Health inspection·August 30, 2023

F 0558 2x for Resident #38. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #23's face sheet dated 08/30/23 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Hyperkalemia (high blood level of potassium), Chronic Obstructive Pulmonary Disease (Difficult to breathe) , Hypertension, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, Obesity due to excess calories, Heart failure, Type 2 Diabetes Mellitus, Chronic Kidney Disease and Muscle Weakness. Residents Affected - Few Record review of Resident #23's MDS assessment dated [DATE] revealed her BIMS score was 12 of 15 which indicated moderate cognitive impairment. Resident #23 required 2-person assistance regarding transfers and required 2-person physical assistance with bed mobility, toileting, and bathing. Urinary Continence was coded as 3 -Always incontinent (no episodes of continent voiding). Bowel continence was coded as 2 - frequently incontinent (2 or more episodes). Record review of Resident #23's weight summary revealed a height of 66 inches and as of 06/05/2023, a weight of 324 pounds with a BMI (measure used to calculate a healthy weight) of 52.29 indicative of obesity. In an interview on 08/28/23 at 4:00 pm, Resident #23 reported that her brief size was 3x and above, however she was wearing a 2x brief at that time. She stated there were many occasions in the past she had to wear smaller size as her size brief was not available at the facility. She stated she might compromise for a 2x size brief while sleeping, however 2x size was uncomfortable and inconvenient as they came off easily and made a mess while sitting or ambulating. She stated she complained in the past about the unavailability of the correct size briefs , however no actions were taken to resolve this issue. An observation on 08/29/23 at 03:00 PM, of the main central supply closet and the closets in all the halls revealed the absence of size 3x or 4x briefs. The largest size brief observed in the closets was 2x. The DON, who was accompanying with the investigator during the observations in the closets, also witnessed the unavailability of larger briefs. In an interview on 08/29/23 at 3:30 PM, the MRS stated she ordered medical and nursing care supplies every week. including briefs of all sizes. When the investigator asked the reason for the frequent unavailability of 3x briefs at the facility, MRS stated she was not aware of any shortage and thought the order she placed every time was sufficient for one week, until the next batch of supplies arrived. In an interview on 08/29/23 at 3:30 PM, the DON stated, at the facility there were two residents who needed 3x size briefs. She said she had received complaints from the residents and their families of not having appropriate briefs at the facility and communicated this message to the procurement department on time. DON said she believed they were not ordering enough 3x briefs every time when placing the order with the suppliers. She stated the unavailability of the right size briefs and diapers was uncomfortable to the residents and thus affected the quality of care. DON said the facility placed an interim order for 3x on that day to make sure they were available immediately. In an interview on 8/30/23 at 2:30 PM, the ADM stated, he was not aware that large size briefs were not available for residents on 08/29/23. When the investigator stated that the residents and families complained about the frequent unavailability of 3x briefs, the ADM stated sometimes the quantity of the briefs used were higher than anticipated. He added, in such situations the facility either (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676432 If continuation sheet Page 2 of 5 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 676432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Pointe Health and Wellness Center 1301 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 0558 Level of Harm - Minimal harm or potential for actual harm borrowed from the neighboring facility or purchased from local market. He stated the uninterrupted supply of nursing care items were important for maintaining the quality of care. He said unfit briefs causes leaking of the content, poor blood circulation, and even skin integrity. Record review of facility policy titled Resident Rights dated 10/04/2016 reflected: Residents Affected - Few As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States . . You have a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676432 If continuation sheet Page 3 of 5 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 676432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Pointe Health and Wellness Center 1301 Cottonwood Creek Trail Cedar Park, TX 78613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, for 1 of 2 residents (Resident #60) reviewed for oxygen in that: Residents Affected - Few 1. The facility failed to ensure Resident #60's O2 tubing was dated. 