Inspection·May 2, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some they felt like it, and he could not see his legs and feet and had not refused the aides from applying cream on him. Observation and Interview on 05/01/23 at 11:47 a.m., the DON and CNA A revealed Resident # 1's thighs had about 25 % dry skin, the lower legs had 50% dry skin, and both feet were covered with patches of dry skin. Resident #1 asked CNA A to massage his feet with lotion, and while she rubbed the resident's feet, the skin was flaking off. Interview on 05/02/23 at 12:09 p.m., CNA A said she gave Resident #1 a bed bath on Sunday, 04/30/23, and applied lotion on his skin . She said when a resident was not applied cream, the resident skin could become dry. She said when the resident asked her to massage his feet with lotion, and when she did, the skin was flaking off. She said she had not signed any in-service on preventing resident skin from drying. She said the resident had dry skin from his feet to his thigh. CNA A said dry skin could cause skin breakdown. Interview on 05/02/23 at 1:46 p.m. LVN C said if Resident #1 was not applied lotion or cream after a shower and as needed, it could cause dry skin, which could start to crack and break down. She said Resident#1 had not complained about his dry skin, and the nurses did the weekly skin assessment. She also said the aides had not complained the resident refused lotion being applied on him during grooming. Interview on 05/02/23 at 4:07 p.m., the DON said the staff should put moisturizer cream on Resident # 1 on shower day because the soap dries the resident skin and as needed during grooming. She said if the Resident was not moisturized, it had the potential for skin breakdown. Resident # 2 Record review of Resident #2's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), diabetes mellitus (the body does not make enough insulin or does not use it the way it should) hemiplegia (a condition cause by brain injury, that resulted in a varying degree of weakness, stiffness and lack of control in one side of the body) and hypertension(blood is pumping with more force than normal through arteries). Record review of Resident #2's Quarterly MDS Assessment, dated 04/21/23, revealed the BIMS score was 07 out of 15, which indicated severely impaired cognition. Further review of the MDS revealed he required extensive to total care with one to two staff assistance with all ADL (activity of daily living). The resident was always incontinent of bowel and bladder. Record review of Resident #2's care plan, initiated 09/13/2022 and revised on 04/25/2023, revealed the following: Resident #2 was incontinent of bowel and bladder and the goal was to reduce the risk for skin breakdown and promote dignity by keeping the resident clean, dry, and free from odor every shift. Interventions: be sure the resident was kept clean and dry each shift, give incontinent care as needed. Observation and Interview on 05/02/23 at 8:30 a.m., Resident #2 reported that he had not received incontinent care recently and was unsure of how long it had been since he was last changed. Interview on 05/02/23 at 8:35 a.m., CNA A said that she had yet to change Resident #2's brief since (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 2 of 4 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 05/02/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some starting work that morning. She explained that it was the responsibility of the night aides to change the resident's brief, and she planned to change it after breakfast. Interview on 05/2/23 at 8:40 a.m. with the DON and CNA A, DON said the night aides were making rounds by 6:00 a.m. when she came to work this morning, and when this surveyor asked her if the night aide changed Resident #2, she said she was not sure. CNA A said she came to work at 6:25 a.m., and the night aide was walking out of the door when she came, and she did not give any report. Observation and Interview on 05/2/23 at 8:45 a.m. of Resident #2's incontinent care provided by CNA A revealed Resident #2's incontinent brief was saturated from front to back. The wet indicator was all mashed, the inside was light brown, and it had streaks of bowel movement stains, and the draw sheets had bowel movement stains. CNA A said the brief was heavy and looked like it had not been changed for more than two hours. Interview on 05/02/23 at 10:38 a.m., the Corporate Nurse said CNA B should make rounds and provide incontinent care every two to three hours for Resident #2. She said the resident could have skin breakdown if the resident was not changed timely. During an interview on 05/02/23 at 12:16 p.m. CNA A said she came to work at 6:32 a.m. and was Resident #2's aide. She said she did not change the resident and was waiting to change him after breakfast because breakfast started at 7:30 a.m. She said if Resident #2 was left with a wet incontinent brief, Resident # 2 would have skin breakdown or infection. She said she had in-service on incontinent care, and the aides make rounds every two hours to change the resident. She said the brief was heavy and saturated from front to back. She also