Health inspection·May 9, 2023

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 05/04/2023 at 4:25pm of blood sugar check for Resident #1 by LVN A. LVN A took the residents blood sugar that that was 145. When LVN A finished taking the resident blood sugar, she removed her gloves and left the resident room without washing her hands. LVN A returned to her medication cart placing the glucometer machine inside of the medication cart without sanitizing the device. Interview on 04/05/2023 at 5:10pm the DON said when the nurse used the glucometer to test a resident blood sugar, the nurse should be sanitizing the machine after each use for infection control purposes. The DON said she would speak with LVN A regarding not sanitizing the glucometer machine after use and infection control prevention. Interview on 05/04/2023 at 5:15pm LVN A said the reason handwashing and sanitizing of resident care equipment should be done prior to and after resident care was to prevent the spread of germs. Resident #2 Record review of Resident #2's face sheet revealed an [AGE] year-old male admitted to the NF on 01/21/2021 with diagnoses that included the following: type 2 diabetes mellitus, chronic obstructive pulmonary disease (group of lung diseases that block airflow making it difficult to breathe), hypertension, heart failure, spinal stenosis (narrowing of the spine), and Parkinson's disease (nerve cell damage in the brain that effects movement in the body). Record review of Resident #2's MDS dated [DATE] revealed that resident BIMS score was 15 indicating that resident cognition was intact. Observation on 05/09/2023 at 12:40pm revealed CNA B provided incontinent care for Resident #2 who was incontinent of urine. When CNA B left out of Resident #2's room she did not wash or sanitize her hands. CNA B proceeded to carry out of Resident #2's room a pack of disposable wipes to room [ROOM NUMBER]. CNA B placed the pack of disposable wipes inside of a drawer. Interview on 05/09/2023 at 1:05pm CNA B said the reason she took the wipes out of Resident #2's room was because some rooms did not have wipes in them. CNA B said and she sometimes had to search for wipes to provide care for the residents. Observation on 05/09/2023 at 1:10pm of the supply room with CNA B revealed 3 large boxes of disposable wipes inside of the supply room. Interview on 05/09/2023 at 1:10pm CNA B said she should have not taken disposable wipes from one resident room to another because of infection control. CNA B said the importance of hand washing was to prevent the spread of germs. Interview on 05/09/2023 at 1:20pm the DON said staff were supposed to wash their hands before and after resident care. In a Ffurther interview with the DON said staff were not to take patient care supplies from one room to another to prevent cross contamination. Record review of the NF policy on Glucometer Disinfection revised October 2022 revealed in part: .The purpose of this procedure is to provide guidelines for disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne disease to residents and employees . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 2 of 3 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 05/09/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Record review of the NF policy on Standard Precautions Infection Control Protocol dated October 2022 revealed in part: .Hand hygiene after touching blood, body fluids, secretions, excretions, contaminated items; before and after removing PPE, between resident contacts . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 3 of 3