Inspection·January 5, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few OOHDNRs. The DON stated they monitor to ensure the DNRs are legal by using a checklist for all new admissions. The DON stated they reviewed in quarterly IDT meetings for each resident, as well. The DON stated they entered an order for each OOHDNR, and she was not sure how the physician signature on Resident #29's DNR was missed. The DON stated the potential negative impact of such a failure was first responders might not have the right information, and that could result in a resident who did not want to prolong end of life being treated as if he were a full code. Review of facility policy dated [DATE] and titled Advance Directives reflected the following: Advanced directives will be respected in accordance with state law and community policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 2 of 40 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 01/05/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview, and record review, the facility failed to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS for 3 of 9 residents (Resident #32, Resident #41, and Resident #103) reviewed for comprehensive assessments. Interviews for activity preferences for Residents #32, #41, and #103 were not completed in the most recent comprehensive MDS assessments. This failure placed residents at risk of not having their recreational needs met. Findings included: Review of the undated face sheet for Resident #32 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure, congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), pleural effusion (accumulation of excess fluid in the area surrounding the lungs), metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), symbolic dysfunctions, need for assistance with personal care, speech disturbances, unsteadiness on feet, muscle weakness, lack of coordination, psychophysiological insomnia (sleep disorder due to imbalances in physical and psychological condition), major depressive disorder, dysthymic disorder (a long term and chronic form of depression), chronic pain, and encounter for palliative care (comfort support for end of life care). Review of the admission MDS assessment for Resident #32 dated 09/30/23 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #32 dated 10/03/23 reflected no care planning for activities or activity preferences. It reflected the following: The resident uses antidepressant medication, and The resident has an ADL self-care performance deficit r/t weakness/debility. Encourage the resident to participate to the fullest extent possible with each interaction. Observation and interview on 01/04/24 at 09:25 AM revealed Resident #32 was transferred by mechanical lift from his bed to his wheelchair. The CNAs who transferred him placed his bedside table in front of him with a remote and a pitcher of ice water and asked if he wanted anything else before leaving the room. Resident #32 stated he spent his days at the facility watching television and had nothing to do. He stated he was not sure what he would want to do, because he did not know what there was to do. Review of the undated face sheet for Resident #41 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral infarction (death of brain tissue), aphasia (speech difficulties), history of transient ischemic attack (minor stroke), unsteadiness on feet, reduced mobility, difficulty in walking, protein-calorie malnutrition, weakness, cognitive communication deficit (communication difficulty caused by impaired cognition), fluency disorder (interruption in the flow of speaking), muscle weakness, speech disturbances, bipolar disorder, hearing loss, and lack of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 3 of 40 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 01/05/2024 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 0636 coordination. Level of Harm - Minimal harm or potential for actual harm Review of the significant change MDS for Resident #41 dated 10/20/23 reflected a BIMS score of 03, indicating severe cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Residents Affected - Some Review of the care plan for Resident #41 dated 10/18/23 reflected the following: I can hear okay in some settings but not as well in large groups or large rooms. Has a variety of activity interests and a general willingness to take part in 1:1 activities. I will express daily satisfaction with daily social contacts and leisure activities by next reevaluation date. Encourage low-commitment, short 1:1 duration social activities to gain comfort due to my recent decline. Decrease the background noise. Encourage and praise attendance, engagement and participation within activities. I love to read. I will be offered reading material on a daily bases (sic). I will be offered adapted TV(closed captioning, magnified screen, or earphones). I will make selections and decisions within activities. Encourage the resident to use bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Observation on 01/05/24 at 09:36 AM revealed Resident #41 seated in a geriatric chair in the day area between 500 and 600 halls. He was staring toward the wall and made eye contact but did not respond when addressed. Review of the undated face sheet for Resident #103 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of humerus fracture (bone of upper arm), dysthymic disorder (a long term and chronic form of depression), epilepsy, history of malignant neoplasm of breast (breast cancer), major depressive disorder, secondary malignant neoplasm of brain (the breast cancer has spread to the brain), protein-calorie malnutrition, weakness, malaise, unsteadiness on feet, lack of coordination, and reduced mobility. Review of the admission MDS for Resident #103 dated 09/30/23 reflected a BIMS score of 13, indicating intact cognition . The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #103 dated 11/21/23 reflected no care planning for activities or activity preferences. It reflected the following: Impaired Coping. Resident Will Demonstrate Effective Coping Mechanisms. Monitor for signs / symptoms of depression. Provide care in a calm and reassuring manner. Observation on 01/05/24 at 08:50 AM revealed Resident #103 sitting on her bed, which was in low position, and touching her shoes and shoelaces. She made eye contact and engaged when approached, but when she tried to speak, her words could not be deciphered. She had an anxious expression on her face and continued to make eye contact as if she were trying to communicate but could not. During an interview on 01/05/24 at 02:37 PM, the AD stated she had been the AD for seven years until last year, had worked in a different role for over a year, and had just gotten back into the role in October 2023. The AD stated she was responsible for the activity preferences section of the MDS. She stated she had noticed a lot of the MDS activity assessments had not been done while she was not in the role. The AD stated she was not waiting until the next comprehensive MDS assessments were due but was catching up on the assessments as she could and triggering the activities task on the quarterly assessments. The AD stated she also completed the care plans, but since the MDS assessments (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 4 of 40 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 01/05/2024 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were not conducted, the care plans were not triggered. She stated she was not sure the potential impact on the resident of not having activities assessed or care planned, but some residents might not be able to do the activities they most enjoyed. During an interview on 01/05/24 at 02:55 PM, MDSN A stated he was the MDS nurse for the long-term side of the facility, so he oversaw the assessments, including the activities section. He stated the activities section should have been completed by the AD, but if the sections were not completed, he should have prompted the AD to fill them out. He stated the problem was the assessment questions had been answered with the answers Not Assessed in the most recent comprehensive assessments for Residents #32, #41, and #103, so the section turned green in the EMR, and it made him think they had been completed. During an interview on 01/04/24 at 02:18 PM, the ADM stated the facility used the CMS RAI Manual to determine procedure for MDS assessments and did not have a distinct facility policy. Review of undated facility policy titled Activities Program reflected the following: Complete activity/recreation services assessments are maintained by the activity department and are updated as necessary, but at least annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 5 of 40 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 01/05/2024 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 - Some 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 a comprehensive person-centered care plan for each resident for 3 of 8 (Resident #2, Resident #32, and Resident #103) residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #32's and Resident #103's care plans addressed their activity preferences. 2. The facility failed to ensure Resident #2's care plan reflected her current wounds. These failures placed residents at risk of not having interventions in place to address wounds and activities. Findings included: 1. Review of the undated face sheet for Resident #32 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure, congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), pleural effusion (accumulation of excess fluid in the area surrounding the lungs), metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), symbolic dysfunctions, need for assistance with personal care, speech disturbances, unsteadiness on feet, muscle weakness, lack of coordination, psychophysiological insomnia (sleep disorder due to imbalances in physical and psychological condition), major depressive disorder, dysthymic disorder(a long term and chronic form of depression), chronic pain, and encounter for palliative care (comfort support for end of life care). Review of the admission MDS assessment for Resident #32 dated 09/30/23 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #32 dated 10/03/23 reflected no care planning for activities or activity preferences. It reflected the following: The resident uses antidepressant medication, and The resident has an ADL self-care performance deficit r/t weakness/debility. Encourage the resident to participate to the fullest extent possible with each interaction. Observation and interview on 01/04/24 at 09:25 AM revealed Resident #32 was transferred by mechanical lift from his bed to his wheelchair. The CNAs who transferred him placed his bedside table in front of him with a remote and a pitcher of ice water and asked if he wanted anything else before leaving the room. Resident #32 stated he spent his days at the facility watching television and had nothing to do. He stated he was not sure what he would want to do, because he did not know what there was to do. During an interview on 01/04/24 at 09:25 AM, CNA Q stated Resident #32 only ever sat in his chair watching television. CNA Q stated hhe ad never seen Resident #32 be offered or participate in any (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 6 of 40 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 01/05/2024 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 activities. Level of Harm - Minimal harm or potential for actual harm Review of the undated face sheet for Resident #103 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of humerus fracture (bone of upper arm), dysthymic disorder (a long term and chronic form of depression), epilepsy, history of malignant neoplasm of breast (breast cancer), major depressive disorder, secondary malignant neoplasm of brain (the breast cancer has spread to the brain), protein-calorie malnutrition, weakness, malaise, unsteadiness on feet, lack of coordination, and reduced mobility. Residents Affected - Some Review of the admission MDS for Resident #103 dated 09/30/23 reflected a BIMS score of 13, indicating intact cognition. