Inspection·June 30, 2023

F 0656 Record review of Resident #1's care plan revised 06/07/2023 revealed the following: Level of Harm - Minimal harm or potential for actual harm * Residents Affected - Few Resident #1 had impaired cognitive function and impaired thought processes. Goals included: The resident will maintain current level of cognitive function. The resident's needs will be met, and dignity will be maintained. Interventions included: Administer medications as ordered. * Resident #1 has a camera in room that may or may not have sound per family request. Goals included: Family and Resident choice to have a camera in the room will be respected. Interventions included: Do not be intimidated by the camera. Continue to provide good care as you always do. * Resident #1 has altered cardiovascular status due to hypertension, history of cardiac arrest, tachycardia, CAD (coronary artery disease is the most common type of heart disease), NSTEMI (partial blockage of one of the coronary arteries, causing reduced blood flow of oxygen-rich blood to the heart muscle), DVT (a blood clot that develops within a deep vein in the body), HLD (high levels of lipids in the blood), and cardiomegaly (enlarged heart). Goals included: The resident will be free from complications of cardiac problems. Interventions included: Monitor vital signs as ordered. Notify doctor of significant abnormalities. Monitor/document as needed any signs and symptoms of CAD. * Resident #1 has a history of CVA (also known as stroke. When blood flow to a part of your brain is stopped). Goals included: Minimize the risk of complications for CVA. Interventions included: Give medications per doctor orders - monitor labs and report to doctor. * Resident #1 had a cerebral vascular accident (CVA/stroke), functional quadriplegia, and Parkinson's. Goals included: The resident will be free from signs and symptoms of complications of CVA. Interventions included: Give medications as ordered by the physician. Monitor/document side effects and effectiveness. Monitor vital signs as ordered. Notify doctor of significant abnormalities. Observation of Resident #1 on 06/30/2023 at 10:45 a.m. revealed he was asleep in bed on an air mattress. He did not open his eyes or respond in any way to verbal stimulus. Record review of Resident #1's physician's orders for June 2023 revealed the following: * Metoprolol Tartrate Tablet 25 MG via G-Tube every morning (12.5) and at bedtime (12.5). Hold if SBP is less than 110, DBP is less than 60, Pulse is less than 55 BPM related to Essential (primary) Hypertension (when you have abnormally high blood pressure that is not the result of a medical condition). (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 06/30/2023 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 0656 Record review of Resident #1's MAR for June 29, 2023, revealed the following: Level of Harm - Minimal harm or potential for actual harm * Residents Affected - Few Metoprolol Tartrate Tablet 25 MG. Give 12.5 mg via G-Tube every morning and at bedtime. Hold if SBP is less than 110, DBP is less than 60, Pulse is less than 55 BPM related to Essential (primary) Hypertension. 8:00 a.m. BP: 135/60. The entry box was checked and initialed by LVN A, which indicated LVN A administered the medication. Record review of an email Resident #1's family member sent to the ADON and DON on 06/29/2023 at 10:12 a.m. revealed, Subject: Agency Nurse . The nurse this morning just went in the room to give Resident #1's medications and then took his vitals afterwards! We are getting tired of having to police the agency nurses. Resident #1's well being is at stake. Why would a nurse give medicine before taking vitals? This is dangerous and has to stop!! Please talk to her and all of the other agency nurses who either do not know what they are doing or perhaps just do not care! In an interview with the DON on 06/30/2023 at 9:50 a.m., she stated Resident #1 could not communicate, he was bed bound, he had a G-tube, and he required repositioning every two hours. The DON said Resident #1's family member called and said she saw the agency nurse (LVN A) who cared for Resident #1 on 06/29/2023 on camera when she gave him the blood pressure pill before taking his blood pressure. The DON said Resident #1's family member told her she (LVN A) went back and took Resident #1's blood pressure after she gave him the medicine. The DON said she had to look at Resident #1's MAR to see if he had parameters (orders to hold blood pressure medicine if the blood pressure was over or under a given number). The DON said she previously did an in-service in April 2023 (04/07/2023) because staff previously failed to check Resident #1's vitals prior to administering his medication. She said she would do another in-service for all nurses to ensure they checked blood pressure before administering blood pressure medication. She also stated LVN A would be placed on the do not use list and would not be allowed to return to the facility. In a follow up interview with the DON on 06/30/2023 at 1:00 p.m., she stated Resident #1 did have parameters, so every time nurses give blood pressure medication, they have to take his (Resident #1's) blood pressure first. The DON said the problem usually occurred when they had agency nurses in the evenings. She said she would post signs in Resident #1's room to remind nurses to check his blood pressure prior to administering medication. She said she had to figure out where to post the sign, but she should not have to do that (post signs to remind nurses to check blood pressure before administering medication) for nurses. In an interview with the ADON on 06/30/2023 at 3:36 p.m., she stated she just called Resident #1's family member approximately 10 minutes prior to let her know she (the ADON) had just placed a sign in Resident #1's room to make sure nurses (only nurses administered medications) checked blood pressure prior to administering blood pressure medication. The ADON said there was a camera in Resident #1's room, so any time his family questioned something was because they saw it on the camera. The ADON said Resident #1's family member previously expressed concern regarding nurses administering his blood pressure medication before checking his blood pressure. The ADON said Resident #1 had orders to check blood pressure prior to administering medication, but if any resident had blood pressure medication, nurses needed to check before giving the medication to make sure the residents' blood pressure did not go too low. In a telephone interview with LVN A on 06/30/2023 at 3:56 p.m., she stated she was an agency nurse (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 06/30/2023 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who worked at the facility on 06/29/2023 from 6:00 a.m. until 2:00 p.m. LVN A said she gave Resident #1 his blood pressure medication before checking his vitals on 06/29/2023. She said she knew that was not the correct way to administer the blood pressure medication, but she had to handle a 911 emergency fall across the hall from Resident #1. She said she should always check a resident's blood pressure before administering blood pressure medication. LVN A said she was a little behind with Resident #1's medication and she was told his family watched on his camera. She said she did take Resident #1's blood pressure after administering the medication and it was within the ordered parameters. LVN A said she was overwhelmed with various incidents and that hall was new to her. She said she tried to accommodate all families and resident needs and she knew not to do that again. LVN A said she paused and realized after she gave Resident #1 the medication, and said to herself, she should have taken his blood pressure prior to giving the medication. LVN A said it would not happen again and she realized Resident #1's blood pressure could have dropped too low if it was already low. She said she made sure she checked after she realized her mistake. She said there was no negative outcome with Resident #1. Unsuccessful attempts were made to contact Resident #1's family member on 06/30/2023 at 9:15 a.m. and 7:58 p.m. Voice mail messages and text messages were left but were not returned. Record review of Education/Training Attendance Record dated 04/07/2023 revealed, Training Title: Importance of Vital Signs Prior to Administration of Blood Pressure Medication. 1. Taking vital signs before medication administration is very important. 2. Safety: Vital signs, such as blood pressure, heart rate, respiratory rate, and temperature, can indicate potential health problems or changes in a patient's condition that could affect the safety of medication administration. For example, if a patient's blood pressure is too low, administering certain medications could cause a dangerous drop in blood pressure . 5. Taking vital signs before medication administration is a critical step in ensuring patient safety, monitoring response to treatment, and maintaining accurate documentation . Record review of facility policy, Medication Administration revised February 2023 revealed, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vitals outside the physician's prescribed parameters . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 4 of 4