Inspection·October 12, 2023

F 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few diabetes, and interventions of dietary consult for nutritional regimen and ongoing monitoring, discuss meal times, portion sizes, dietary restrictions, snack allowed in daily nutritional plan, compliance with nutritional regimes, fasting serum blood sugar as ordered by doctor, monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd (abdominal pain), Kussmaul breathing (labored breathing), acetone breath (smells fruity), stupor (state of near unconsciousness-insensibility), coma, monitor/document/report PRN (as needed) any s/sx (signs or symptoms)of hypoglycemia: sweating, tremor, increased heart rate (tachycardia) Pallor(unusual signs of brightness in complexion) nervousness, confusion, slurred speech, ack of coordination, staggering gait, monitor/document/report PRN compliance with diet and document any problems, offer substitutes for foods not eaten, and refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. Review of Resident #1's orders, dated 10/10/2023, revealed no orders for insulin medications, to monitor for blood sugar levels, or orders for accu-checks. Review of Resident #1's September 2023 administration records, dated 10/10/2023, revealed no documentation of insulin orders, or or accu-checks completed. Review of Resident #1's October 2023 administration records, dated 10/10/2023, revealed no documentation of insulin orders, or accu-checks completed. Review of Resident #1's September 2023 weights and vitals records, undated, revealed no documentation for blood sugar levels, no information listed for a blood sugar summary. Review of Resident #1's October 2023 weights and vitals records, undated, revealed no documentation for blood sugar levels, no information listed for a blood sugar summary. Review of Resident #1's progress notes, dated 10/10/2023 at 16:38 (04:38 p.m.), revealed a note. Effective date:10/02/2023 Type: SBAR (Situation, Background, Assessment, and Recommendation or Request) Situation: The Change of Condition/s reported were Altered Mental Status BP 106/57-10/02/2023 17:13 (05:13 p.m.) position, lying down with right arm Pulse 81 Temp 97.6 Pulse Oximetry O2 (oxygen) 98 percent Blood Glucose was blank. Mental Status Evaluation was altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 2 of 8 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 10/12/2023 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 0635 PCP feedback, recommendations is STAT CBC BMP MG UA, sent to ER per family request. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #1's Stat Lab Results, dated 10/02/2023, CBC w/Auto Diff (Complete Blood Count with Differential) revealed: Collection Date: 10/02/2023 18:05 (06:05 p.m.), Comprehensive Metabolic Panel Residents Affected - Few Glucose: 498 mg/dl Review of Resident #1's Hospital Records, dated 10/11/2023, revealed an admit date of 10/02/2023, the Assessment/Plan indicated: AKI (acute kidney injury), hyperglycemia, hyperkalemia, hyponatremia, NSTEMI (non-ST elevated myocardial infarction). Further review of Resident #1's Hospital Records revealed History of Present Illness, [AGE] year-old male with past medical history of CHF, CKD not on dialysis, diabetes, high cholesterol presents from nursing facility. His (Resident #1) family went to visit him today and stated that he was confused and not at his baseline. His (Resident #1) last know well per family was yesterday. No report of trauma. EMS evaluated patient, noted him to have a wild complex rhythm, and concern for possible peak T waves. Under medical direction, they administered 2 g of calcium gluconate and started on albuterol nebulizer. Patient (Resident #1) received 5 mg albuterol prior to arrival. Additional review of Resident #1's Hospital Records revealed, Comprehensive Metabolic Panel on 10/02/2023 at 21:01(09:01 p.m.), glucose level was at 539 mg/dl. During an interview on 10/10/2023 at 11:50 a.m., NP stated she did not see Resident #1, these are notes from her colleague at the facility. NP stated she dive give the accu-check orders over the phone. NP added, per the record review there was nothing out of the ordinary, his routine labs were changed to stat labs, when the results came in the facility notified the on-call provider and Resident #1 was sent to the hospital. During an interview on 10/10/2023 at 02:53 p.m., DON stated Resident #1 was sent to the hospital, Resident #1s family was visiting and notice changes with Resident #1, family notified RN A, the on-call NP was notified, the NP had labs that were scheduled as routine, then changed it to stat labs, labs were completed the day Resident #1 was sent to the hospital, when the results came back, Resident #1 had been sent to the hospital for altered mental status. the stat labs results were taken on 10/02/23 at 18:05 (06:05 p.m.), and his glucose level was 498. DON stated that the on-call NP did give orders, she does not recall if it was written, it may have been from a telephone order, as sometimes NPs will be at the facility, that day the NPs were not. DON stated that the orders for the accu-checks should have been transcribed to Resident #1's EMR, RN A should have created the orders so it can be followed, and accu-checks were not completed. DON stated the facility investigated the incident, and reported the incident to HHSC, RN A was suspended at this moment. During an interview on 10/10/2023 at 04:03 p.m., RN A stated she was the nurse that admitted Resident #1, when he arrived, he was talking, weak, and RN A recalled that the resident (Resident #1) stated he was in pain. RN A stated he was on pain medications, and the hospital discontinued those medication. RN A stated that the resident's (Resident #1) primary diagnosis was CHF (congestive heart failure). RN A stated that she does not remember seeing orders to address Resident #1's diabetes, she recalled Resident #1 had medication orders for Levimir used for decreased appetite. RN A paged the on-call NP, and had a call with NP, there were telephone orders to Resident #1's blood sugars regularly. RN A stated that the order was used to monitor Resident #1's blood sugar levels, to check for anything abnormal, or high levels. RN A stated that she did not place the orders on Resident #1's EHR, stating, I missed to add the accu-check in the MAR and there was no accu-check completed, I should (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 3 of 8 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 10/12/2023 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few have double checked it, I remember being so busy that night, I am sorry, I did make a mistake and I am sorry, I wish that did not happen. RN A stated she does not recall having a discussion with Resident #1, or with his family about his diabetes. During an interview on 10/11/2023 at 09:00 a.m., Resident #1's family stated, Resident #1 was diabetic for the last 30 years and he was taking insulin for the last three years on a PRN (Pro Re Nata-As needed) bases. Family stated his primary care physician at Waco clinic recommended him to take insulin when his (Resident #1) blood sugar level exceed 400 mg/dl. Family further stated the facility have not given him any insulin or measured his blood sugar level, and that staff did not that he (Resident #1) had diabetes. During an interview on 10/11/2023 at 09:48 p.m., Hospital Doctor stated that Resident #1 was admitted due to a concern of pneumonia, his glucose was levels was at 539 mg/dl and that indicates he was not getting his insulin at the nursing facility, this was possibly due to his uncontrolled diabetes. The Hospital Doctor stated Resident #1s renal failure could have led to his hyperglycemia, it was hard to say, there were concerns focused on sepsis most likely from his pneumonia. During an interview on 10/11/2023 at 11:20 a.m., Facility MD stated that she looked at the hospital records, and the resident was admitted for the concerns of his (Resident #1's) significant heart failure, with volume overload, and possibility of pneumonia, the hospital did not note issues of hypoglycemia. MD stated that the nurse (RN A) should have transcribed the accu-checks, although there was no evidence that the lack of accu-checks resulted to Resident #1 being hospitalized , MD stated, there is no evidence of harm., the resident (Resident #1) had many chronic issues, and he (Resident #1) would have eventually gone to the hospital. Record Review of the Facility's Telephone Order Policy, dated January 2020, revealed a policy statement, Verbal telephone orders may be accepted from each resident's attending physician. Policy Interpretation and Implementation 1. Verbal telephone orders may only be received by licensed personnel (e.g. RN, LPN/LVN, licensed therapist, pharmacist, physician N.P., etc). Orders must be reduced to writing (handwritten on order, faxed, electronically, etc.), by the person receiving the order, and recorded in the resident's medical record. The ADM was notified on 10/11/2023 at 04:05 p.m. an IJ situation was identified due to the above failures and the IJ template was provided. The plan of Removal was accepted on 10/12/2023 at 03:36 p.m., and included: The facility staff failed to ensure that a Resident had sufficient physician orders for the resident's immediate care, orders were given for a resident's accu-checks were transcribed to the medical records system. Resident is a 79 y/o female admitted on [DATE] with diagnoses of Heart failure, acute kidney failure, weakness, and diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 4 of 8 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 10/12/2023 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few The Regional Director of Resident Care Service and Education conducted an inservice with facility DON and ADONs on admission Checklist on October 10, 2023. A re-inservice on admission Checklist will be conducted on October 12, 2023. The DON & ADON's In-serviced facility nurses & agency nurses on Completion of the New admission Checklist to include items below. Those staff members who are not present at the time of inservice, will not take a shift/return to work until the New admission Checklist inservice is completed. For any future staff members, this admission Checklist inservice will be part of orientation. o Admitting nurse validated new admitting resident name matches to transfer order - Ask Res. their name, if need to call RP to verify/describe resident. o Nurse completing the admission - All admitting orders verified by MD/N.P. on admission whether in person/phone. o All orders are scheduled appropriately - order written in PCC correctly and completely and is showing up in the MAR/TAR in PCC. o All orders have appropriate diagnosis to support the order o All orders transcribed appropriately after review and approve by MD/N.P. o Diabetes section of admission Checklist to be reviewed and Checked off by admitting Nurse includes: Accu check order & frequency Blood Sugar perimeters for MD/N.P. notification The Regional Director of Resident Care Services and Education will receive scanned copies from the facility DON and/or ADON's, a minimum of a weekly basis, each new admission Checklist for monitoring, validating compliance, and completion. This is for ongoing monitoring and compliance. Started 10/11/2023 Completed: 10//12/2023 and ongoing. DON Inservice nurses on Second Nurse validation check on Completion of admission Checklist and validating with hospital D.C. transfer orders and new orders given by MD/NP are entered into PCC. o (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 5 of 8 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 10/12/2023 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Inservice to be done in person for staff present, and then inservice to be recorded by Regional Director of Resident Care Services and Education. Recording will be presented to any staffing agency and all staff who are not present at the time of the initial in-person inservice. The recording will be viewed prior to the scheduled shift to be worked. o Residents