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #103 dated 11/21/23 reflected no care planning for activities or activity preferences. It reflected the following: Impaired Coping. Resident Will Demonstrate Effective Coping Mechanisms. Monitor for signs / symptoms of depression. Provide care in a calm and reassuring manner. Observation on 01/05/24 at 08:50 AM revealed Resident #103 sitting on her bed, which was in low position, and touching her shoes and shoelaces. She made eye contact and engaged when approached, but when she tried to speak, her words could not be deciphered. She had an anxious expression on her face and continued to make eye contact as if she were trying to communicate but could not. During an interview on 01/05/24 at 02:37 PM, the AD stated she had been the AD for seven years until last year, had worked in a different role for over a year, and had just gotten back into the role in October 2023. The AD stated she was responsible for the activity preferences section of the MDS. She stated she had noticed a lot of the MDS activity assessments had not been done while she was not in the role. The AD stated she was not waiting until the next comprehensive MDS assessments were due but was catching up on the assessments as she could and triggering the activities task on the quarterly assessments. The AD stated she also completed the care plans, but since the MDS assessments were not conducted, the care plans were not triggered. She stated she was not sure the potential impact on the resident of not having activities assessed or care planned, but some residents might not be able to do the activities they most enjoyed. During an interview on 01/05/24 at 02:55 PM, MDSN A stated he was the MDS nurse for the long-term side of the facility, so he oversaw the assessments, including the activities section. He stated the activities section should have been completed by the AD, but if the sections were not completed, he should have prompted the AD to fill them out. He stated the problem was the assessment questions had been answered with the answers Not Assessed in the most recent comprehensive assessments for Residents #32 and #103, so the section turned green in the EMR, and it made him think they had been completed. The MDSN A stated he was only responsible for the nursing portion of the care plans, and the other department heads were supposed to complete their own care plan items. He stated he might remind the other department heads to complete their portions of the care plan, but he had no actual authority over them, and it was up to the administrator to enforce. 2. A record review of Resident #2's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of multiple sclerosis (autoimmune disease), paraplegia (impairment in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 7 of 40 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 01/05/2024 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 - Some motor or sensory function), and pressure ulcer of unspecified site, unstageable (the wound is covered with a dark tissue known as eschar and the depth and staging cannot be determined). A record review of Resident #2's Medicare 5-day MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Section M (Skin Conditions) reflected she had one or more unhealed pressure ulcers/injuries. A record review of Resident #2's surgical note authored by the Wound Care Physician dated 10/31/2023 reflected she had a stage 4 pressure injury to left hip, thoracic spine, and left fibula, and a stage 3 pressure injury to the left lateral lower extremity. A record review of Resident #2's weekly wound progress report dated 11/01/2023 reflected she had four pressure injuries-one on the upper-mid vertebrae, one on the left trochanter (hip), and two on the left lower leg. A record review on 1/03/2024 of Resident #2's care plan reflected it was revised on 1/03/2024 to include a wound to her left ischial area, left leg and left sacral area. Prior to 1/03/2024, Resident #2's care plan had been revised on 10/24/2023 to reflect she had increased risk for further pressure ulcer development and on 12/10/2023 to reflect she had been re-admitted with a surgical flap to the lumbar spine.] During an interview and observation on 1/04/2024 at 3:02 p.m., Resident #2 was observed lying in bed. Resident #2 stated she had been there since October 2023, had wounds when she came in, and said she thought they had been getting better. During an interview on 1/05/2024 at 3:01 p.m., MDSN A stated he revised care plans for the long-term side of the facility, and that MDSN B was responsible for revising care plans on the 200 and 300 halls where Resident #2 resided. MDSN A stated MDSN B had been in that role for six years. MDSN A stated if care plans did not reflect a resident's current wounds, there could be a potential negative outcome if the resident were to transfer to another facility. MDSN A stated yes he considered two months to be a delay in revising Resident #2's care plan. MDSN A stated he could not say what happened in Resident #2's case. MDSN A stated MDSN B was on extended leave and not available for interview. During an interview on 1/05/2024 at 4:19 p.m., the DON stated the MDS coordinators were the ones who revised care plans, but other staff could revise them too. The DON stated ideally, they were revised when there was a change or something new. The DON stated at the time Resident #2 was admitted , there was not a dedicated treatment nurse and it should have been reflected on time. The DON stated MDSN B covered that side of the facility, and it would have been up to her to update Resident #2's care plan. The DON stated she had taken on the role of treatment nurse, and she would create lists and wound reports which MDSN B reviewed. The DON stated, I realized it was missed. The DON stated if care plans did not reflect residents' current wounds, a potential negative resident outcome could include inventions not being followed through. The DON stated with Resident #2, her interventions were put in via orders. The DON stated the facility wanted to make sure it was care planned so it popped up on their electronic records system for nurses to see. The DON stated the facility did not have a written care plan policy, but they went by the RAI manual. During an interview on 1/05/2024 at 4:50 p.m., the ADM stated she started working at the facility on 11/20/2023. The ADM stated yes wounds were supposed to be included in residents' care plans and resolved once something was healed. The ADM stated the facility monitored for care plans during their (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 8 of 40 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 01/05/2024 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 morning clinical meetings. The ADM stated sometimes the treatment nurse would take over the skin part of the care plan, and right then they did not have a permanent treatment nurse. The ADM clarified that this was how it worked at her last facility. The ADM stated the MDS nurses, ADON, DON or charge nurses could revise care plans. The ADM stated there was a possibility of missing a treatment if staff did not have the resident's full plan of care. Residents Affected - Some Review of undated facility policy titled Activities Program reflected the following: Complete activity/recreation services assessments are maintained by the activity department and are updated as necessary, but at least annually. The activity care plan contains a listing of activities that the veteran/resident enjoys, or may enjoy, and that has been approved by the veteran/resident and his or her attending physician. Individualized activity plans are integrated into the veteran/resident's total care plan and are reviewed at least quarterly. The plan is reviewed every time there is a change in the veteran's/resident's physical or mental condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 9 of 40 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 01/05/2024 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 0679 Provide activities to meet all resident's needs. 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 provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 4 residents of 24 residents (Resident #32, Resident #41, Resident #103, and Resident #104) reviewed for activities. Residents Affected - Some 1. Residents #32 and #103 were not engaged in a person-centered activity program and were not receiving activities. 2. The group activity program did not occur as scheduled from 01/04/24 to 01/05/24, and there were no activities scheduled on 01/03/24. 3. Residents #41, and #104 were observed sitting and doing nothing for hours in a common area of the facility. 4. Residents #32, #41, and #103 did not receive activity assessments on their comprehensive assessments. These failures placed residents at risk of boredom, depression, and a diminished quality of life. Findings included: Review of the undated face sheet for Resident #32 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure, congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), pleural effusion (accumulation of excess fluid in the area surrounding the lungs), metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), symbolic dysfunctions, need for assistance with personal care, speech disturbances, unsteadiness on feet, muscle weakness, lack of coordination, psychophysiological insomnia (sleep disorder due to imbalances in physical and psychological condition), major depressive disorder, dysthymic disorder (a long term and chronic form of depression), chronic pain, and encounter for palliative care (comfort support for end of life care). Review of the admission MDS assessment for Resident #32 dated 09/30/23 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #32 dated 10/03/23 reflected no care planning for activities or activity preferences. It reflected the following: The resident uses antidepressant medication, and The resident has an ADL self-care performance deficit r/t weakness/debility. Encourage the resident to participate to the fullest extent possible with each interaction. Review of initial activity evaluations for Resident #32 from his admission on [DATE] to 01/05/24 reflected one had not been completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 10 of 40 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 01/05/2024 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 0679 Review of activity logs for Resident #32 from 12/06/23 to 01/05/24 reflected no activities documented. Level of Harm - Minimal harm or potential for actual harm Observation on 01/03/24 from 08:30 AM to 03:20 PM revealed Resident #32 was in his room and not engaged in any activities. Residents Affected - Some Observation and interview on 01/04/24 at 09:25 AM revealed Resident #32 was transferred by mechanical lift from his bed to his wheelchair. The CNAs who transferred him placed his bedside table in front of him with a remote and a pitcher of ice water and asked if he wanted anything else before leaving the room. Resident #32 stated he spent his days at the facility watching television and had nothing to do. He stated he was not sure what he would want to do, because he did not know what there was to do. Observation on 01/05/24 from 08:30 AM to 01:05 PM revealed Resident #32 was in his room and not engaged in any activities. Review of the undated face sheet for Resident #103 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of humerus fracture (bone of upper arm), dysthymic disorder (a long term and chronic form of depression), epilepsy, history of malignant neoplasm of breast (breast cancer), major depressive disorder, secondary malignant neoplasm of brain (the breast cancer has spread to the brain), protein-calorie malnutrition, weakness, malaise, unsteadiness on feet, lack of coordination, and reduced mobility. Review of the admission MDS for Resident #103 dated 09/30/23 reflected a BIMS score of 13, indicating intact cognition. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #103 dated 11/21/23 reflected no care planning for activities or activity preferences. It reflected the following: Impaired Coping. Resident Will Demonstrate Effective Coping Mechanisms. Monitor for signs / symptoms of depression. Provide care in a calm and reassuring manner. Review of initial activity evaluations for Resident #103 from her admission on [DATE] reflected one had not been completed. Review of activity logs for Resident #103 from 12/06/23 to 01/05/24 reflected no activities documented. Observation on 01/03/24 at 08:50 AM revealed Resident #103 sitting on her bed, which was in low position, and touching her shoes and shoelaces. She made eye contact and engaged when approached, but when she tried to speak, her words could not be deciphered. She had an anxious expression on her face and continued to make eye contact as if she were trying to communicate but could not. Review of the undated face sheet for Resident #41 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral infarction (death of brain tissue), aphasia (speech difficulties), history of transient ischemic attack (minor stroke), unsteadiness on feet, reduced mobility, difficulty in walking, protein-calorie malnutrition, weakness, cognitive communication deficit (communication difficulty caused by impaired cognition), fluency disorder (interruption in the flow of speaking), muscle weakness, speech disturbances, bipolar disorder, hearing loss, and lack of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 11 of 40 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 01/05/2024 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 0679 coordination. Level of Harm - Minimal harm or potential for actual harm Review of the significant change MDS for Resident #41 dated 10/20/23 reflected a BIMS score of 03, indicating severe cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Residents Affected - Some Review of the care plan for Resident #41 dated 10/18/23 reflected the following: I can hear okay in some settings but not as well in large groups or large rooms. Has a variety of activity interests and a general willingness to take part in 1:1 activities. I will express daily satisfaction with daily social contacts and leisure activities by next reevaluation date. Encourage low-commitment, short 1:1 duration social activities to gain comfort due to my recent decline. Decrease the background noise. Encourage and praise attendance, engagement and participation within activities. I love to read. I will be offered reading material on a daily bases (sic). I will be offered adapted TV(closed captioning, magnified screen, or earphones). I will make selections and decisions within activities. Encourage the resident to use bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Review of activity logs for Resident #41 from 12/06/23 to 01/05/24 reflected no activities documented. Observations on 01/03/24 at 08:30 AM, 10:00 AM, and 12:55 PM revealed Resident #41 seated in a geriatric chair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. Observations on 01/04/24 from 10:12 AM to 11:57 AM and again from 01:10 PM to 03:00 PM revealed Resident #41 seated in a geriatric chair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. Observation on 01/05/24 at 09:36 AM revealed Resident #41 seated in a geriatric chair in the day area between 500 and 600 halls. He was staring toward the wall and made eye contact but did not respond when addressed. Review of the undated face sheet for Resident #104 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia, protein-calorie malnutrition, unsteadiness on feet, lack of coordination, cognitive communication deficit, muscle weakness, malaise, and dysthymic disorder. Review of the admission MDS assessment for Resident #104 dated 10/27/23 reflected a BIMS score of 06, indicating severe cognitive impairment. The activity preferences section of the assessment reflected staff assessed that it was important to Resident #104 to engage in listening to music, keeping up with the news, doing things with groups of people, and participating in his favorite activities. Observations on 01/03/24 at 08:30 AM, 10:00 AM, and 12:55 PM revealed Resident #104 seated in a wheelchair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. He stared into space. Observations on 01/04/24 from 10:12 AM to 11:57 AM and again from 01:10 PM to 03:00 PM revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 12 of 40 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 01/05/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #104 seated in a wheelchair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. Observation and interview on 01/05/24 at 09:36 AM revealed Resident #104 seated in a wheelchair in the day area between 500 and 600 halls. Resident #104 said he was fine and did not know where he was or what was going on. Review of the activity calendar for January 2024 reflected no activities scheduled for 01/03/24. On 01/04/24 was scheduled the following: 10:00 AM Independent Activity of Your Choice 11:00 AM Chicken Foot Game 01:00 PM Uno Card Game 02:00 PM Skip-Bo Card Game 03:00 PM Dominos On 01/05/24 was scheduled the following: 08:30 AM Reflect & Pray 10:00 AM Bingo w/ (volunteer) 11:00 AM 1431 Café Outing 02:00 PM Residents Choice Observation on 01/03/24 between 08:30 AM and 02:00 PM revealed no activities going on. At 03:00 PM, a volunteer arrived at the facility to call bingo. Observation on 01/04/24 at 11:10 AM, 01:10 PM, 02:15 PM, and 03:20 PM revealed Chicken Foot, Uno, Skip-Bo, and Dominos were on a table in the activity room. There was no one in the activity room facilitating the games. Observation on 01/05/24 between 08:30 AM and 03:30 PM revealed none of the scheduled activities occurring. During a confidential interview with nine anonymous residents, they all agreed that activities had barely been occurring and anyone who was not part of the core group of residents who participated in group activities was not receiving any activities at all. They all said the AD was back, and they loved her, but she was too busy going to meetings or something else to assist them with the activities they liked to do. They stated there was always an excuse, and they did not really know what the problem was, but they had complained about it, and nothing had changed . During an interview on 01/05/24 at 02:37 PM, the AD stated she had been the AD for seven years (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 13 of 40 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 01/05/2024 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some until last year, had worked in a different role for over a year, and had just gotten back into the role in October 2023. The AD stated she was responsible for the activity preferences section of the MDS. She stated she had noticed a lot of the MDS activity assessments had not been done while she was not in the role. The AD stated she was not waiting until the next comprehensive MDS assessments were due but was catching up on the assessments as she could and triggering the activities task on the quarterly assessments. The AD stated she also completed the care plans, but since the MDS assessments were not conducted, the care plans were not triggered. She stated she was not sure the potential impact on the resident of not having activities assessed or care planned, but some residents might not be able to do the activities they most enjoyed. The AD stated Resident #104 was offered individualized activities and mostly liked to watch television. She stated she had offered individualized activities but had not documented and did not document activities in any log for any resident. The AD stated Resident #103 had moved from short term to long term at the facility, and the AD had not interacted with her since she had been there. The AD stated she did not know if Resident #103 was receiving any activities. The AD stated she had seen Resident #103 in bingo, but Resident #103 did not participate. The AD stated she did not know what Resident #103 liked. The AD stated that she did not know Resident #32 and had not assessed him or engaged with him in any way. The AD stated she had received grievances from the resident council about the activities program. She stated they have mostly told her they would like her to be more present. The AD stated she was not present, because she was busy in care plan meetings and doing MDS assessments. The AD stated things had fallen through the cracks but would not elaborate on what she meant. The AD stated none of the residents had withdrawn or become more depressed that she was aware of. She stated she had been sick for the previous couple of days and had been catching up that day 01/05/24. She stated nobody was designated to take over activities when she was not there. She stated some people called bingo while she was gone, but the regular activities that were scheduled on the calendar had not occurred in her absence. The AD stated it was important for all residents to receive recreational therapy because without it, they could decline, have poor motivation, not want to eat, lose weight, or become more depressed. The AD stated when she had the role of activity director before, she had an assistant, but she no longer had one. She stated it was very hard to meet the recreational needs of over 100 residents with just one person, especially when she was catching up on assessments and care plans. During an interview on 01/05/24 at 02:55 PM, MDSN A stated he was the MDS nurse for the long-term side of the facility, so he oversaw the assessments, including the activities section. He stated the activities section should have been completed by the AD, but if the sections were not completed, he should have prompted the AD to fill them out. He stated the problem was the assessment questions had been answered with the answers Not Assessed in the most recent comprehensive assessments for Residents #32, #41, and #103, so the section turned green in the EMR, and it made him think they had been completed. The MDSN A stated he was only responsible for the nursing portion of the care plans, and the other department heads were supposed to complete their own care plan items. He stated he might remind the other department heads to complete their portions of the care plan, but he had no actual authority over them, and it was up to the administrator to enforce. During an interview on 01/05/24 at 04:33 PM, the ADM stated there were lots of opportunities to improve the activities program. She stated she had not addressed activities formally with the QAPI , but she needed to work with the AD. The ADM stated she did not think the entire facility's activity needs could be met by one person. The ADM stated residents were all entitled to recreation based on their abilities and preferences and potential negative impacts of not receiving activities were boredom, weight loss, and increased behaviors. Review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 14 of 40 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 01/05/2024 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 0679 undated facility policy titled Activities Program reflected the following: Level of Harm - Minimal harm or potential for actual harm The community provides an ongoing, organized program of activities designed, in accordance with the comprehensive assessment, to meet the interests and to maintain the physical, mental, and psychosocial well-being of each veterans/resident. Residents Affected - Some The activities program is an essential component of the community's fulfillment of its obligation to care for its veterans/residents in a manner and environment that maintain or enhance each veteran/resident's quality of life. The activity program is designed to encourage restoration of self-care and maintenance of normal activity and is geared to meet the individual veterans/resident's needs. The activities program consists of individualized and group sessions, and: flexible schedules, choices, and rights of the veteran/resident; is offered at hours convenient to the veterans/residents, including evenings, holidays, and weekends; reflects the cultural and religious interests of the veterans/residents; appeals to both men and women, as well as to all age groups of veterans/residents residing in the community. The activity program consists of individual and small and large group activities that are designed to meet the needs and interests of each veteran/resident and includes, at a minimum: -social activities -Indoor and outdoor activities -Activities away from the community -Religious programs -Creative activities -Intellectual and educational activities -Exercise