Inspection·March 7, 2024

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some urine or stool every shift. Further review reflected a treatment order for a dried scab area to the left fifth toe, did not begin until it was ordered on date 2/29/2024. Record review of Resident #26's, undated, care plan reflected the Focus - Resident #26 had ADL self-care performance deficit r/t limited mobility. Interventions included: the resident required skin inspection. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. Focus - Resident #26 was at risk for pressure ulcers as evidenced by impaired mobility, desire to stay supine, repositions self onto back, declines to be turned/repositioned. Interventions included: educate resident on the importance of repositioning, incontinent care every 2 hours and as needed and weekly skin assessments. Focus Resident #26 was at risk for pressure/venous/stasis ulcers r/t diabetes. Interventions included: encourage activity attendance, monitor skin for changes - redness, circulatory problems, breakdown and report to MD/RP. Focus - Resident #26 had impairment to skin and at risk for further skin breakdown. Interventions included: assess skin and record findings, notify MD and RP of any skin concerns. Record review of Resident #26's Physician notes, dated 12/04/2023, reflected no suspicious lesions to the skin. Record review of Resident #26's skin assessments reflected on 2/02/2024 the skin was intact. On 02/07/2024 she had open skin areas to the right thigh (rear), left thigh (rear, left gluteal fold) and right gluteal fold. On 02/16/2024 and on 02/23/2024 the skin was intact. Record review of Resident #26's skin assessment dated [DATE] and written by TN reflected that Resident #26 had excoriation between the legs of the groin, left fifth toe had a dried scab area measuring 1.4cm x 1cm and skin prep (a protective film) was applied. She had purple/blue bruising to the right side of the abdomen and yellow/blue bruising to the right lower arm. The resident was to be assessed by WCD. The MD and RP were made aware. Record review of Resident #26's current physician orders, as of 03/01/2024, reflected an order for zinc oxide ointment for the groin and sacrum every shift and an order for weekly skin assessments with a start date of 01/05/2024. Further review reflected an order for the dried scab area to the left fifth toe: cleanse with normal saline, pat dry and apply skin prep then leave open to air, order dated 02/29/2024. Observation on 02/28/2024 at 3:15 PM revealed Resident #26 was asleep in bed lying on her back with the HOB raised. Observation and interview on 02/29/2024 at 2:07 PM revealed Resident #26 was lying asleep on her back. She was easily awoken. There was a dark thick, dry wound to the fifth toe on the left foot. The area was not open, and it measured approximately ½ inch in diameter. The resident denied pain and denied knowing about the area on the toe. The TN stated she was aware of the resident's excoriation to the perineal area (the triangle area between the legs), but was not aware of the area on the toe. The TN stated the CNAs and nurses should have notified her so she could assess, call the MD and begin treatment. The TN stated she would notify the MD and the wound care doctor would assess tomorrow (3/01/24). Observation on 03/01/2024 at 8:42 AM revealed Resident #26 was lying on her back asleep with the HOB elevated and on an air mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 2 of 31 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 03/07/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 02/29/2024 at 2:20 PM, CNA L stated she had an in-service about one month ago on skin care. CNA L stated she had not seen Resident #26's foot and did not know there was a wound. CNA L stated she would report it to the nurse if she found it. She stated the risk of not reporting skin issues was the wound could get worse. Interview on 02/29/2024 at 4:07 PM, the DON stated CNAs were responsible to notify the charge nurse as soon as possible when they noticed skin changes and the opportunities for CNAs to assess skin were: during peri care, bathing or showering three times per week and during dressing and undressing the residents. The DON stated the skin changes could be communicated by verbal means or the use of stop and watch forms. The DON expected the CNAs to report open areas and obvious changes that may not have been on the resident the day before. The DON stated skin changes should be reported because they could get bad or worse and open wounds could get infected, deeper or worse. She stated the charge nurse, unit manager and treatment nurses continued to communicate well and she conducted staff in-services regarding notifying the treatment nurse no matter what the issue may be. The DON stated she did not know why there was a wound to Resident #26's toe and did not know if the CNA would have even recognized it as an issue to report. The DON stated the admitting nurse was responsible for the skin assessments upon admit and the next day the treatment nurse would be responsible as well. The DON said she expected the nurse conducting the skin assessment to make sure it was complete and some nurses were not so good with making immediate decisions. She stated all skin assessments conducted should be a head-to-toe evaluation and more detailed if needed to better identify any skin issues She stated the unit managers and ADON were responsible to ensure the skin assessments were complete and accurate. The DON stated skin issues would be communicated during morning meetings or during one-on-one nurse reporting. The DON stated if skin issues were identified a day before then it would be brought to IDT meetings for discussion, the MD and wound care physician would be notified. She said it would also be discussed during care plan meetings, QAPI meetings along with weekly weight meetings. The DON stated she would want to make sure the facility had what was needed to heal the skin issues. Interview on 03/01/24 at 9:53 AM, CNA L stated Resident #26 