Inspection·October 27, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few said she did not want to be resuscitated if she were to stop breathing or her heart were to stop. I made that clear to my son and daughter. Resident #93 said she did not recall if the facility knew or documented her code status preference. Interview with RN A on [DATE] at 3:01 PM revealed he identified himself as Resident #93's nurse. When asked what was Resident #93's code status, RN A said Let me check. After RN A reviewed Resident #93's electronic record, he said There isn't a code status listed on her profile or in her doctors orders. The code status should be indicated in the doctor's orders. I can't find a Do Not Resuscitate (DNR) Form so I have to assume she is a full code, meaning if she stopped breathing or her heart stopped, we would try all attempts to revive her. RN A said it was Very important to have a code status identified Resident #93's profile and physician order so that staff could implement the correct resuscitation measures. Interview with the DON on [DATE] at 4:17 PM revealed she said Resident #93's electronic record should have had an updated and definite code status. The DON said she did not know why Resident #93's code status was not received and documented or how her care plan included a DNR status if Resident #93 did not have a legal DNR signed document. The DON said the code status of each resident was important to have documented and readily available to all staff to ensure We are fulfilling the resident and the family's wishes. We do not want to resuscitate anyone that wished not to be and [NAME] versa. The DON said monthly audits were conducted of care plans, including code status to ensure compliance. I think we would have picked it up on the next audit. The DON said she and the licensed nurses caring for the residents were responsible for ensuring physician orders and care plans were correct. Record review of the facility's undated Advance Directives policy and procedure documented To provide all individuals with information relating to the individual's rights under Texas law to make decisions concerning medical care, including the right to accept or refuse medical and surgical treatment and the right to formulate Advance Directives All advance directive information and forms are provided to the resident and/or responsible party at the time of admission to the community. The resident's chart will reflect all decisions made related to advance directives. A copy of the advance directives will be maintained in the medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 2 of 11 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 676327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare and Rehabilitation 1500 Cottonwood Creek Trail Cedar Park, TX 78613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframe's to meet a resident's medical and nursing needs for one (Residents #29) of 20 residents reviewed for person-centered care plans: The facility failed to recognize, develop, and implement a correct advance directive objective and care interventions in Resident #29's comprehensive person-centered care plan. These failures could affect residents in the facility by placing them at risk of not being provided necessary care and services, and not having plans developed to address their needs. The findings included: Record review of Resident #29's Face Sheet dated [DATE] documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Acute respiratory failure and malignant neoplasm [cancer] of lung and bone. Record review of Resident #29's Out of Hospital Do Not Resuscitate (DNR - a medical order written by a doctor that instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a person's breathing stopped or if the heart stopped) Order dated [DATE] revealed a signed declaration for a DNR order. Record review of Resident #29's significant change Minimum Data Set, dated [DATE] documented he had an active diagnosis of cancer and the resident has a condition or chronic disease that may result in a life expectancy of less than 6 months. Record review of Resident #29's [DATE] Physician's Orders documented [DATE] - Admit to Silverado Hospice with diagnosis: Malignant neoplasm [cancer] of lung Record review of Resident #29's comprehensive care plan dated [DATE] documented Resident wishes their code status to be full code. Interview with Registered Nurse (RN) A on [DATE] at 3:01 PM revealed he identified himself as Resident #29's current nurse. RN A said Resident #29 was considered a DNR code status. After RN A reviewed Resident #29's electronic profile and current physician orders, he said Yes, he is listed as DNR. When asked to review Resident #29's most recent care plan, RN A said It says he is a full code but I know that is not right because he just got picked up by hospice at the beginning of this month. RN A said Resident #29's care plan should have been updated at the time his DNR went into effect. RN A said it was important to ensure Resident #29's code status was correct to ensure the correct resuscitation was performed, at the resident's request, when needed. Interview with the Minimum Data Set Coordinator (MDSC) on [DATE] at 3:41 PM revealed he said he was responsible for ensuring that long term stay resident's care plans were updated and accurate. The MDSC said the care plan was a plan created that documented the care and interventions the resident needed to promote their most optimal well-being. The MDSC said the care plan was a reference for all staff caring for the resident to refer to to implement the care needed. The MDSC reviewed Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 3 of 11 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 676327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare and Rehabilitation 1500 Cottonwood Creek Trail Cedar Park, TX 78613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #29's care plan dated [DATE] and said the care plan documented that Resident #29 was a full code. The MDSC said Resident #29 was recently admitted to hospice.The MDSC did not respond to why Resident #29's care plan was not updated. In an interview with the Director of Nurses (DON) on [DATE] at 11:16 AM, she said the usual process was that the code status was put in the system upon admission. The DON said the code status of each resident was important to have documented and readily available to all staff to ensure We are fulfilling the resident and the family's wishes. We do not want to resuscitate anyone that wished not to be and [NAME] versa. The DON said monthly audits were conducted of care plans, including code status to ensure compliance. The DON said she, the MDS Coordinator, and the licensed nurses caring for the resident were responsible for ensuring physician orders and care plans were correct. Record review of the facility's Care Plans, Comprehensive Person-Centered policy and procedure dated [DATE] documented A comprehensive. person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial ad functional needs is developed and implemented for each resident The care planning process will incorporate the resident's personal and cultural preferences in developing the goals of care. The plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 4 of 11 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 676327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare and Rehabilitation 1500 Cottonwood Creek Trail Cedar Park, TX 78613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure that 1 of 4 (Resident #56) residents receiving oxygen on hallway 400 reviewed for respiratory care was provided care inconsistent with professional standards of practice. Residents Affected - Few Resident #56's oxygen tubing was not dated and was on the floor. This deficient practice could affect residents who received oxygen treatments and result in a respiratory infection. The findings included: Review of Resident #56's quarterly MDS dated [DATE] revealed an admission date of 9/29/2021 with diagnoses of Chronic Obstructive Pulmonary Disease with (acute) exacerbation. Observation on 10/26/22 beginning at 10:54 AM revealed nasal cannula being worn by Resident #56 while lying in bed. Resident #56's Oxygen tubing was on the floor and was undated. Interview on 10/26/2022 at 11:08 AM DON revealed she stated the tubing should be dated and should not be on the floor. The DON then immediately changed out the oxygen tubing with new tubing and dated it. Review of Resident 56's Physician Orders dated 10/02/21 and revised 10/09/21 documented Change nasal cannula and humidifier every week on Saturdays. Date tubing and humidifier when changing. Clean oxygen filter and concentrator every night shift, every Saturday. Interview on 10/27/2022 at 10:30 AM, Administrator was asked what could happen if oxygen tubing was left on the floor and undated. She stated So, it could be infection control. Something unclean, on the floor on a medical piece of equipment. Interview on 10/27/2022 at 11:00 AM with the DON concerning Oxygen tubing, DON stated, We know that there is risk for infection. The tubing can get tangled, increases the fall risk. Safety hazard as well. Review of the facility's policies and procedures titled MED-PASS, Inc Oxygen administration dated 2001 (revised 2010) includes instructions to check for kinks in the hose after placement but no instructions to date tubing. Review of In-service dated 10/25/2022 titled Oxygen and Continuous Positive Airway Pressure and Nebulizer included instructions to make sure tubing is not on the floor and is dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 5 of 11 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 676327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare and Rehabilitation 1500 Cottonwood Creek Trail Cedar Park, TX 78613 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 - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments on 1 of 9 medication carts reviewed for storage of drugs. 400 hall Nurses' Medication Cart was left unlocked by the 200/300 hall nurse's station area. This deficient practice could affect residents who have medications on the Nurses' Medication Cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. The Findings included: Observation on 10/25/22 at 2:18 PM revealed 400 hall nurse medication cart unlocked and unattended. A resident was on the right side of the medication cart less than one foot away. Six staff members were around the nurses station conducting shift change report. This surveyor opened the top drawer recognizing the cart being unlocked. Multiple medications in bulk bottles were easily assessable and removable. This surveyor was able to open all drawers and go through various medications for approximately 5 minutes before a nurse came around and asked what I needed. Interview on 10/25/22 at 2:23 PM revealed LVN H came around nurse's station and identified herself as being responsible for the unlocked medication cart. LVN H stated, I have never worked here before (was LVN H's first day of employment at the facility) and I apologize. I haven't even been here for an hour. This surveyor asked if leaving the nurse medication cart unlocked is normal practice for her and LVN H stated, no, I usually always lock my cart. This surveyor asked why it is important to keep nurse cart locked and LVN H stated, so people are not able to get into the cart that are not supposed to. Interview on 10/26/22 at 01:38 PM with Administrator and DON revealed Competency Training is conducted for all new staff and agency staff on their first shift. DON stated, the training includes, introduction to staff and residents, as well as, hand washing, medication administration, g-tubes, transfer, peri care and anything pertaining to the care the nurse/staff will be providing on their shift. [NAME] stated, random audits are conducted on new staff and agency staff to ensure competency. DON stated nursing staff informed her that they saw this surveyor open and look through the nurse's medication cart and assumed this surveyor was given access to the cart. I informed DON, this surveyor was not given access and found the nurse medication cart unlocked and unattended. Interview with DON revealed the facility began In-service on 10/26/2022 for Locked Medication Carts for all staff. Record review of Locked Medication Carts reviewd and verified. 