activities -Individualized activities -In room activities -Community activities -Military holidays and observance Each resident must have an individualized care plan, and the community is obligated to provide activities that meet each resident's individual needs. Once the veteran/resident is admitted , complete an activity service assessment to identify his or her past and present interests. This assessment is used to develop an individual activity plan that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 15 of 40 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 01/05/2024 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 0679 will allow the resident to participate in activities of his or her choice and interest. Level of Harm - Minimal harm or potential for actual harm Sometimes physical and mental conditions prevent residents from participating in activities they have enjoyed throughout their lifetimes. These preferences and passions are noted and included in the assessment. Residents Affected - Some When there is limitation on their ability to participate, the community should find alternative means of addressing the interest. Complete activity/recreation services assessments are maintained by the activity department and are updated as necessary, but at least annually. The activity care plan contains a listing of activities that the veteran/resident enjoys, or may enjoy, and that has been approved by the veteran/resident and his or her attending physician. Individualized activity plans are integrated into the veteran/resident's total care plan and are reviewed at least quarterly. The plan is reviewed every time there is a change in the veteran's/resident's physical or mental condition. Activities are conducted in accordance with the activity schedule, which should include input from the community's resident council. The Activity Director is responsible for keeping appropriate departmental records in order to maintain, plan, and develop the activity programs. The following records, at a minimum are maintained by activity department personnel: -Activities services -Attendance records -Calendar of events -Activity, progress, notes -Individualized activity plan -Quarterly MDS assessments -Record of reviews and updates -Other recordkeeping reports as necessary and appropriate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 16 of 40 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 01/05/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for 1 of 6 halls (hall 600) and 1 of 24 residents (Resident #11) reviewed for accident hazards. The shower room located next to room [ROOM NUMBER] was unlocked due to a broken lock. Residents had full access to the room. Toxic solutions with poison control warnings and hazardous sharps items were stored in the room unsecured. The locking cabinet inside the room was missing a lock. Resident #11 had an unmonitored bottle of hand sanitizer on the resident bedside table. The bottle had a poison control warning. These deficient practices place residents in the facility at risk for avoidable accidents and hazards. Findings include: A record review of Resident #11's Care Plan and admission record reflects, I have impaired cognitive function I display impaired decision making. Date initiated 12/13/18 Revision 4/28/2020 and a diagnosis of Schizophrenia, unspecified. A record review of Resident #11 MDS assessment reflects MDS Diagnosis indicated as 02 Non-Traumatic Brain Dysfunction Brief interview for Mental Status (BIMS) score is 10 . An observation on 01/03/24 at 09:48 a.m. revealed Resident #11 had a bottle of Purell hand sanitizer on her bedside table. Residents state Mine when the surveyor touched the bottle . She was able to get the bottle herself. The bottle ingredients listed active ingredients as Ethyl Alcohol 70%. The warnings on the label include: do not use in eyes, keep out of reach of children .If swallowed get medical help or contact poison control right away. An observation on 01/03/24 at 10:08 a.m. revealed an unlocked shower room located next to room [ROOM NUMBER]. The room contained an overflowing sharps container with approximately 7 disposable shaving razors laying on top or partially protruding out of the sharp container and dirty nail clippers laying on the sink counter. An unlocked cabinet in the room contained multiple bottles of [NAME] Mouthwash with a product warning saying, Keep out of reach of children. In case of accidental ingestion, seek professional assistance or contact a poison control center immediately. The room also contained overflowing trash container and used bath towels laying on the floor . The door of the shower room had a number pad lock that a passing staff member stated was broken and 2 holes drilled through the door approximately ½ inch in diameter. Paper had been stuffed in the holes to protect privacy. During an interview on 1/3/24 at 10:08a.m. CNA H stated they do not use the shower room on hall 600room for residents as they are bathed in the front shower; it is just used for storage. She said the door should have been locked. She stated that the clippers are dirty and would not be used on a resident. She stated the locking code was out of order. Regarding the risk to residents, CNA H stated that they would have to take the lid off razors to get hurt but it is a possibility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 17 of 40 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 01/05/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview regarding the shower room on 01/03/24 at 10:21 a.m. RN C stated, so it needs a lock pretty much. She stated the potential risk is harm if a patient gets in. She denied knowing when the lockwent out of service. During an interview on 1/5/24 at 3:33 pm ADON stated that her expectations on areas with hazardous material was I wouldn't want them going in there. She stated that overflowing sharps containers should be changed at the full line and that she would consider that hazardous if they were overflowing. ADON stated that alcohol hand sanitizers should up out of reach from residents-Ideally locked up. She stated that she would consider unmonitored mouthwash and alcohol sanitizers to be potentially hazardous for cognitively impaired residents. She said the potential risk would be if residents were to get these items, confused resident could ingest them. During an interview on 1/5/24 at 4:12 pm DON stated that her expectations on areas with hazardous material for residents was Expect they can't get to the material. She stated that overflowing sharps containers should be emptied, locked, secured and put away in the Biohazard room and that she would consider that hazardous if they were overflowing. DON stated that regarding alcohol hand sanitizers in patient rooms Ideally no but, some have preferences after covid. We try to avoid that happening. She stated that she would consider unmonitored mouthwash and alcohol sanitizers to be potentially hazardous for cognitively impaired residents. She said the potential risk to residents would be Poison control - risk of ingesting. During an interview on 1/5/24 at 4:45 pm ADM stated that her expectations on areas with hazardous material for residents was the areas should be locked and residents do not have access. She stated that overflowing sharps containers should not exist and that they would consider them very much so a hazard. The ADM stated that alcohol hand sanitizers in resident's room should not be accessible to them. She said unmonitored mouthwash and alcohol hand sanitizer could possibly be hazardous for cognitively impaired resident depending on ingredients. They should not have access. ADM stated the risk would be that they could get ill to the point of harm. A record review of the policy titled Sharps Disposal Policy Statement from the Infection Control Section of Nursing Services Policy and Procedure Manual for Long Term Care 2001 Med-Pass, Inc,(Revised January 2012) reflects Designated individuals will be responsible for sealing and replacing containers when they are full to protect employees from punctures and/or needlesticks when attempting to push sharps in to the container. A record review of the policy titled Hazardous Areas, Devices and Equipment from the Resident Safety Section of Nursing Services Policy and Procedure Manual for Long Term Care 2001 Med-Pass, Inc,(Revised January 2017) reflects, All hazardous areas, devices and equipment in the community will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. The policy also reflects, Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous .The safety committee will periodically check for the implementation and integrity of measures intended to prevent residents from accessing hazardous areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 18 of 40 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 01/05/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 to meet the needs of each resident for 1 of 24 residents (Resident #42) reviewed for pharmaceutical services. The facility failed to ensure that Resident #42 received his medications on the morning of 01/03/24. This failure placed residents at risk of not receiving medication therapy. Findings included: Review of the undated face sheet for Resident #42 reflected a [AGE] year-old male admitted to the facility on [DATE] with chronic obstructive pulmonary disease, type two diabetes mellitus, obstructive sleep apnea, atrial fibrillation, morbid obesity due to excess calories, lack of coordination, need for assistance with personal care, ataxic gait, age related, physical debility, muscle wasting and atrophy, unsteadiness on feet, insomnia, difficulty in walking, asthma, muscle weakness, vitamin D deficiency, cellulitis, hyperlipidemia, constipation, hypokalemia, edema, anxiety disorder, heart failure, canis of skin and nail, acquired absence of kidney, cognitive communication deficit, major depressive disorder, dementia, obstructive and reflux neuropathy, gastroesophageal reflux disease, and anemia. Review of the annual MDS assessment for Resident #42 dated 12/17/23 reflected a BIMS score of 15, indicating intact cognition. Review of the care plan for Resident #42 last revised 12/18/23 reflected the following: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Administer ANTIDEPRESSANT medications as ordered by physician Monitor/document side effects and effectiveness Q-SHIFT. Give medications as ordered. Monitor for side effects, effectiveness. Give cardiac medications as ordered. Review of the physician orders for Resident #42 dated 01/05/24 reflected the following: -Flonase Suspension 50 mcg/act 1 spray in both nostrils one time a day for SR start date 04/07/23 -Olmesartan Medoxomil Oral Tablet 20 mg give one tablet by mouth one time a day related to essential hypertension. Hold for SBP less than 110. Start date 06/03/23. -Potassium chloride ER tablet extended release 10 MEQ give 1 tablet by mouth one time a day for hypokalemia start date 11/10/22 -Slow-Mag Tablet Delayed Release 71.5-119 mg (magnesium CL - calcium carbonate) give one tablet by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 19 of 40 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 01/05/2024 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 0755 mouth one time a day for hypo magnesium start date 11/10/22 Level of Harm - Minimal harm or potential for actual harm -Tamsulosin HCL capsules 0.4 MG give one capsule by mouth, one time a day related to disorder of kidney and ureter unspecified; obstructive and reflux neuropathy; do not open or crush capsule start date, 01/19/21 Residents Affected - Few -Torsemide oral tablet 20 mg give one tablet by mouth one time a day related to heart failure start date 08/18/23 -Vitamin D3 capsule give 1000 IU by mouth one time a day related to vitamin D deficiency start date 10/15/2022 -Xarelto oral tablet 20 MG give one tablet by mouth one time a day related to paroxysmal atrial fibrillation start date 07/02/23 -Zoloft tablets give 75 MG by mouth, one time a day for depression start date 09/01/20 -Zyrtec allergy tablet 10 MG give one tablet by mouth one time a day related to other asthma start date 08/31/21 -Guaifenesin ER tablet extended release 12 hour 600 MG give one tablet by mouth two times a day for congestion start date 12/27/23 -Tramadol HCL tablet 50 MG 50 MG by mouth two times a day for pain start date 05/12/23 -Tylenol extra strength tablet 500 MG give 1000 MG by mouth two times a day for pain do not exceed 3G in 24 hours Review of the January 2023 MAR for Resident #42 reflected the following medications were documented as administered on 01/03/24 at the respective times listed: -Flonase Suspension 50 mcg/act 09:00 AM by MA L -Potassium chloride ER tablet extended release 10 MEQ 06:30 AM by MA L -Slow-Mag Tablet Delayed Release 71.5-119 mg (magnesium CL - calcium carbonate) 06:00 AM- 10:00 AM by MA L -Tamsulosin HCL capsules 0.4 MG 06:00 AM-10:00 AM by MA L -Torsemide oral tablet 20 mg 06:00 AM-10:00 AM by MA L -Vitamin D3 capsule 06:00 AM-10:00 AM by MA L -Xarelto oral tablet 20 MG 06:00 AM- 10:00 AM by MA L -Zoloft tablets give 75 MG 06:00 AM-10:00 AM by MA L -Zyrtec allergy tablet 10 MG 06:00 AM-10:00 AM by MA L (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 20 of 40 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 01/05/2024 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 0755 -Guaifenesin ER tablet extended release 12 hour 600 MG 06:00 AM-10:00 AM by MA L Level of Harm - Minimal harm or potential for actual harm -Tramadol HCL tablet 50 MG 06:00 AM-10:00 AM by MA L -Tylenol extra strength tablet 500 MG 06:00 AM-10:00 AM by MA L Residents Affected - Few The following medication was not marked as administered , and there was a blank spot in the administration record: -Olmesartan Medoxomil Oral Tablet 20 mg 06:00 AM-10:00 AM Review of the medication audit document for Resident #42 for 01/03/24 reflected the following actual administration times: -Flonase Suspension 50 mcg/act 12:22 PM by MA L -Olmesartan Medoxomil Oral Tablet 20 mg 06:00 AM-10:00 AM 09:31 PM by the ADON -Potassium chloride ER tablet extended release 10 MEQ 12:21 PM by MA L -Slow-Mag Tablet Delayed Release 71.5-119 mg (magnesium CL - calcium carbonate) 12:20 PM by MA L -Tamsulosin HCL capsules 0.4 MG 12:22 PM by MA L -Torsemide oral tablet 20 mg 12:22 PM by MA L -Vitamin D3 capsule 12:20 PM by MA L -Xarelto oral tablet 20 MG 12:22 PM by MA L -Zoloft tablets give 75 MG 12:21 PM by MA L -Zyrtec allergy tablet 10 MG 12:20 PM by MA L -Guaifenesin ER tablet extended release 12 hour 600 MG 12:22 PM by MA L -Tramadol HCL tablet 50 MG 12:22 PM by MA L -Tylenol extra strength tablet 500 MG 12:20 PM by MA L During an observation and interview on 01/03/24 at 01:27 PM, Resident #42 stated he had not received his morning medication that day. He stated he was not feeling any negative effects, but he was angry about the oversight. He stated he had filed a grievance about the incident. Observation of Resident #42 at this time revealed he was not exhibiting any signs of pain and had no unusual swelling of his extremities. He was not sweating or short of breath, and his skin color was normal. His demeanor was not agitated or resigned; rather he was laughing about the missed medications. During an interview on 01/05/24 at 01:48 PM, MA L stated she was from a staffing agency and had only worked a few times at the facility. She stated she had been assigned to work Resident #42's hall (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 21 of 40 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 01/05/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on 01/03/24. She stated morning administration workload could be a little heavy especially when she had to look for the residents somewhere else in the building. MA L stated someone could have told her where Resident #42 would be, but she did not think to ask, and she did not find him in his room. MA L stated when she arrived at his room, he had gone to breakfast, and she cannot administer medications in the dining room. She stated she revisited his room after breakfast, but he was not there, and she did not ask anyone to help her find him. MA L stated by the time she went looking for him, it was past the time for his medications, and they were late. MA L stated he refused his medications at that time. She stated it was close to 02:00 PM on 01/03/24 when he refused his medications officially. She stated she did not report the refusal to a nurse or anyone else. She stated she documented the medications as administered in the MAR, because she did not know what else to do and did not ask. MA L stated the DON had given her an in-service the following day on 01/04/24 about the correct procedure for medication administration and documentation. During an interview on 01/05/24 at 03:54 PM, the DON stated Resident #42 had filed a grievance about not receiving his morning medications on 01/03/24, and she had conducted a one on one in-servicing with MA L. The DON stated when they learned he had not received his morning medications, they had requested and obtained a one-time order to give the medications late , but he refused at that time, even taking his blood pressure. The DON stated she had notified the NP about the missed medications. The DON stated she was not aware of any adverse effect, and the nurses had been monitoring for that. The DON stated she had followed up again herself yesterday 01/04/24 and made sure Resident #42 was okay. The DON stated potential negative impacts of missing doses of the medication Resident #42 missed were Increase in blood pressure, complaints of pain, or fluid overload. During an interview on 01/05/24 at 04:29 PM, the ADM stated she understood the medication aide went to Resident #42 later than the administration window, and he was frustrated and said she was too late. The ADM stated she ensured medications were administered on time by relying on the EMR, which shifts colors and tells the staff when medications were late. She stated the ADON also periodically pulled a report to see if there were any late or missing medications. The ADM stated the potential negative outcome for residents depended on what medications were missed and what they were used for. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 22 of 40 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 01/05/2024 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 - Many 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 ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication storage rooms (Transition Care Unit Storage room) and 4 of 5 medication carts (600 Hall MA cart, 600 Hall Nurse cart, 300 Hall Nurse cart, 400/500 Hall MA cart) reviewed. The facility failed to ensure expired medications were removed, food products were not in the carts and failed to ensure the carts were clean of potential contaminants. These failures could place residents who receive medications at risk for receiving outdated or contaminated medications which could result in residents not receiving the intended therapeutic effects of their medications. Findings included: Observation on 1/04/20243 at 7:40 AM in the medication storage room on the Transitional Care Unit revealed 1 bottle of Slow-Mag plus Ca with expiration date 10/2023 and 3 bottles of Slow-Mag plus Ca with expiration date 11/2023, MVI with expiration date 12/2023, Ca plus D 5 mcg with expiration date 05/2022, Thiamin B-1 100 mg with expiration date 12/2023, Ocular Vitamins expired 10/2023, 2 bottles Mucus relief Dextromethorphan with expiration dates 03/2023 and 09/2022. In an interview on 01/04/2024 at 7:49 AM ADON stated expired medications could possibly do harm to a patient if given and would not be as effective. Observation on 01/04/2024 at 8:10 AM of the 600 Hall MA cart revealed 1 bottle of Vit B-12, 1,000 mg expired 01/2023, Slow-Mag with Ca expired 11/2023, Vision eye drops expired 12/2023 and Sodium Chloride 1 gm expired 11/2023. In an interview on 01/04/2024 at 8:16 AM the CS/MR stated she had worked in the facility full-time for one year but was still learning her role as the person responsible for checking expired dates on medications. She stated she had not been able to check the carts due to training for medical records and being off for vacation. She stated she tried to check the medication carts once a week on Mondays. Observation on 01/04/2024 at 8:25 AM of the 600 Hall Nurse cart revealed 2 packages of petroleum-based dressings open and with sticky residue on them in the cart with other medications. There were 4 NS 100 ml with expiration dates 11/30/2022, an Albuterol Sulfate inhaler expired on 07/25/2023 and an Albuterol Sulfate Inhaler expired on 10/23/2023. A bottle of Chlorhexidine Gluconate solution (antimicrobial and antiseptic) had an expiration date of 09/2021. In an interview on 01/04/2024 at 8:48 AM RN C stated every nurse is responsible for ensuring medications are not expired. She stated the petroleum-based dressing should have been bagged and dated but would be thrown away. She stated she was supposed to check the cart every day, but she had not checked medications for expired dates on 01/04/2023. She stated she checked the dates on the medications she was administering but no one person was responsible for ensuring expired medications were not on the carts. She further stated the risk to the resident could be adverse side effects and potential (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 23 of 40 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 01/05/2024 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 harm. Level of Harm - Minimal harm or potential for actual harm Observation on 01/04/2024 at 9:25 AM of the 300 Hall nurse cart revealed tea bags and artificial sweetener in the top drawer of the cart. A loose white powder was observed in the bottom of a box that contained several topical medications. Residents Affected - Many In an interview on 01/04 2024 at 9:30 AM LVN F stated tea bags should not be in the cart. She stated she did not know what the white powder was in the box with the topical medications but speculated it might have been an antifungal power. She further stated the loose powder could potentially contaminate the other medications in the box. Observation on 01/04/2024 at 9:39 AM of the 400/500 Hall MA cart revealed a vitamin herbal complex with an expiration date of 11/2023. In an interview on 01/04/2024 at 9:45 AM MA K stated she had worked at the facility for three years. She stated a resident should not take expired medications as they could have an adverse reaction and the potency would not be as good. In an interview on 01/05/2024 at 11:18 AM the DON stated nurses should be checking the medication expiration dates prior to administering. She stated the CS/MR was responsible for checking the medication storage rooms and they should have been checked prior to her leaving on vacation. She stated she was surprised the Pharmacist did not catch the expired medications. She stated the nurses and medication aides are responsible for keeping the carts clean and that food items are not acceptable in the medication carts. She stated if medications are past their expiration dates it could affect their potency. She stated her expectation was for the medication carts and medication storage rooms to be audited at least weekly for expired medications. In an interview on 01/05/2024 at 1:40 PM the RPh stated she would recommend audits of the medication storage rooms and medication carts either at the beginning or end of the month. She stated the potential risk for residents receiving expired medications would be they would not receive the full potency of the medication. In an interview on 01/05/2024 at 1:43 PM the DRC stated her expectation was for the facility to remove expired medications from the medication carts and storage rooms. She stated food items should not be on the medication carts. She stated the opened petroleum gauze should have been bagged and the resident's name written on it, otherwise it should have been discarded. She stated the carts should be kept clean to prevent contamination of medications. In an interview on 01/05/2024 at 4:50 PM the ADM stated there should not be any expired medications on the carts or in the medication storage rooms. She stated the potential negative outcome to a resident if they received an expired medication was the effectiveness would be changed and it would not treat their medical issue appropriately. She further stated the carts should be kept clean to prevent contamination of medications and to prevent any harm to the nurse handing the medications. She stated any opened wound care products should have been discarded and food items should not be kept in the carts. Record review of the facility Policy and Procedure for Pharmacy Services revised on 12/01/2021 reflected Receipt of medication: Upon delivery by the pharmacy, the facility nurse or designee will assume responsibility for the receipt, proper storage, and distribution of medications. The consultant (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 24 of 40 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 01/05/2024 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 pharmacist will ensure the proper labeling and storage of all pharmaceutical products, to include medications and biologicals are stored safely, securely, and properly based on manufacturers recommendations and/or currently accepted professional standards. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 25 of 40 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 01/05/2024 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 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, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for food storage and sanitation. The facility failed to ensure all foods were properly covered, labeled, dated and discarded. The facility failed to ensure chemicals were not stored near food items. The facility failed to ensure the trash can was covered when not in use. The facility failed to ensure CK N washed her hands in between tasks. The facility failed to ensure sanitized the food processor after washing it. These failures placed residents at risk for foodborne illness. Findings included: An observation of the kitchen's walk-in refrigerator on 1/03/2024 at 8:17 a.m. revealed a steam pan of leftover enchiladas dated 12/29/2023. The steam pan was halfway covered with plastic wrap, leaving half of the pan exposed to air. An observation of the kitchen's walk-in refrigerator on 1/03/2024 at 8:18 a.m. revealed a steam pan of unidentifiable substance unlabeled and undated. There was also a 12-quart container of an unidentifiable liquid unlabeled and undated. During an interview on 1/03/2024 at 8:24 a.m., DA O stated the unidentifiable substances were pasta salad and soup from the night prior and they forgot to put a date on it. When asked if the enchiladas should be covered, DA O stated, it's trash and stated leftovers were only kept for three days. An observation of the kitchen's prep area on 1/03/2024 at 8:30 a.m. revealed CK N was preparing a food item at the prep table approximately four feet away from an uncovered trash can which was not in use. An observation of the kitchen on 1/03/2024 at 10:31 a.m. revealed CK N was pureeing green beans. Observed CK N take the food processor to a two-compartment prep sink, wash it, and return it to the prep counter. The two compartment sink did not contain sanitizer. CK N removed her gloves and put on new gloves without washing her hands. CK N proceeded to puree fried chicken. An observation on 1/03/2024 at 10:45 a.m. revealed CK N took off her gloves after she finished pureeing fried chicken, put on new gloves, and rinsed off and scrubbed the food processor using a sudsy liquid from a small red bucket. CK N then removed her gloves and put on new gloves without washing her hands. CK N proceeded to puree scalloped potatoes. During an interview on 1/03/2024 at 10:48 a.m., CK N stated the small red bucket contained dish soap. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 26 of 40 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 01/05/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observations of the kitchen's dry room storage on 1/03/2024 at 10:59 a.m. revealed one gallon container of Italian dressing and three-gallon containers of pickles with no received date. There were also two boxes filled with 6 bottles each of bleach stored in proximity to food items. An observation of the kitchen's prep area on 1/03/2024 at 11:08 a.m. revealed CK M was preparing cookies approximately 5 feet away from an uncovered trash can which was not in active use. An observation of the puree process on 1/04/2024 at 10:28 a.m. revealed CK N pureed green peas, took the food processor to the three compartment sink in the dish room, and washed, rinsed and sanitized it using a sprayer to squirt sanitizer on the processor. The third compartment did not contain sanitizer. An observation on 1/04/2024 at 10:36 a.m. revealed that after washing the food processor, CK N removed her gloves, put on new gloves, and began pureeing rice. CK N did not wash her hands. An observation on 1/04/2024 at 10:43 a.m. revealed the three compartment sink was then filled with sanitizer solution. CK N washed, rinsed and submerged the food processor in sanitizer. CK N then removed her gloves and put on new gloves but did not wash her hands. CK N proceeded to puree meat. An observation of the kitchen's prep area on 1/04/2024 at 10:53 a.m. revealed CK M was preparing a dessert item approximately four feet from an uncovered trash can which was not actively being used. During an interview on 1/04/2024 at 10:53 a.m., CK N stated she usually used the three compartment sink to wash the food processor but she did not do that the day prior (1/03/2024) because they were working on it. CK N explained that someone else had been using the sink at that time. CK N stated yes that items needed to be submerged in sanitizer solution for them to be sanitized. CK N stated she usually washed her hands after handling dirty dishes, but she had not done that because she wanted to speed it up. During an interview on 1/05/2024 at 8:59 a.m., the DM stated he would need to refer to the facility's written policy to cite what it said in regard to food storage. The DM stated foods should be covered in airtight bags with a label and date. The DM stated yes items also needed a received date. The DM stated they did not have lids for the trash cans, they had been trying to get some, but they were not available through their supplier. The DM stated they tried to keep the trash far away from the prep area. The DM stated chemicals were stored off the ground in the dish room or in a utility closet. The DM stated he was aware of there being bleach in the dry storage room and said, I think we just put it there. The DM stated it was off the ground and not over or under anything, but said he guessed he could find room somewhere else. The DM stated the process for sanitizing dishes was to wash, rinse, sanitize and air dry and said hands needed to be washed in between handling dirty dishes and preparing a food item. The DM stated he monitored the kitchen for food storage and sanitation through daily walk throughs and checklists. The DM stated all dietary staff had been trained in those areas. The DM stated he did not know whether he had done an in-service on food storage in a while but said everyone knew to label and date. The DM stated he had recently completed an in-service on handwashing and said he did hands-on training with staff as well. The DM stated the RD monitored via monthly kitchen audits. The DM said he had worked in the facility for a year and a half and said the facility was a rough one when he first started. The DM stated if food storage and sanitation practices were not followed, it could result in sickness and in this population it's extremely important. During an interview on 1/05/2024 at 1:45 p.m., the RD stated he would have to look up the exact (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 27 of 40 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 01/05/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many wording of the facility's food storage policy. The RD stated he was unaware of why the kitchen did not have lids to the trash can, stated his company's policy was to discard leftovers after 72 hours, and said he would need to get back to the surveyor on when dietary staff needed to wash their hands. The RD stated if food was not stored properly and sanitation practices were not followed, it could lead to foodborne illness. During an interview on 1/05/2024 at 4:27 p.m., the ADM stated leftovers needed to be labeled, dated and stored for no more than 72 hours. The ADM stated food should not be open to air when stored on the shelf. The ADM stated items needed to be dated when they were received, and she would not expect chemicals to be stored in the same room as food. The ADM stated no the sanitizing process should not be skipped and said hands needed to be washed after washing equipment. The ADM stated the DM, the RD and herself monitored the kitchen for food storage and sanitation through rounding. The ADM stated the trashcan should be covered when not in use. The ADM stated if foods were not stored properly or sanitation practices were not followed, it could lead to contamination of the food which could make residents ill. A record review of the FDA's 2017 Food Code reflected the following: 7-201.11 Separation. POISONOUS OR TOXIC MATERIALS shall be stored so they can not contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLESERVICE and SINGLE-USE ARTICLES by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning; P and (B) Locating the POISONOUS OR TOXIC MATERIALS in an area that is not above FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE or SINGLE-USE ARTICLES. This paragraph does not apply to EQUIPMENT and UTENSIL cleaners and SANITIZERS that are stored in WAREWASHING areas for availability and convenience if the materials are stored to prevent contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. 7-201.11 Separation. POISONOUS OR TOXIC MATERIALS shall be stored so they can not contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLESERVICE and SINGLE-USE ARTICLES by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning; P and (B) Locating the POISONOUS OR TOXIC MATERIALS in an area that is not above FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE or SINGLE-USE ARTICLES. This paragraph does not apply to EQUIPMENT and UTENSIL cleaners and SANITIZERS that are stored in WAREWASHING areas for availability and convenience if the materials are stored to prevent contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 28 of 40 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 01/05/2024 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 0812 (B) After using the toilet room Level of Harm - Minimal harm or potential for actual harm (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B) Residents Affected - Many (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. A record review of the facility's in-service dated 10/07/2023 reflected dietary staff were in-serviced on the sanitization procedure. A record review of the facility's policy titled Garbage Receptacles dated June 1 2019 reflected the following: Policy: The facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 29 of 40 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 01/05/2024 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 0812 Indoor receptacles: Level of Harm - Minimal harm or potential for actual harm Waste handling units for refuse and for use with materials containing food residue shall be durable, cleanable, insect and rodent resistant, leak proof, and nonabsorbent. Residents Affected - Many Trash cans will be kept with lid in place when not in use. A record review of the facility's policy titled Manual Cleaning and Sanitizing of Utensils and Portable Equipment dated October 1 2018 reflected the following: Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Procedure: 1. Use a three-compartment sink with running hot and cold water for cleaning, rinsing and sanitizing. 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75°F or ii. A minimum of 12.5 parts per million of available iodine in a solution with a pH not higher than five and a temperature not less than 75°F or iii. Any other chemical sanitizing agent which has been demonstrated to be effective and non-toxic under use conditions and for which a suitable field test is available. Such other sanitizing agents, in-use solutions, shall provide the equivalent sanitizing effect of a solution containing at least 50 parts per million of available chlorine at a temperature not less than 75°F. The concentration and contact time for quaternary ammonium compounds shall be in accordance with the manufacturer's label directions. A record review of the facility's policy titled Food Storage dated June 1 2019 reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedures: 1. Dry storage rooms i. Do not use or store cleaning materials or other chemicals where they might contaminate foods. