in there for four weeks now pending company picking up and he would have to follow-up with the company. He stated he did not inspect the food quality at delivery, and he had some items that was returning. He wasn't aware he needed to label it. He stated the black ripe bananas were kept in the kitchen for residents who require soft foods for consumption. He stated the expectation was for cooks to begin meal prep no more than two house prior to meal service. He discussed that he was not aware that [NAME] L was preparing lunch as early as 9:00 am on 4/15/2025 and that this can cause concerns for residents. In an interview on 4/17/2025 at 2:54 PM the ADM stated the DM receives in-services directly from the Dietician. The ADM stated the expectation was for the food to be warm and appetizing, that it tastes good, right temperature, and nutritious. The ADM stated she was aware of a few residents not liking the meals and being offered alternatives, which they decline as they were provided meals by their family. Surveyor requested in-service logs for all dietary staff (not provided to surveyor prior to exiting). In an interview on 4/17/2025 at 2:54 PM the DON stated she was aware that some residents don't like the type of food that was being prepared by the kitchen and were offered alternatives. She stated some residents have notified her that the food was sometimes cold, but this wasn't often. Record Review of Storage Freezer: Dietary Policy, no date revealed 2. Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. 2. Label and date all items. Record Review of Storage: Refrigerator: Dietary Policy, no date revealed 7. Keep refrigerated foods wrapped or covered and in sanitary containers. Record Review of Dietary Daily Functions: Dish machine: Dietary Policy, no date revealed Monitor and record temperatures and sanitizer solution at each meal. Record Review of Meal Delivery: Dining Rooms: Dietary Policy, no date revealed 3. Service must be prompt and efficient so that food will remain at the appropriate temperatures for consumption. 5. If the resident refuses any food item, the kitchen will supply a substitute of similar nutritive value. Acceptance or refusal of such substitution should be documented. Record Review of Menu Planning: Dietary Policy, no date revealed Menus will be posted and clearly (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 29 of 33 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 04/17/2025 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 visible to residents. Level of Harm - Minimal harm or potential for actual harm Record Review of Dietary General Policies: Organizational Goals: Dietary Policy, no date revealed Provide the best quality food and food service for the residents within the budget as predetermined by the administration and according to established guidelines of all other regulatory agencies. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 30 of 33 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 04/17/2025 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 - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. The facility failed to ensure [NAME] J were practicing proper hand hygiene while preparing foods. The facility failed to ensure DM were practicing proper hand hygiene as he entered and exited the kitchen. The facility failed to check produce for quality prior to delivery. The facility failed to ensure food service employees have received training related to dishwasher sanitation. The facility failed to ensure record keeping of dishwasher sanitation checks. The facility failed to keep refrigerated foods tightly wrapped or packaged. The facility failed to label and date all refrigerator and freezer items. The facility failed to provide an outline of dietary in-services and sign in attendance sheets for food service employees. These failures could place residents who were served from the kitchen at risk for consuming contaminated food, and/or developing foodborne illnesses. Findings included: Observation on 4/15/2025 at 9:00 AM revealed the entrance to the kitchen had a marked off orange area for staff entryway that was within proximity of the ice machine for resident consumption and coffee and iced tea station with trays of washed coffee mugs and cups for resident consumption of liquids. The walk-in refrigerator contained a large, unlabeled, and uncovered produce box of 8 lettuce heads with black leaves that indicated rotting. Observation on 4/16/2025 at 11:22 AM revealed DM returning from the dining room area without washing or sanitizing his hands and putting ice into a pitcher and filling it with water for residents. Observation on 4/16/2025 at 11:46 AM of [NAME] J cutting vegetables revealed that she removed her gloves to go check her personal phone call in the locker room. [NAME] J was observed checking her personal cell phone and returned to her workstation without washing or sanitizing her hands, she put her gloves on, and returned to cutting vegetables. Observation on 4/17/2025 at 9:30 AM of kitchen after breakfast meal service revealed DM and DA Q were working the hot temperature dishwasher. Staff was observed testing the temperature and logging it. There was no log or records for dishwasher sanitation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 31 of 33 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 04/17/2025 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 - Many In an interview on 04/15/2025 at 9:00 AM the DM stated the Dietician consults him on food storage and procurements, conducts walk through of kitchen, walk through of freezers and refrigerators and pinpoints areas to work on in the kitchen. In an interview on 4/16/2025 at 11:33 AM the Dietician stated she provides the facility 20 hours per month of clinical and kitchen consultation. She stated she performs kitchen walk throughs with DM, reviews