Health inspection·November 10, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some toilet. She then pointed to the scrub brush and cleaning solution in her cart. She stated she would go back to room [ROOM NUMBER] then work her way down the hall like usual, sinc she was done with room [ROOM NUMBER]. Observation on 11/09/22 at 2:00 PM of the restroom for Resident #25, revealed it was unchanged from 11/08/22. The toilet bowl contained the large bowel movement. It was smeared and stained with brown matter. The restroom in Resident #29 and #32's room had the plastic bag covering the toilet. The toilet bowl was empty of water had large brown stains. Housekeeper A was not available for an interview. Interview and observation on 11/8/22 at 3:04 PM Resident #44 said she used the restroom for ADL care and to use the shower. She said her roommate used the toilet and there is always feces on the floor, toilet and walls. She said she did not like to go into the restroom because it was not clean. Resident #44 said she had told staff, but it had not been cleaned for weeks. Observation of Resident #44's restroom revealed brown smears on the toilet seat, on the wall by the toilet paper holder and several dried brown spots on the restroom floor including the shower floor. The room had the odor of bowel movement. The housekeeping staff was not available for an interview. Interview on 11/09/22 at 5:40 PM, the Maintenance Director stated there was no Housekeeping Director because she quit last week. He stated he was overseeing the housekeeping department. He stated the housekeeper assigned to the hall was responsible to ensure the resident restrooms were cleaned and that they are to be cleaned daily. He stated he was unsure how many housekeepers there were and that there should be a housekeeper for each hallway. He stated he was just made aware of the restroom for Resident #25. He was shown photos the Surveyor had taken on 11/08/22 of the condition of the toilet. He stated that was unacceptable. He stated he would not feel comfortable using the toilet in that condition. He stated he would look for work order logs. Surveyor requested policy and procedures for housekeeping. No logs or policy and procedures were submitted by the time of exit. Interview on 11/09/22 at 6:05 PM the DON stated the restrooms were unsanitary when not cleaned and left in the condition they were. The DON stated it was a risk of infection to the resident. Record review of the facility's job description for the Housekeeping Aide, Reports to: Housekeeping Supervision, revised on 1/01/2018 read in part: Cleans and services nursing home facility areas . Essential Job Functions: Understands an agrees with skilled service's philosophy and goal to maintain, improve and/or enhance each resident's quality of care, quality of life .Dusts/washes furniture, sinks, toilets, showers .Uses sanitizing agents and disinfects areas .Reports any broken/damaged equipment or mechanical failures to supervisor .Respects the privacy, dignity and confidential rights of residents . Record Review of Facility Policy on Homelike Environment dated February 2001 reflected Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 1. Staff provided person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 2 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 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 0584 - clean, sanitary, and orderly environment; Level of Harm - Minimal harm or potential for actual harm . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 3 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 5 of 50 days reviewed for nursing services , in that: The facility failed to maintain RN coverage in the facility for eight consecutive hours on 5 days (on 9/18/22, 10/2/22, 10/16/22, 10/29/22 and 10/30/22). This failure could place residents at risk of not having nursing and medical needs met that can only be provided by a Registered Nurse. Findings include: Record review of the Nursing Time Card Report from 9/18/22 to 10/31/22 revealed 5 of 50 days there was no RN scheduled to work eight consecutive hours on: Sunday 9/18/22, no hours for RN. Sunday 10/2/22, no hours for RN. Sunday 10/16/22, no hours for RN. Saturday 10/29/22, no hours for RN. Sunday 10/30/22, no hours for RN. During an interview on 11/10/22 at 9:40 a.m., the DON said she was responsible for the staff schedule at the facility. She said it was her responsibility to make sure the facility had a RN coverage 8 hours a day, 7 days a week. The DON explained she recently hired a RN, but the RN only worked every other weekend. She said she had an RN who had not been working because of a family death. The DON said she worked 8 hours a day Monday through Friday. She said it was difficulty to hire and retain nursing staff. She said the facility used agency staff. However, the agency does not always have RN's. The DON said the residents may not get a proper assessment if there was no RN scheduled 8 hours per day. During an interview on 11/10/22 