refused to get out of bed when she offered. CNA L stated the resident could reposition herself from side to side and could move around on her own. CNA L stated Resident #26 likes to sleep a lot and was more awake later in the day. Interview on 03/01/2024 at 12:35 PM, the WCD stated Resident #26's left toe looked more like a trauma, maybe hit it on something and she did not have much feeling in the area. The WCD stated she was very large all over and would have difficulty getting through the door, she was already in a large bed. In an interview on 03/03/2024 at 9:38 AM, LVN U stated she started orientation on 2/27/2024 and was assigned to Resident #26. LVN U stated she was still getting familiar with the residents, and was not aware of Resident #26's wound. LVN U stated the areas on the body that were more susceptible to pressure injures included the heels and buttocks. LVN U stated residents who were at higher risk of developing pressure injuries were residents who were immobile and any resident who had a history of wounds. LVN U stated closed wounds could be treated and if not identified then the risk to the residents would be worsening of wounds. LVN U stated wound prevention would include off loading and repositioning. LVN U stated all nursing staff were responsible to help prevent pressure injuries. LVN U stated she received in-services which included wound care, repositioning, reporting and neglect on 03/02/2024 and in-services were ongoing for her since 2/27/2024. LVN U stated she was responsible to ensure the aides repositioned the residents and notified the nurses about any changes to the resident. LVN U stated communication took place typically during morning clinicals, reports and walking rounds with the night nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 3 of 31 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 03/07/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 03/03/2024 at 10:10 AM, Resident #26 stated her little toe bothered her some, it tingled and she was not aware that she had a sore on her toe. Resident #26 stated she did not know how it got there. Interview on 03/03/2024 at 11:45 AM, CNA V stated she worked with Resident #26 on 03/02/2024 and was not aware of any wounds. CNA V stated the CNAs were responsible to report skin changes to the nurse as they were the ones who would see the skin especially during bathing. CNA V stated some people had different work ethics and all aides went to the same CNA school. CNA V stated some aides didn't do what they were supposed to do. She was taught to report any skin issues right away. She stated residents more prone to skin issues were those who stayed in bed all the time, those who did not turn every two hours, independently. She said the areas more susceptible to pressure injuries would be the sacrum, under the breasts and the heels. She said the risks for the residents if they developed pressure injuries and they were not identified early would be they could get worse and become full blown wounds. She said she had training on skin assessments two weeks ago. She said she took care of the residents with passion and rounds two to three times a day, depending on their needs. In an interview on 03/03/2024 at 10:20 AM revealed CNA W, was assigned to Resident #26 and was unaware of the area on the left toe. CNA W stated not reporting wounds to the nurse or the treatment nurse was probably d/t nursing not paying attention. CNA W stated wounds could occur from not turning, or repositioning, from not getting up out of bed or not using pillows for propping. CNA W said she had training on skin assessments and was taught to check the skin and if she saw something new, she would report it to the nurse and if the nurse did not take care of it she would tell the ADON or the DON. She stated she looked at residents' skin during brief changes, dressing, undressing and taking socks off. 2. Record review of Resident #202's face sheet, dated 3/5/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #202 had diagnoses which included COVID-19 (an infectious disease caused by the SARS-CoV-2 virus), viral pneumonia (infection of the air sacs in one or both the lungs caused by a virus), type 2 diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), immunodeficiency (inability to produce antibodies to fight infection) due to drugs, respiratory failure (condition that affects breathing function or the lungs themselves and can result in failure of the lungs to function properly), COPD (Chronic Obstructive Pulmonary Disease, common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough), myasthenia gravis (neuromuscular disorder that leads to weakness of skeletal muscles), muscle wasting and atrophy (loss of muscle leading to its shrinking and weakening), muscle weakness, cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), dementia (group of symptoms that affects memory, thinking and interferes with daily life), insomnia (trouble falling and/or staying asleep), chronic pain syndrome (persistent or intermittent pain that last for more than 3 months), and traumatic brain injury (injury to the brain caused by an external force such as a violent blow to the head, resulting in loss of consciousness, memory loss, dizziness, and confusion, and in some cases leading to long-term health effects, including motor and sensory problems, cognitive and behavioral dysfunction, and dementia). Record review of Resident #202's admission MDS, dated [DATE], with an ARD of 3/1/2024, reflected a BIMS score of 8, which indicated significant cognitive impairment. He had no impairment of either of his upper or lower extremities, and he used a wheelchair for mobility. Resident #202 required assistance, or was totally dependent on staff, with toileting, bathing, dressing, and personal hygiene. He was at risk of pressure injury, but he did not have any current pressure injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 4 of 31 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 03/07/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #202's