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 30 of 40 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 01/05/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Label and store them in their original containers when possible. Store in a locked area away from any food products. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 31 of 40 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 01/05/2024 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 maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 6 residents (Resident #51, Resident #65, Resident #97 and Resident #314) reviewed for infection control, in that: Residents Affected - Some 1. The facility failed to ensure Resident #97's enteral formula was timed and initialed after it was opened. 2. LVN E did not wash or sanitize her hands during glove change following removal of Resident #314's old wound care dressing. 3. Resident #65's oxygen nasal canula was not dated and was laying on the floor and Resident #51's oxygen nasal cannula was laying on the floor. These deficient practices place residents in the facility at risk for infections due to improper care practices. Findings include : A record review of Resident #51's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, epilepsy, metabolic encephalopathy (disturbed brain function), and cognitive communication deficit. A record review of Resident #51's 5-day MDS assessment dated [DATE] reflected a BIMS score of 07, which indicated severely impaired cognition. Resident #51 required moderate to extensive assistance from another person and frequent bowel and bladder incontinence. A record review of Resident #65's face sheet dated 1/05/2024 reflected a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses of Fracture right femur, metabolic encephalopathy (disturbed brain function), transient cerebral ischemic attack, hypertension, atrial fibrillation, and hypertension. A record review of Resident #65's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08, which indicated moderately impaired cognition. Resident #65 required extensive assistance from another person and had bowel and bladder incontinence. A record review of Resident #97's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of aphasia (difficulty communicating), metabolic encephalopathy (disturbed brain function), dysphagia (difficulty swallowing), gastrostomy status (artificial external opening into the stomach for nutritional support), gastro-esophageal reflux disease (acid reflux) and adult failure to thrive. A record review of Resident #97's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 32 of 40 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 01/05/2024 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 Residents Affected - Some A record review of Resident #97's care plan last revised on 10/24/2023 reflected she received tube feedings related to dysphagia and she was to receive 1 carton of [enteral formula] 1.5 via bolus (intermittent) feedings TID. A record review of Resident #314's face sheet, dated 01/05/24, reflected an [AGE] year-old female admitted on [DATE] with diagnoses of osteoarthritis of left hip, atrial fibrillation, chronic pain syndrome, diabetes mellitus type 2, hypertension, cognitive communication deficit, restless leg syndrome, reduced mobility and unsteadiness on feet. A record review of Resident #314's admission MDS assessment dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Resident #314 required extensive assistance via wheelchair and walker, and bowel and bladder incontinence. A record review of Resident #314's care plan initiated on 12/28/23 reflected she was admitted to skilled services/therapy due to weakness/debility w/potential for decreased functional abilities with acute illness and/or injury, and Resident #314 has actual impairment to skin integrity of the left heel which was initiated on 01/03/24. Intervention for left heel blister initiated on 01/04/24 included to cleanse left heel blister with normal saline and pat dry, apply calcium alginate and cover with dry dressing daily. Replace dressing PRN if soiled, loose, or removed. An observation on 1/03/24 at 8:20am revealed Resident #51's oxygen nasal canula was not dated and was laying on the floor. CNA I entered the room and placed the nasal canula in the resident's nose without cleaning it. An observation on 1/03/2024 at 9:05 a.m. revealed Resident #97 was lying in bed sleeping. There was an opened container of enteral formula dated 1/2/24 sitting on Resident #97's dresser. The formula was not timed or initialed. Resident #97 was non-interviewable. An observation on 1/3/24 at 11:30am revealed Resident #65's O2 nasal cannula on the floor. CNA J picked up the canula to place it back on the resident, but the resident refused to wear it at that time. The cannula was then draped on the resident's left shoulder so he could put it in his nose when needed. The canula was not cleaned by the CNA. An observation on 1/03/2024 at 11:59 a.m. revealed the formula dated 1/2/24 was sitting in the same spot located on Resident #97's dresser. An observation on 1/04/2024 at 9:24 a.m. revealed there was a one third full container of enteral formula dated 1/4/24 on Resident #97's dresser. The formula was not timed or initialed. During an interview on 1/04/2024 at 9:28 a.m., LVN P stated Resident #97 ate food by mouth but if she did not eat, she received extra formula. LVN P stated that morning Resident #97 had refused breakfast, so she got extra formula. An observation on 01/04/24 at 01:26 PM of wound care for Resident #314 with LVN E revealed LVN E washed her hands, donned gloves, and disinfected the bedside table. LVN E removed gloves, placed wax paper on the clean surface, and gathered wound care supplies. DON washed hands, donned gloves, and assisted with Resident #314's left lower limb positioning. LVN E removed the old dressing from the left heel and changed gloves. Resident #314's left heel blister was observed a deep purple color and approximately 3.5cm x 3.0cm. LVN E cleansed the left heel blister with normal saline and 4 x 4 gauze. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 33 of 40 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 01/05/2024 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 Residents Affected - Some LVN E changed her gloves, and no handwashing or hand hygiene was observed with the glove change. LVN E applied calcium alginate to the left heel wound and covered it with an adhesive dressing that was initialed and dated. LVN E and DON conducted handwashing upon completion of wound care. During an interview on 01/04/24 at 01:46 PM with LVN E revealed she should have brought hand sanitizer to the bedside while conducting wound care for Resident #314, and an adverse outcome of not sanitizing hands when changing gloves would be a possible wound infection. During an interview on 1/5/24 at 10:30 am CNA G stated that she was trained on infection control and resident items on the floor would concern her. She stated that she would sanitize them first before residents handle them. She stated that a nasal canula on the floor should be trashed and replaced with a new one. If it could not be replaced, she stated it should be sanitized. Failing to sanitize could lead to an infection for the resident. During an interview on 1/5/24 at 10:43am RN C stated that if a nasal canula was on the floor she would discard it and get a new one. She stated if a new one was not available, she would sanitize before use. She indicated that failing to sanitize would create a source of infection as they did not know what is on the floor. During an interview on 1/05/2024 at 3:37 p.m., the ADON stated she oversaw the short-term wing where Resident #97 resided. The ADON stated as long as formulas were dated, they could be used at room temperature for 24 hours as long as they were capped. The ADON stated nurses administered formula and they had all been trained on how to store it. The ADON stated nurses were supposed to date, time and initial the bottle when it was opened. During an interview on 01/05/24 at 03:47 PM with DON revealed her expectation of hand hygiene while providing wound care to residents was handwashing/hand hygiene and glove change should be conducted when going from dirty to clean, such as after removing and disposing of the old dressing, and after going from clean to dirty, such as gathering and setting up wound care field and then removing old dressing. DON further stated an adverse outcome of staff not following infection protocol while providing resident care would be a possible wound infection. During an interview on 1/05/2024 at 3:52 p.m., the DON stated opened enteral formulas were dated and timed and said they were good for 24-48 hours. The DON stated opened containers could be used later but if it was not marked with what time it was opened, nurses should discard it. The DON stated Resident #97's enteral formula was on backorder, so they had to order larger containers. The DON stated nurses monitored other nurses to ensure enteral formulas were labeled appropriately. The DON stated formula administered past its recommended storage time could result in a less potent formula or GI symptoms such as upset stomach. During an interview on 1/05/24 at 4:30 p.m., the DON stated her expectation of a nasal canula on the floor would be to change it. She stated an alternative if they could not change it, is to disinfect following the time guidelines on the wipes. She indicated the risk of not disinfecting or replacing the nasal cannula could cause a respiratory infection. During an interview on 1/5/24 at 4:45 p.m., the ADM stated her expectation for a nasal cannula on the floor would be to replace it. If it could not be replaced, then sanitize and date it to avoid the risk of infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 34 of 40 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 01/05/2024 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 Residents Affected - Some During an interview on 01/05/24 at 04:47 PM with ADM revealed her expectation for infection control protocol during wound care was for staff to conduct handwashing before and after to prevent spread of infection. ADM further stated the potential adverse outcome of staff not following infection control protocol during resident care would be cross contamination of wound care products. A record review of the physician orders dated 6/16/23 reflected Resident #65 was prescribed 2-3 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of the physician orders dated 12/6/23 reflected Resident #51 was prescribed 2 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of the facility's policy titled Handwashing dated 10/24/22 reflected, All staff members are required to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice. The CDC guidelines regarding handwashing are to be followed by staff members after each resident contact. A record review of the facility's policy titled Infection Control - Surveillance for Infections dated September 2017 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility. A record review of the facility's policy titled Enteral Feedings - Safety Precautions dated November 2018 reflected the following: Purpose To ensure the safe administration of enteral nutrition. General Guidelines Preventing contamination 2. Maintain strict adherence to storage conditions and timeframes. a. Store unopened liquid enteral formulas in temperature and light-controlled conditions (cool, away from direct sunlight). b. Maintain inventory controls and discard any formula past the expiration date. 3. Maintain strict adherence to maximum hang times: a. Powdered, reconstituted formula and formula with additives have a maximum infusing (hang) time of 4 hours. b. Sterile formula in a closed system has a maximum hang time of 48 hours. Preventing errors in administration 2. On the formula label document initials, date and time the formula was hung, and initial that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 35 of 40 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 01/05/2024 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 label was checked against the order. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 6 residents (Resident #51, Resident #65, Resident #97 and Resident #314) reviewed for infection control, in that: Residents Affected - Some 1. The facility failed to ensure Resident #97's enteral formula was timed and initialed after it was opened. 2. LVN E did not wash or sanitize her hands during glove change following removal of Resident #314's old wound care dressing. 3. Resident #65's oxygen nasal canula was not dated and was laying on the floor and Resident #51's oxygen nasal cannula was not dated and was laying on the floor. These deficient practices place residents in the facility at risk for infections due to improper care practices. Findings include: A record review of Resident #51's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia, acute respiratory failure with hypoxia (low oxygenation), chronic obstructive pulmonary disease (lung disease), epilepsy (seizure disorder), metabolic encephalopathy (disturbed brain function), and cognitive communication deficit. A record review of Resident #51's 5-day MDS assessment dated [DATE] reflected a BIMS score of 07, which indicated severely impaired cognition. Resident #51 required moderate to extensive assistance from another person and frequent bowel and bladder incontinence. A record review of the physician orders dated 12/6/23 reflected Resident #51 was prescribed 2 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of Resident #65's face sheet dated 1/05/2024 reflected a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses of Fracture right femur (hip bone), metabolic encephalopathy (disturbed brain function), transient cerebral ischemic attack (blood clot in brain), hypertension, atrial fibrillation, and hypertension. A record review of Resident #65's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08, which indicated moderately impaired cognition. Resident #65 required extensive assistance from another person and had bowel and bladder incontinence. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 36 of 40 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 01/05/2024 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 Residents Affected - Some A record review of the physician orders dated 6/16/23 reflected Resident #65 was prescribed 2-3 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of Resident #97's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of aphasia (difficulty communicating), metabolic encephalopathy (disturbed brain function), dysphagia (difficulty swallowing), gastrostomy status (artificial external opening into the stomach for nutritional support), gastro-esophageal reflux disease (acid reflux) and adult failure to thrive. A record review of Resident #97's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. A record review of Resident #97's care plan last revised on 10/24/2023 reflected she received tube feedings related to dysphagia and she was to receive 1 carton of [enteral formula] 1.5 via bolus feedings TID. A record review of Resident #314's face sheet, dated 01/05/24, reflected an [AGE] year-old female admitted on [DATE] with diagnoses of osteoarthritis of left hip, atrial fibrillation, chronic pain syndrome, diabetes mellitus type 2, hypertension, cognitive communication deficit, restless leg syndrome, reduced mobility and unsteadiness on feet. A record review of Resident #314's admission MDS assessment dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Resident #314 required extensive assistance via wheelchair and walker, and bowel and bladder incontinence. A record review of Resident #314's care plan initiated on 12/28/23 reflected she was admitted to skilled services/therapy due to weakness/debility w/potential for decreased functional abilities with acute illness and/or injury, and Resident #314 has actual impairment to skin integrity of the left heel which was initiated on 01/03/24. Intervention for left heel blister initiated on 01/04/24 included to cleanse left heel blister with normal saline and pat dry, apply calcium alginate and cover with dry dressing daily. Replace dressing PRN if soiled, loose, or removed. An observation on 1/03/24 at 8:20am revealed Resident #51's oxygen nasal canula was not dated and was laying on the floor. CNA I entered the room and placed the nasal canula in the resident's nose without cleaning it. An observation on 1/03/2024 at 9:05 a.m. revealed Resident #97 was lying in bed sleeping. There was an opened container of enteral formula dated 1/2/24 sitting on Resident #97's dresser. The formula was not timed or initialed. Resident #97 was non-interviewable. An observation on 1/3/24 at 11:30am revealed Resident #65's O2 nasal cannula on the floor. CNA J picked up the canula to place it back on the resident, but the resident refused to wear it at that time. The cannula was then draped on the resident's left shoulder so he could put it in his nose when needed. The canula was not cleaned by the CNA. An observation on 1/03/2024 at 11:59 a.m. revealed the formula dated 1/2/24 was sitting in the same spot located on Resident #97's dresser. An observation on 1/04/2024 at 9:24 a.m. revealed there was a one third full container of enteral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 37 of 40 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 01/05/2024 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 formula dated 1/4/24 on Resident #97's dresser. The formula was not timed or initialed. Level of Harm - Minimal harm or potential for actual harm During an interview on 1/04/2024 at 9:28 a.m., LVN P stated Resident #97 ate food by mouth but if she did not eat, she received extra formula. LVN P stated that morning Resident #97 had refused breakfast, so she got extra formula. Residents Affected - Some An observation on 01/04/24 at 01:26 PM of wound care for Resident #314 with LVN E revealed LVN E washed her hands, donned gloves, and disinfected the bedside table. LVN E removed gloves, placed wax paper on the clean surface, and gathered wound care supplies. DON washed hands, donned gloves, and assisted with Resident #314's left lower limb positioning. LVN E removed the old dressing from the left heel and changed gloves. Resident #314's left heel blister was observed a deep purple color and approximately 3.5cm x 3.0cm. LVN E cleansed the left heel blister with normal saline and 4 x 4 gauze. LVN E changed her gloves, and no handwashing or hand hygiene was observed with the glove change. LVN E applied calcium alginate to the left heel wound and covered it with an adhesive dressing that was initialed and dated. LVN E and DON conducted handwashing upon completion of wound care. During an interview on 01/04/24 at 01:46 PM with LVN E revealed she should have brought hand sanitizer to the bedside while conducting wound care for Resident #314, and an adverse outcome of not sanitizing hands when changing gloves would be a possible wound infection. During an interview on 1/5/24 at 10:30 am CNA G stated that she was trained on infection control and resident items on the floor would concern her. She stated that she would sanitize them first before residents handle them. She stated that a nasal canula on the floor should be trashed and replaced with a new one. If it could not be replaced, she stated it should be sanitized. Failing to sanitize could lead to an infection for the resident. During an interview on 1/5/24 at 10:43am RN C stated that if a nasal canula was on the floor she would discard it and get a new one. She stated if a new one was not available, she would sanitize before use. She indicated that failing to sanitize would create a source of infection as they did not know what is on the floor. During an interview on 1/05/2024 at 3:37 p.m., the ADON stated she oversaw the short-term wing where Resident #97 resided. The ADON stated as long as formulas were dated, they could be used at room temperature for 24 hours as long as they were capped. The ADON stated nurses administered formula and they had all been trained on how to store it. The ADON stated nurses were supposed to date, time and initial the bottle when it was opened. During an interview on 01/05/24 at 03:47 PM with DON revealed her expectation of hand hygiene while providing wound care to residents was handwashing/hand hygiene and glove change should be conducted when going from dirty to clean, such as after removing and disposing of the old dressing, and after going from clean to dirty, such as gathering and setting up wound care field and then removing old dressing. DON further stated an adverse outcome of staff not following infection protocol while providing resident care would be a possible wound infection. During an interview on 1/05/2024 at 3:52 p.m., the DON stated opened enteral formulas were dated and timed and said they were good for 24-48 hours. The DON stated opened containers could be used later but if it was not marked with what time it was opened, nurses should discard it. The DON stated Resident #97's enteral formula was on backorder, so they had to order larger containers. The DON stated nurses monitored other nurses to ensure enteral formulas were labeled appropriately. The DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 38 of 40 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 01/05/2024 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 Residents Affected - Some stated formula administered past its recommended storage time could result in a less potent formula or gastrointestinal symptoms such as upset stomach. During an interview on 1/05/24 at 4:30 p.m., the DON stated her expectation of a nasal canula on the floor would be to change it. She stated an alternative if they could not change it, is to disinfect following the time guidelines on the wipes. She indicated the risk of not disinfecting or replacing the nasal cannula could cause a respiratory infection. During an interview on 1/5/24 at 4:45 p.m., the ADM stated her expectation for a nasal cannula on the floor would be to replace it. If it could not be replaced, then sanitize and date it to avoid the risk of infection. During an interview on 01/05/24 at 04:47 PM with ADM revealed her expectation for infection control protocol during wound care was for staff to conduct handwashing before and after to prevent spread of infection. ADM further stated the potential adverse outcome of staff not following infection control protocol during resident care would be cross contamination of wound care products. A record review of the facility's policy titled Handwashing dated 10/24/22 reflected, All staff members are required to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice. The CDC guidelines regarding handwashing are to be followed by staff members after each resident contact. A record review of the facility's policy titled Infection Control - Surveillance for Infections dated September 2017 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility. A record review of the facility's policy titled Enteral Feedings - Safety Precautions dated November 2018 reflected the following: Purpose To ensure the safe administration of enteral nutrition. General Guidelines Preventing contamination 2. Maintain strict adherence to storage conditions and timeframes. a. Store unopened liquid enteral formulas in temperature and light-controlled conditions (cool, away from direct sunlight). b. Maintain inventory controls and discard any formula past the expiration date. 3. Maintain strict adherence to maximum hang times: a. Powdered, reconstituted formula and formula with additives have a maximum infusing (hang) time of 4 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 39 of 40 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 01/05/2024 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 b. Sterile formula in a closed system has a maximum hang time of 48 hours. Level of Harm - Minimal harm or potential for actual harm Preventing errors in administration Residents Affected - Some 2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676327 If continuation sheet Page 40 of 40