at 2:50 p.m., the Administrator stated she was aware the facility was short a RN for some weekend coverage. She said they recently lost an RN due to a family concern. She said the facility used agency nursing staff as well, but the agency staff canceled the jobs. She said the facility was trying to hire a RN for weekends. She said not having a RN at the facility for 8 hours daily, could affect the quality of life of the residents health care needs. Review of the facility's policy/procedure Staffing, Sufficient and Competent Nursing revised August 2022 read in part .Our facility provides sufficient numbers of numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents .3. A registered nurse provides services at least eight consecutive hours every 24 hours, seven days a week . 7. Inquiries or concerns relative to our facility's staffing should be directed to the director of nursing services or designee . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 4 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 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 (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 3 of 10 residents (Resident #15, Resident #32 and Resident #93) reviewed for pharmacy services. -The facility failed to discard expired insulin vials for Resident #15, Resident #32 and Resident #93 that were located in the 100 Hall Nurse Cart This failure could place residents at risk of not receiving the therapeutic benefit of medications and/or adverse reactions to medications. Findings Include: In an observation and interview on 11/09/22 at 07:12 AM, inventory of the 100 Hall Nursing Cart with LVN J revealed: - An Open and in use vial of Novolin R Insulin for Resident #15 with an open date of 09/09/22 with manufacturer's instructions to discard 42 days after opening (10/21/22). - An open and in use 10 ml vial of Lantus (Insulin glargine) for Resident #32 with an open date of 09/30/22 with manufacturer's instructions to discard 28 days after opening (10/28/22). - An open and in use vial of Humulin R Insulin for Resident #93 with an open date of 10/03/22 with manufacturer's instruction to discard 31 days after opening (11/03/22). LVN J said that nursing staff were expected to check the medications in their carts daily as used. She said when an insulin pen or vial is taken from the fridge, the open date is written in order to track the expiration date. LVN J said she did not know how long each insulin was good for and didn't have a reference document in her cart to determine the BUD. LVN J said she did not know what happened to insulin after it expired, but she knew it could no longer be used. So it had to be discarded in the drug disposal bin located in the medication storage room. Resident #15 Record review of Resident #15's face sheet, dated 11/09/22, revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: high blood pressure, heart failure, irregular heartbeat, depression and type 2 diabetes. Record review of Resident #15's quarterly MDS assessment, dated 09/06/22, revealed impaired vision with the use of corrective lenses, intact cognition as indicated by a BIMS score of 15 out of 15, total dependence for most ADLs and always incontinent of both bladder and bowel. Record review of Resident #15's undated care plan revealed, resident had impaired visual function related to diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 5 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 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 Record review of Resident #15's physician's order, dated 03/30/21, revealed Novolin R 100 unit/ml Inject as per sliding scale: if 200-249= 2 units; 250-299= 4 units; 300-349= 6 units . subcutaneously before meals related to type 2 diabetes mellitus with unspecified complications. Record review of Resident #15's MAR for October 2022 revealed, Resident #15 received 8 doses of Novolin R after the BUD of 10/21/22. - 10/23/22 2 units at 11:00 AM - 10/23/22 4 units at 04:30 PM - 10/26/22 4 units at 07:30 AM - 10/26/22 4 units at 11:00 AM - 10/28/22 4 units at 11:00 AM - 10/28/22 3 units at 04:30 PM - 10/30/22 6 units at 04:30 PM - 10/31/22 8 units at 04:30 PM Record review of Resident #15's MAR for 11/2022 revealed, Resident #15 received 3 doses of Novolin R after the BUD of 10/21/22. - 11/01/22 2 units at 04:30 PM - 11/05/22 2 units at 11:00 AM - 11/08/22 2 units at 04:30 PM Resident #32 Record review of Resident #32's face sheet, dated 11/09/22, revealed, a [AGE] year-old male admitted on [DATE] with diagnoses which included: severe dementia with agitation, epilepsy, and diabetes with polyneuropathy (nerve malfunction). Record review of Resident #32's quarterly MDS assessment, dated 10/18/22, revealed severely impaired cognition as indicated by a BIMS score of 7 out of 15, total dependence with most ADLs, and always incontinent of both bladder and bowel. Record review of Resident #32's undated care plan revealed resident has type 2 diabetes and is on long term use of insulin. One of the