10/26/22 01:32 PM Record review of Controlled Substances Policy dated April 2019 line 4 states; Access to controlled medication remains locked at all times and access is recorded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 6 of 11 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 676327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare and Rehabilitation 1500 Cottonwood Creek Trail Cedar Park, TX 78613 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 10/26/22 Record review of the Facility's Administering Medication Policy dated April 2019, states; Line 19 Level of Harm - Minimal harm or potential for actual harm During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medication and all outward sides must be inaccessible to residents or others in passing by. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 7 of 11 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 676327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare and Rehabilitation 1500 Cottonwood Creek Trail Cedar Park, TX 78613 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 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an Infection Prevention and Control Program designed to help prevent the standard and transmission based precautions to be followed to prevent the spread of infections or diseases for three residents (Resident #70, #87, and #96) of seven residents reviewed for medication pass and tracheostomy care. Residents Affected - Some 1.) CMA B did not clean or disinfect the electronic blood pressure cuff and monitor before or after it was used on Resident # 70 and then Resident #96. 2.) RN D failed to maintain a sterile field as per facility protocols. These failures could have affect residents who receive personal medical care at risk for improper care, infections, and illnesses. Findings included: 1.) Record review of Resident #70's October 2022 Physician Orders revealed his orders included to check blood pressure daily and document and Metoprolol Tartrate (used to lower high blood pressure) 25 mg daily for Hypertension (high blood pressure). Record review of Resident #96's October 2022 Physician Orders revealed her orders included to check blood pressure daily and document and Metoprolol Succinate (used to lower high blood pressure) 25 mg daily for Hypertension. Observation of medication pass performed by CMA B on 10/25/22 beginning at 9:50 AM revealed CMA B retrieved an electronic blood pressure cuff and monitor from the top drawer of her medication cart. CMA B used the blood pressure cuff and monitor to check Resident #70's blood pressure on his right upper arm. CMA did not clean or disinfect the blood pressure cuff prior to or after using it. At 10:07 AM, CMA B used the same blood pressure cuff and monitor to check Resident #96's blood pressure on her left upper arm. CMA B did not disinfect the blood pressure cuff or monitor before or after using the it. In an interview with CMA B on 10/25/22 at 10:35 AM, she said she should have disinfected the blood pressure cuff and monitor after each use, between resident use. CMA B said she did not disinfect the cuff this time because I forgot, but I know I'm suppose to disinfect it after I use it to prevent cross contamination. When asked what she used to disinfect the blood pressure cuff, CMA B said We use the bleach disinfecting wipes but I don't have any in my cart. CMA B said it was important to disinfect the cuff/monitor to prevent infection. CMA B said she was in-serviced on infection control approximately one month ago. During an interview with the Director of Nurses (DON) on 10/27/22 at 11:21AM, she said it was important for staff to disinfect the reusable equipment between resident use for infection control purposes, we do not want to spread any infections from one resident to the other. The DON said she had presented an in-service regarding disinfecting of resident care equipment in the past several months and the facility contract pharmacy assists us with med pass and med carts audits on a monthly basis. The DON explained the pharmacy conducted random medication pass observations to ensure staff compliance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 8 of 11 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 676327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare and Rehabilitation 1500 Cottonwood Creek Trail Cedar Park, TX 78613 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 0880 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Cleaning and Disinfection of Resident Care Items and Equipment policy and procedure dated October 2018 documented Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control recommendations for disinfection .c. Non-critical items are those that come in contact with intact skin but not mucous membranes. Residents Affected - Some (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. Most non-critical reusable items can be decontaminated where they are used. ----Reusable items are cleaned and disinfected or sterilized between residents (stethoscopes, blood pressure cuffs, durable medical equipment . 3. Durable medical equipment must be cleaned and disinfected before reuse by another resident . 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer instructions. Record review of the facility's Record of In-Service dated 06/09/22 documented All equipment taken into rooms and/or used on residents must be cleaned thoroughly with disinfectant. Equipment examples: vital sign equipment and glucometers CMA B's signature was on the back of the in-service which indicated she received the in-service. 