meal tickets, provides consultation on kitchen operations, provides DM with training on hair restraints and hand washing. She stated that all dietary staff were to wash their hands every time they were soiled. She stated the orange zone near the kitchen entrance was implemented by the facility and allows for non-dietary staff to enter the kitchen up to the orange taped off area since there was no food production in that area. She stated since the ice machine and coffee station were not a food production area the facility does not require staff who stay behind the orange taped off area to wear a hairnet. In an interview on 4/17/2025 at 9:30 AM DA Q stated she had been employed with the facility for four months and had not been trained to use the dishwasher, but she had used the posters on the wall to help guide her to washing dishes. She stated she often washes the dishes, but she does not perform dishwasher temperature and sanitation checks. She stated she has not been trained on monitoring records and does not log information. She stated she would like more training to help her do her job better. DA Q stated she was under the impression the dishes were washed as long as the hot water temperature reached over 160 degrees. In an interview on 4/17/2025 at 9:30 AM the DM stated he was not familiar with checking dishwasher temperatures or sanitation. He stated his cooks usually perform this task. He stated there was a dishwasher temperature log that was up to date, but he was not aware he needed to keep sanitation logs and he was not sure how to perform sanitation testing. He stated to ensure dishes were washed the hot water temperature would have to reach above 160 degrees. He stated his cooks were not trained to check dishwasher sanitation levels as they did not have a log to document readings. They were only trained to check the sanitation levels of the 3 compartment sinks. In an interview on 4/17/2025 at 1:59 PM [NAME] J stated she had limited dietary training, but throughout her years as a cook she had been trained on infection control and proper hand washing. She stated that the policy for hand washing was staff were to wash hands every 30 minutes and each time they leave the kitchen area and return. She stated that the policy for hairnets was that all staff were to wear one when they enter the kitchen, no exceptions. She stated that if staff did not practice proper hand hygiene or use hairnets in the kitchen it could put the resident at risk of getting sick. She stated she does recall not washing her hands after returning from the locker and stated she overlooked this task as she was moving quickly. In an interview on 04/17/2025 at 2:21 PM the DM stated he had been trained on infection control and proper hand hygiene. He stated that dietary staff were all required to wash their hands after each task. He stated all staff members were required to wear hairnets and beard guards when entering the kitchen past the orange taped off area. He stated if staff did not perform proper hand hygiene it could cause the food to become contaminated and make the residents sick. He stated he was not sure why he did not wash his hands each time he entered the kitchen as he was to be modeling proper hand hygiene for his team and that he would be working on this. He stated that he was constantly reminding staff about hand hygiene and was aware that some of the dietary staff move quickly and forget to wash their hands between tasks. He stated he was responsible for monitoring to ensure that all staff were washing their hands. He stated he monitors the hand washing by reminding the staff and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 32 of 33 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 04/17/2025 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 observation. Level of Harm - Minimal harm or potential for actual harm In an interview on 4/17/2025 at 2:54 PM the ADON stated she has been trained on infection control and hand hygiene. She stated that all dietary staff were to wash their hands when entering the kitchen and all staff regardless of what department they worked in should be wearing a hairnet if entering the kitchen. She stated that the DM was responsible for providing dietary staff with in-services on dietary related topics. She stated she has conducted an in-service on hand washing for all facility staff. Residents Affected - Many Record Review of Hand Washing: Dietary Policy, no date revealed Hands must be washed: 1. As soon as you report on duty. 2. Before and after handling of food. 3. Before and after personal use of toilet. Proper Hand Washing is the single most important means of preventing the spread of infections. 2. Wash hands and wrists thoroughly. Record Review of Consultant Registered Dietician: Policy Interpretation and Implementation: Dietary Policy, no date revealed The RD (Registered Dietician) will review food service operation, and provide guidance and direction for the DM. Record Review of Dietary In-Service: Dietary Policy, no date revealed Educational programs designed to develop and improve skill and knowledge of the employees with respect to the needs of the residents will be planned on a yearly basis by the Dietician and/or DM. Purpose: These programs will enable the staff to acquire skills and techniques necessary to provide quality care to the residents. 2. Content on in-services will vary but must include at least one yearly in-service on: a. Proper food handling, c. Nutrition. 3. Attendance at the above in-services will be mandatory for all food service personnel. 4. An outline of each in-service and related handout(s) will be kept on file. 5. Every person attending the in-service will be required to sign an attendance sheet that will be kept on file with the outline. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676226 If continuation sheet Page 33 of 33