interventions specified to give meds per order. Record review of Resident #32's physician's order dated 11/27/21 revealed, Insulin Glargine- Inject 10 unit under the ski two times a day for diabetes. Record review of Resident #32's MAR for 10/2022 revealed, Resident #32 received 6 doses of Novolin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 6 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 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 R after the BUD of 10/28/22. Level of Harm - Minimal harm or potential for actual harm - 10/29/22 10 units at 07:00 AM - 10/29/22 10 units at 04:00 PM Residents Affected - Few - 10/30/22 10 units at 07:00 AM - 10/30/22 10 units at 04:00 PM - 10/31/22 10 units at 07:00 AM - 10/31/22 10 units at 04:00 PM Record review of Resident #32's MAR for 11/2022 revealed, Resident #32 received 16 doses of Novolin R after the BUD of 10/28/22. - 11/01/22 10 units at 07:00 AM - 11/01/22 10 units at 04:00 PM - 11/02/22 10 units at 07:00 AM - 11/03/22 10 units at 07:00 AM - 11/03/22 10 units at 04:00 PM - 11/04/22 10 units at 07:00 AM - 11/04/22 10 units at 04:00 PM - 11/05/22 10 units at 07:00 AM - 11/05/22 10 units at 04:00 PM - 11/06/22 10 units at 07:00 AM - 11/06/22 10 units at 04:00 PM - 11/07/22 10 units at 07:00 AM - 11/07/22 10 units at 04:00 PM - 11/08/22 10 units at 07:00 AM - 11/08/22 10 units at 04:00 PM - 11/09/22 10 units at 07:00 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 7 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 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 Reisdent #93 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #93's face sheet, dated 11/09/22, revealed a [AGE] year-old male admitted to the facility with diagnoses which included: mild protein-calorie malnutrition, iron deficiency anemia, hypertensio,n and type 2 diabetes with hyperglycemia . Residents Affected - Few Record review of Resident #93's admission MDS assessment, dated 09/12/22, revealed impaired vision, moderately impaired cognitive skills for daily decision making, total dependence for most ADLs, frequently incontinent of bladder and always continent of bowel. Record review of Resident #93's undated care plan revealed resident is a diabetic and is at risk for: hyperglycemia. One of the interventions specified to give meds per order, monitor labs, and report abnormal labs to MD. Record review of Resident #93's physician's order dated 09/26/22 revealed, Humulin R Solution 100 unit/ml (Regular Human), Inject as per sliding scale: if 201-250= 4units, 251-300= 6units, 301-35= 8units . subcutaneously before meals and at bedtime related to type 2 diabetes with hyperglycemia Record review of Resident #93's MAR for 11/2022 revealed, Resident #93 received 3 doses of Humulin R after the BUD of 11/03/22. - 11/04/22 6 units at 06:30 AM - 11/05/22 4 units at 06:30 AM - 11/05/22 4 units at 11:00 AM In an interview on 11/09/22 at 11:55 AM, the DON said that nursing staff were expected to check their carts daily, as used, for expired medications. She said that insulin must be labeled with the date it was opened in order to track its expiration date and once expired insulin must be discarded in the drug disposal bin located in the med room. The DON said after insulin expired, it could become less efficient and contaminated and if used it could place residents at risk of a diminished therapeutic effect and glycemic control. Record review of the facility's document titled Table 1. Insulin Options to Manage Type 1 Diabetes with no revision date revealed. Insulin type- regular, Expiration date- 31-42 days. Insulin type- Lantus, Expiration date- 28 days. Record review of the facility policy titled Storage of Medications revised April 2017 revealed, 4- The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All drugs shall be returned to the dispensing pharmacy or destroyed. Record review of the Manufacturer's document titled Lantus Highlights of Prescribing Information revised May 2019 revealed, In-use (opened ) 28 days refrigerated or room temperature. Record review of the Manufacturer's document titled Novolin R Highlights of Prescribing Information revised 02/2012 revealed, Unopened and opened (In use) Novolin R vials must be discarded 42 days after they are first kept out of the refrigerator, even if they still contain Novolin R insulin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 8 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Record review of the Manufacturer document titled Humulin R Highlights of Prescribing Information revised 06/2022 revealed, When stored at room temperature, HUMULIN R can only be used for a total of 31 days including both not in-use (unopened) and in-use (opened) storage time. . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 9 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 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 0759 Ensure medication error rates are not 5 percent or greater. 