2. The facility failed to ensure Resident #60's humidifier bottle and oxygen tubing were changed as ordered. These failures placed residents receiving oxygen as needed at risk for infections. The findings were: Record review of Resident #60's admission Record , undated, revealed the resident was admitted to the facility on [DATE] with diagnoses that included Stroke, Hemiplegia (paralysis to one side of the body), Hemiparesis (weakness to one side of the body), Hypertension, Bipolar Disorder, Dementia, Other Reduced Mobility, Chronic Obstructive Pulmonary Disease and Dysphagia (difficulty swallowing). Record review of Resident #60's MDS dated ___ did not indicate the use of oxygen therapy. Record review of Resident #60's Order Summary Report , undated, revealed an order for Oxygen at 2L/min via nasal cannula for saturation <92% on room air with an order start date of 05/10/2023. The Report also reflected, Change O2 tubing and humidifier bottle, provide clean plastic bag with label to put in o2 tubing when not being used - every night shift on Sunday. Observation on 08/28/2023 at 11:55 AM revealed Resident #60 had an oxygen concentrator next to her bed. Further observation revealed a plastic bag, dated 06/12/2023, attached to the machine that contained O2 tubing placed inside. A No Smoking; Oxygen in Use sign was posted outside of Resident #60's door. During an interview on 08/28/23 at 2:17 PM revealed Resident #60 was hooked up to the oxygen concentrator and the machine was in use by the resident. Observation of the plastic bag attached to the Oxygen concentrator revealed it was empty. During an interview on 08/28/23 at 2:17 PM, Resident #60 stated she was doing well. She stated she uses the Oxygen concentrator very close to daily or when they think she needs it. She stated she has not had any issues with the machine. She stated she has observed the staff change the bags regularly. Observation on 8/29/23 at 8:53 AM revealed the plastic bag that contained O2 tubing, attached to the Oxygen concentrator was still dated for 06/12/2023. During an interview on 08/29/2023 at 12:35 PN, LVN A stated it was the night nurse's responsibility to check on Oxygen concentrators; to include changing and labeling the O2 tubing and nebulizers. LVN A stated that when the machine equipment is changed, it should be labeled with that date. She stated some nurses will date the water concentrator bottle, the tubing, and the plastic bag and some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676432 If continuation sheet Page 4 of 5 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 676432 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cedar Pointe Health and Wellness Center 1301 Cottonwood Creek Trail Cedar Park, TX 78613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurses date one or the other. She stated the water concentrator and plastic bag attached to the water concentrator should be changed weekly, as well as the tubing, and this usually occurred on Sunday nights. She stated nurses can access Resident #60's order for the machine equipment to be changed on their computers. LVN A was asked why Resident #60's plastic bag that contained the O2 tubing, and water concentration bottle did not reveal an updated label and she stated it may have not been checked. She stated not providing or updating labels on the Oxygen concentrator equipment could place the resident at risk for infection. LVN A stated she would change and re-label the equipment. Observation on 8/29/23 at 12:40 PM in the presence of LVN A revealed the plastic bag that contained O2 tubing, attached to the Oxygen concentrator was still dated for 06/12/2023. The water concentrator bottle attached to the O2 concentrator was dated for 07/13/2023. During an interview on 08/30/23 at 1:07 PM, the DON stated that during patient rounds, nurses should check on O2 tubing to ensure it was working properly. The DON stated that when the Oxygen concentrator is not in use, the O2 tubing is placed in a plastic bag and attached to the machine. She stated that the O2 tubing is changed out weekly, and this task is usually done by the night shift nurse. The DON stated that Resident #60 has orders for the tubing and water concentrator to be changed, adding that sometimes, the date is placed on the actual tubing. She stated the plastic bag dated 06/12/23 that was observed attached to the Oxygen concentrator did not indicate if the tubing had not been changed as nurses need to date the actual tubing. The DON stated the plastic bag is only changed if it is needed. She stated the water concentrator bottle should change and re-labeled weekly. The DON stated that Resident #60's O2 tubing, and water concentrator should have been changed as not changing them poses the risk of infection to the resident. Observation on 08/30/23 at 1:15 PM of Resident #60's O2 tubing and water concentrator in the presence of the DON revealed the plastic bag attached to the Oxygen concentrator, the O2 tubing, and the water concentration bottle was dated for 08/30/2023. The DON was observed asking LVN A for the tubing, that was changed. The DON stated that observation of the tubing did not reveal the presence of a date. During an interview on 08/30/23 at 3:40 PM, the ADM stated that nurses were expected to check Oxygen concentrator machines weekly, adding that the tubing should be changed and labeled with a date. He stated the plastic bag attached and filter should be changed as needed. He stated the night nurse is responsible for ensuring the equipment is changed and labeled appropriately per Resident #60's orders. He stated this is important and not completing those tasks could pose infection control risks to the resident. Record review of facility policy and procedure titled Oxygen Administration, undated, revealed It is the policy of this facility that oxygen therapy is administered, as ordered by the physician. The policy further states Instructions for Tubing and Humidifier Changes . 1. Label humidifier with the day . 2. Oxygen tubing is to be replaced every 7 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676432 If continuation sheet Page 5 of 5