said the brief had stained with bowel movements, which meant he was not clean properly when he had bowel movements. In addition, the draw sheet was stained with bowel movement. Interview on 05/02/23 at 4:10 p.m., the DON said CNA A was supposed to round every two hours and provide care as indicated for Resident #2. She said the resident could have skin breakdown if left in a wet incontinent brief. She said the DON, Nurse managers, and the charge nurse monitored the aides and made sure the aides provided care to the residents. The DON said CNA A had skills check for incontinent care. Resident # 3 Record review of Resident #3's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), diabetes mellitus (the body does not make enough insulin or does not use it the way it should) hemiplegia (a condition cause by brain injury, that resulted in a varying degree of weakness, stiffness and lack of control in one side of the body) and hypertension(blood is pumping with more force than normal through arteries). Record review of Resident #3's Quarterly MDS Assessment, dated 03/17/23, revealed the BIMS score was 15 out of 15, which indicated intact cognition. Further review of the MDS revealed she was depended on staff, required two or more staff assistance with all ADL (activity of daily living) with exception of eating which required one staff. The resident was always incontinent of bowel and bladder. Record review of Resident #3's care plan, initiated 12/20/21 and revised on 03/20/23, revealed the following: the resident had self-care performance related to activity intolerance, fatigue, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 3 of 4 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 05/02/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hemiplegia, stroke, and mobility. Interventions: bathing/showering; the resident was totally dependent on (2 -5) staff to provide bath/shower. Personal hygiene: the resident required extensive to total assistance by (2 5) staff. skin inspection: the resident requires skin inspection, observed for redness, open areas, scratches, cuts, bruises and report to the nurse. Further review of the care plan revealed she was totally incontinent of bowel and bladder related to self-care deficit. Goal: goal was to reduce the risk for skin breakdown and promote dignity by keeping the resident clean, dry, and free from odor every shift. Interventions: be sure the resident was kept clean and dry each shift, give incontinent care as needed. Observation and Interview on 05/02/23 at 8:55 a.m., Resident #3 said she was wet and was changed at 3:00 a.m. Observation of the resident's feet revealed they had dried patches of skin. She said the aides do not apply lotion on her daily. She said she was given a bed bath yesterday, and they applied the cream on her body, and she was unsure if they applied lotion on her feet. She said she did not want her feet to dry but could not see or feel them. She also said she does not want any wounds on her feet from dry skin because it would not heal because she had bad circulation in her feet. Observation and Interview on 05/02/23 at 9:24 a.m. revealed Resident #3's incontinent brief was saturated from front to back, and the wet indicator faded. CNA B said Resident #3's incontinent brief was saturated, and it looked like she had not been changed for more than four hours. She also stated Resident # 3's feet had dry patches of skin, and the resident needed lotion to be applied on her feet. Interview on 05/02/23 at 10:31 a.m., the Corporate Nurse said CNA B should have applied lotion on Resident #3 during shower days and as needed during grooming. She said this would help prevent the resident's skin from drying out. When asked about the adverse outcomes of not applying lotion, the Corporate Nurse asked the surveyor to provide an answer because she knew this surveyor wanted to document it. Interview on 05/02/23 at 12:52 p.m., CNA B said this was her first day because she was an agency aide. She said Resident #3's feet had dry skin patches, and she needed to apply lotion on her feet to prevent skin breakdown. CNA B said Resident #3's incontinent brief had not been changed for a long time and looked and felt drenched. She said it was saturated from front to back. She said Resident #3 would have a wound, rash, and infection if the resident was left in a wet incontinent brief. She said her agency trained her in incontinent care and skin care. She said she came to work around 8:30 a.m. Record review of the facility in service on importance of incontinent care dated 04/17/23 revealed CNA A name was not on the signature that attended the in service. Record review of CNA A's skills checklist for perineal revealed she met the skills, and it was signed on 11/19/22. Record review of the facility policy on skin integrity dated 02/23 read in part . it is the policy of this facility to ensure residents receive proper treatment and care . Record review of the facility's incontinence dated 01/23 read in part . all residents that ae incontinent will receive appropriate treatment and services . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 4 of 4