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 the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 8% based on 3 errors out of 35 opportunities, which involved 2 of 7 residents (Resident #75 and Resident #81); reviewed for medication errors. Residents Affected - Some - The facility failed to ensure LVN J administered Pantoprazole granules for suspension( a medication used to treat acid reflux/GERD) via Gastrostomy tube ( a tube into the stomach used to deliver food or mediation) correctly to Resident #81 by suspending it in water and not apple sauce or apple juice - The facility failed to ensure MA A administered medications to Resident #75, on time, by administering Aspirin and Pantoprazole more than one hour after the medication was scheduled to be administered. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Include: Resident #75 Record review of Resident #75's face sheet, dated 11/09/22, revealed a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: dementia without behavioral disturbance, type 2 diabetes, coronary artery disease and GERD . Record review of Resident #75's quarterly MDS assessment, dated 10/18/22, revealed the resident admitted from an acute hospital stay, had impaired vision without the use of corrective lenses, her cognition was intact as indicated by a BIMS score of 14 out of 15, she was independent for most ADLs, used a wheelchair for ambulation, had an indwelling catheter, and was occasionally incontinent of bowel. Record review of Resident #75's undated care plan revealed, focus- receiving Aspirin for antiplatelet therapy and is at risk for increased bleeding, bruising, etc. Interventions- give meds per MD order. Focusdiagnosis of GERD and risk for increased abdominal distress, weight loss and GI Bleed, intervention- give medications per order- monitor effectiveness, report to MD if resident complains of increased abdominal distress and comfort. Record review of Resident #75's physician's order, dated 05/04/22, revealed Aspirin 81 mg chewable tablet1 tablet by mouth one time a day and Pantoprazole 20 mg- 1 tablet by mouth one time a day related to GERD. Both medications were scheduled for administration at 8:00 AM. An observation on 11/09/22 at 09:30 AM revealed, MA A preparing medication for administration for Resident #75, the resident's profile was red indicated medications were late on MA A's MAR. She verified the resident's information on the MAR and compared it against the door label. MA A entered into the room and informed the resident she would check her BP prior to administering her medications. MA A checked Resident #75's blood pressure and then returned to her cart to prepare the medication for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 10 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administration. MA A placed 1 tablet of Aspirin 81 mg, and 1 capsule of Pantoprazole 20 mg, along with 10 other oral medications, in a medication cup, entered into the resident's room and administered the medications to the resident at 9:30 AM. In an interview on 11/09/22 at 01:10 PM, MA A said that medications should have been administered to patients between 1 hour before and after the scheduled time. She said her medication administration was interrupted today because she had to help pass meal trays as well as provide meal assistance to patients. MA A said there were not been enough dietary staff, so meals have been late. She stated it, sometimes delayed medication administration since most residents prefer their medications with meals, and sometimes she had to provide snacks, like pudding, to the resident so medications were not given on an empty stomach. Resident #81 Record review of Resident #81's face sheet, dated 11/09/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included; dementia without behavioral disturbance, anxiety disorder, gastrostomy status, and difficulty swallowing. Record review or Resident #81's MDS, dated [DATE], revealed moderately impaired cognitive skills for daily decision making, total dependence for all ADLs, gastrostomy status, and always incontinent of both bowel and bladder. Record review of Resident #81's undated care plan revealed, Resident #81 was NPO and at risk for aspiration , when something swallowed goes down the wrong way and enters the lungs, due to receiving nutrition by tube feeding related to dysphagia (difficulty swallowing). Record review of Resident #81's physician order, dated 11/02/22, revealed Pantoprazole Sodium Packet 40mg- give 1 packet via G-tube one time a day for Acid reflux. An observation on 11/09/22 at 08:35 AM revealed, LVN D preparing medication for administration via G-tube for Resident #81. He retrieved 1 packet of Pantoprazole 40 mg for delayed-release oral suspension with manufacturer's instructions suspension in apple juice or applesauce only written on the front of the packet, 2 tablets of Vitamin D, and 17 grams of MiraLAX and placed them in individual medication cups with the MiraLAX in a water cup. LVN D crushed the Vitamin D, returning it to the medication cup and entered