Affected - Few For all new newly hired staff, as part of onboarding/orientation, the admission Checklist will be covered by the facility DON/ADON's. The orientation checklist will be reviewed by the facility HR department for completion and signature(s). o This DON and/or Administrator will monitor and validate compliance. o The Regional Director of Resident Care Services and Education will review inservice sheets on a weekly basis. Started 10/11/2023 Completed: 10/12/203 and ongoing New admission Checklists to be reviewed by DON, Administrator, and/or ADON in the next day Clinical Morning Meeting for 3rd validation monitoring check. [NAME] discrepancies will be immediately corrected and MD/N.P. notified for further orders. Started 10/11//2023 and ongoing Current inhouse residents with Diabetes diagnosis in E.H.R.'s was audited by the facility DON for accu-check orders and if no order for accu-checks, followed up with MD/N.P. on their medical opinion to add accu-check to the residents E.H.R. orders to be performed or MD/N.P. or rationale not to order accuchecks. Started 10/11/2023 To Be Completed: 10/12/2023 DON/ADON's to check/validate NMAR's for accu-checks completed per frequency order. A monitoring log will be initiated by the DON and monitored daily by the facility Administrator. A minimum of a weekly validation review by the Regional Director of Residence Care Services and Education will be conducted. Started: 10/12/2023 And will be ongoing DON/ADON Inserviced - if missing accu-check noted during validation check - Nurse scheduled at time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 6 of 8 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 10/12/2023 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 0635 Level of Harm - Immediate jeopardy to resident health or safety will be called to validate if completed at time due and not documented or if not performed. If no accu-check obtained since missed check, nursing to immediately perform an accu-check and Notify M.D./N.P. for further orders. A monitoring log will be initiated by the DON and monitored daily by the facility Administrator. A minimum of a weekly validation review by the Regional Director of Residence Care Services and Education will be conducted. Residents Affected - Few Started: 10/12/2023 And will be ongoing The Survey Team monitored the Plan of Removal on 10/12/2023: Observations on 10/12/2023 from 03:40 p.m. to 03:57 p.m., revealed staff in-serviced by Regional RN on admission Checklist, Diabetic Review Accucheck, admission Orders. During an interview on 10/12/2023 at from 03:58 p.m. to 05:12 p.m., 1st shift LVN A, 3rd shift ADON A, 1st shift LVN B, 2nd shift ADON B, and 2nd shift LVN C, stated they were educated and completed in-service on transcribing orders to residents EMR, the process of receiving admitting orders, using the new admission checklist, to consult with the NP for any discrepancies in a resident's admitting orders, consult with the admitting residents or family on medical history, validating with hospital D.C. transfer orders and new orders given by MD/NP are entered into PCC. All nurses were aware of the risks of not following the updated procedures, if plans are not followed residents, or admitting resident, may not receive optimal care and treatment, and if the updated procedures are not followed it may cause potential harm, injury, or death to residents. Further interviews ADON A, ADON B, LVN A, and LVN B, stated they are part of nursing management and have been educated and in-serviced on Second Nurse validation check on Completion of admission Checklist and validating with hospital D.C. transfer orders and new orders given by MD/NP are entered into PCC, next day Clinical Morning Meeting for 3rd validation monitoring check, check/validate NMAR's for accu-checks completed per frequency order, Blood Sugar perimeters and scanning and sending all new admission checklist to the regional director of resident care services and education for monitoring, validating compliance, and completion. During an interview on 10/12/2023 at 05:22 p.m., Regional Nurse stated in-services have been conducted on nurse management, floor nurses, PRN Nurses, she further stated that any PRN nurses that have not been called to work at this time and for all new hires for nurses will receive the same in-services and education as it is ongoing. There are required online videos that educates all incoming nurses, all nurses are required to complete the in-services and education before they start working on the floor. Regional Nurse stated that she will be sent the admission checklist weekly, she will monitor and review for accuracy and compliance. During an interview on 10/12/2023 at 6:00 p.m., DON stated she was in-serviced on requirements of the POR, the updated process of completion of admission checklist, and confirmed the 3 steps validation process for nurses, and the requirement of sending weekly updated of the new admission checklist to the Regional Nurse for monitoring. Record Review on 10/12/2023, revealed in-services on topics of admission Checklist, Second Nurse validation check on Completion of admission Checklist and validating with hospital D.C. transfer orders and new orders given by MD/NP, and missing accu-check noted during validation check process. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 7 of 8 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 10/12/2023 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 0635 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Record review on 10/12/2023, revealed audit by the facility Regional Nurse and DON for accu-check orders and if no order for accu-checks, followed up with MD/N.P. on their medical opinion to add accu-check to the residents E.H.R. orders to be performed or MD/N.P. or rationale not to order accu- checks completed. The ADM was notified on 10/12/2023 at 07:13 p.m. that the Immediate Jeopardy was lowered, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Event ID: Facility ID: 676327 If continuation sheet Page 8 of 8