2.) Record review of Resident #87's clinical file revealed a [AGE] year-old male, with an original admission date of 11/03/2017. Diagnosis included, Anoxic Brain Damage (type of brain injury that isn't usually caused by a blow to the head. Instead, anoxic brain injury occurs when the brain is deprived of oxygen), Age related physical debility, Type 2 Diabetes Mellitus (A condition results from insufficient production of insulin, causing high blood sugar), dysphagia (A condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink), Artificial Opening Status, (an opening in the body that has been created by a health care provider), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), Muscle weakness, Cognitive communication deficit (difficulties with communication that have an underlying cause in a cognitive deficit more than a language or speech deficit), Dysarthria and Anarthria (Difficulty in speech due to weakness of speech muscles), Chronic Pain, Cerebral Infarction (pathologic process that results in an area of necrotic tissue in the brain), Lack of Coordination, Hemiplegia and Hemiparesis (Weakness on half of the body), Traumatic Brain Injury, Dementia ( A group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident #87's most recent Care Plan for Tracheostomy care reviewed, and included: The resident has a tracheostomy r/t injury anoxic brain injury. oThe resident will have clear and infection through the review date. oThe resident will have no abnormal drainage around trach site through the oThe resident will have temp within normal limits through review date. oThe resident will have WBC count within normal limits through review date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 9 of 11 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 676327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare and Rehabilitation 1500 Cottonwood Creek Trail Cedar Park, TX 78613 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 0880 o6/26: Resp therapist to change out Trach Level of Harm - Minimal harm or potential for actual harm oCHANGE TRACH COLLAR every Mon. *NO DRAIN SPONGE TO SITE* Residents Affected - Some oCLEAN PASSY MUIR VALVE WITH WARM SOAPY WATER, RINSE THOROUGHLY IN WARM RUNNING WATER, DRY COMPLETELY BEFORE REPLACING oEnsure that trach ties are secured at all times. oMonitor/document for restlessness, agitation, confusion, increased heart rate (Tachycardia), and bradycardia. oMonitor/document level of consciousness, mental status, and lethargy PRN. oMonitor/document respiratory rate, depth and quality. Check and document q shift/as ordered. oProvide good oral care daily and PRN. oReassure resident to decrease anxiety. oSuction as necessary. oTRACH CARE Q SHIFT. ENSURE TRACH TIES ARE SECURE, MAKE SURE 2 FINGERS ONLY CAN FIT BETWEEN NECK AND TRACH TIE. DO NOT CHANGE TRACH COLLAR ONLY CHANGED ON MONDAYS. CHANGE DISPOSABLE INNER CANULA SHILEY #6 every day shift oTUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. oUse UNIVERSAL PRECAUTIONS as appropriate. Record review of Resident #87's most recent MDS data dated 09/25/22 identified a brief interview of mental status score of 12- moderately cognitively impaired. Resident #87 required total dependance on bed mobility, transfers, locomotion on and off unit, eating, toilet use, personal hygiene, bathing and is an extensive assist with dressing. Tracheostomy Care Observation on 10/27/22 at 01:32 PM by RN D and ADON revealed RN D did not maintain a sterile field while changing Resident #87's old tracheostomy cannula with a new one. RN D put on sterile gloves and used both sterile hands to remove tracheostomy cannula and proceeded to grab the new sterile tracheostomy cannula with both hands and inserted new tracheostomy cannula. Interview with RN D on 10/27/22 02:22 PM revealed she took responsibility for not maintaining a sterile field during tracheostomy cannula changes. RN D stated, I was nervous, and I was having trouble removing the cannula with the one hand so I used both hands. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 10 of 11 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 676327 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Springs Healthcare and Rehabilitation 1500 Cottonwood Creek Trail Cedar Park, TX 78613 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 0880 Level of Harm - Minimal harm or potential for actual harm Simultaneous Interview with Administrator and DON on 1/27/22 at 02:49 PM revealed the facility is planning on having a Respiratory therapist comes and conduct in person training for nursing staff on respiratory care. DON stated Resident #87 is the only tracheostomy resident in the facility at this time and RN D has not provided tracheostomy care in a while since resident was out and just returned to the facility. DON stated they are currently working on getting in person tracheostomy care training as soon as possible. Residents Affected - Some This surveyor asked what some risk factors Resident #87 could face due to RN D not maintaining a sterile field, and DON stated, well, an increase risk for infection and cross contamination. Possibly pneumonia or an upper respiratory infection. Administrator stated she does not have a clinical background but stated, Resident #87 is at risk for cross contamination and possible infection. DON stated, they were going to change out the tracheostomy cannula that was placed by RN D with a new sterile one. DON reiterated that the facility has not had a tracheostomy patient in a while and will be conducting the in person respiratory training. DON stated she asked RN D to get her prior to performing traceostomy care so she could assist but, RN D did not inform her and proceeded without her. Last Respiratory Therapy in service training could not be provided by time of exit. DON stated she has not been with the facility long and was not sure were previous DON placed those records. Record review of the facility Tracheostomy Care Policy, dated August 2013 documented Clean and Removable Inner Cannula, lines 8 through 12; 8. Put on sterile gloves. 9. Secure the outer neck plate with non-dominate hand. 10. Unlock the inner cannula with gloved dominate hand. 11. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident. Tracheostomy Care Policy General Guidelines line 1 (b, c) 1.Aseptic technique must be use:( Aseptic technique is employed to maximize and maintain asepsis, the absence of pathogenic organisms, in the clinical setting. The goals of aseptic technique are to protect the patient from infection and to prevent the spread of pathogens.) b. During all dressing changes until the tracheostomy wound has granulated (healed); and c. During tracheostomy tube changes, either reusable or disposable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 11 of 11