into the resident's room with the medications on a tray. He placed 10-15 ml of water into the vitamin D powder and the pantoprazole and approximately 60 ml in the MiraLAX. LVN D checked for the placement of Resident #81's G-tube by injecting 10 cc of air while listening to stomach sounds and checking for residual. LVN D flushed Resident #81's G-tube with 30 cc of water and then administered each medication individually with a 15 cc flush of water in between, and a 30 cc flush after. In an interview on 11/09/22 at 11:15 AM, LVN D said he did not know that Pantoprazole granules for suspension had to be dissolved in either applesauce or apple juice only. He said the medication was a new prescription for Resident #81 and he had never administered it before that day. LVN D said he would contact his DON and the pharmacy to determine the procedure for administration or if an alternative formulation could be dispensed. In an interview on 11/09/22 at 11:55 AM, the DON said the medication administration window is 1 hour before, up to hour after, a medication was scheduled. She said on that day , 11/09/22, MA A had to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 11 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assist in passing breakfast trays due to insufficient dietary staff which could have contributed to the delay in medication administration. The DON said failure to administer medications as ordered could place residents at risk for a delay in treatment. The DON said that she was unsure of the formulation of pantoprazole that LVN D administered to Resident #81 via G-tube, but if pantoprazole delayed release oral suspension was mixed with applesauce/juice as specified by the manufacturer, it would not dissolve correctly and would not have the desired therapeutic effect. Record review of LVN D's Medication Administration Observation Report, dated 08/08/22, revealed. 20Medication via feeding tube is properly administered, criteria met. Record review of manufacturer's document titled Pantoprazole for delayed-release oral suspension Highlights of Prescribing Information revised May 2012 revealed, PROTONIX For Delayed-Release Oral Suspension should only be administered approximately 30 minutes prior to a meal via oral administration in apple juice or applesauce or nasogastric tube in apple juice only. Because proper pH is necessary for stability, do not administer PROTONIX For Delayed-Release Oral Suspension in liquids other than apple juice, or foods other than applesauce. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 12 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 out of 3 medication carts (400 Hall Nursing Cart) reviewed for medication storage. - LVN S failed to ensure the 400 Hall Nursing Cart was locked when not in use and unsupervised This failure could place residents at risk of adverse reactions to medications and Injury. Findings Include: An observation and interview on 11/09/22 at 07:28 AM revealed, the 400 Hall Nursing Cart parked against the nursing station unlocked with the keys in the lock. The keys remained in the unattended cart until an unknown facility staff locked the cart and then removed the key before handing it to LVN S at 07:30 AM. Inventory of the cart with LVN S revealed the drawers contained medications in vial, bottles and pouches, insulin pen needles and insulin syringes. LVN S said she was an agency nurse and she left her keys in the cart after she completed a shift change cart reconciliation with the nurse on the previous shift. She said that medication carts should be locked when not in use or unsupervised for patient safety because the cart contained medications and needles. LVN S said failure to lock unsupervised/not in-use carts could place residents at risk for adverse reactions or injury. In an interview on 11/09/22 at 11:55 AM, the DON said all medication carts should be locked when not in-use or under the direct supervision of nursing staff. She said med carts contained medications and needles so failure to lock the carts could risk patient safety, placing residents at risk for injury. Record review of the facility policy titled Administering Medications revised 12/2012 revealed, 16- During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 13 of 14 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 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. Residents Affected - Many -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: An observation on 11-08-22 at 9:25 am revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -sized dumpster ¾ full of garbage and the door was open. Interview on 11-08-22 at 11:45 am, with the Administrator she stated that the dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from entering the facility. She stated that she would do in-service training with the facility staff. A copy of the policy and procedure for the waste disposal was requested but not provided before exiting the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 14 of 14