baseline care plan, dated 2/23/2024, reflected he was admitted for short-term care. He was expected to discharge home or to the community with a family member or caregiver. He did not have any wounds or pressure ulcers. He was to receive care per the physician's orders for treatment, be monitored for medication effectiveness and side effects and complications from his illness, have any changes of condition reported to his PCP and RP, medication administration, oxygen therapy and diabetic care. He was scheduled to received OT and PT services. A focus on Resident #202's self-care deficit with interventions which included assistance with his ADL's. A focus on his actual fall on 2/26/2024 with interventions which included ensure his cell phone and call light were placed within reach, reporting any changes of condition, and reviewing to determine the cause of the fall. A focus on Resident #202's risk for skin breakdown with interventions which included repositioning during rounds and as needed, pain medication administration, use of a pressure reducing mattress, provision of incontinence care during rounds and as needed, and an RD consult and weekly skin assessments. Record review of Resident #202's care plan, dated 3/4/2024, reflected a focus on his dementia with interventions which included medication administration, cuing and reorienting, provision of a consistent routine, monitoring and reporting any changes of condition, task segmentation and a possible medication review. Record review of Resident #202's Braden Scale for Predicting Pressure Sore Risk form, dated 2/23/2024, reflected he was at moderate risk of development of pressure sores. Record review of Resident #202's Braden Scale for Predicting Pressure Sore Risk form, dated 3/1/2024, reflected he was at moderate risk of development of pressure sores. Record review of Resident #202's nurse's note, dated 2/23/2024, reflected he was admitted to the facility after discharge from a local hospital. His skin was warm, dry, and intact. Resident #202 complained of redness and tenderness of his scrotum. Record review of Resident #202's Skin Observation Tool form, dated 2/23/2024, reflected he had no open areas, no wounds, and had an IV wound on his right hand. He also had bruising on both hands from previous blood draws or IV placements. Record review of Resident #202's Skin Observation Tool form, dated 2/29/2024, reflected he had discolorations on his abdomen and healing areas on both knees. He had no open skin areas and had no active bleeding. Record review of Resident #202's physicians note, dated 3/1/2024, signed by his NP, reflected he had no skin breakdown observed. Record review of Resident #202's Skin Observation Tool form, dated 3/1/2024, reflected he had a red rash to the groin. He had no open areas of skin. Resident #202 was assessed by the WCD on 3/1/2024. The WCD recommended Nystatin cream be applied every day, instructed the CNA to apply barrier cream until the Nystatin cream arrived, and the RP and PCP were made aware of the concern. Record review of Resident #202's SBAR note, dated 3/1/2024, reflected the SBAR was related to a rash in his groin area. The rash began on 3/1/2024. Applying cream to the area provided Resident #202 with relief. The rash was identified by the TN when the WCD was on rounds on 3/1/2024. The WCD recommended Nystatin cream be applied to the groin area once daily, and barrier cream would be sufficient (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 5 of 31 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 03/07/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm until the Nystatin cream arrived from the pharmacy. Resident #202's RP and PCP were informed of the concern and verbalized their understanding. Record review of Resident #202's February 2024 MAR/TAR reflected there was no treatment documented for the rash to the periarea and groin. Residents Affected - Some Record review of Resident #202's administration note, dated 3/5/2024, reflected Nystatin External Cream was ordered. Cream was ordered for candida (yeast infection) rash, was to be used for ten days, and applied to the groin and perineal area. Record review of Resident #202's medication report, dated 3/5/2024, reflected a prescription ordered on 3/4/2024 for Nystatin External Cream 10,000 units/gm applied topically to the groin area once daily for ten days related to canidadis rash. Record review of Resident #202's March 2023 MAR, printed on 3/5/2024, reflected a prescription for Nystatin External Cream 10,000 units/gm applied topically to his groin area once daily for ten days related to canidadis rash. The prescription was ordered on 3/4/2024 at 2:12 PM. There was no documentation on the MAR that the medication was ever applied. Observation on 2/27/2024 at 10:55 AM of Resident #202 was sleeping on his back, the head of his bed was slightly elevated. Observation and interview on 3/5/2024 at 12:00 PM revealed Resident #202 lying on his back and receiving care. Resident #202 had redness to his groin, the shaft of his penis, scrotum and it extended to his perineal area, rectal area and buttocks. CNA DD reported she completed perineal care immediately prior to the observation. The Corporate RN entered the room with Nystatin cream and applied it to Resident #202's affected areas. Resident #202 winced as if in pain when the medication was administered. Resident #202 had healed wounds on his buttocks. The RP stated the old wounds to the buttocks were not too deep and they took 6 months to heal. RP stated the buttocks area was not red upon admission but were now red in color with excoriated areas. Resident #202 had large purple areas to the left and right buttocks with intact skin. The RP stated the purple areas would get darker if he sits on the area for long periods. Interview on 3/4/2024 at 2:20 PM with the TN, she said she put the order in for Resident #202's Nystatin on 3/4/2024 because she had other orders to put in on Friday, 3/1/2024. The TN said staff were applying barrier cream to Resident #202's rash until the nystatin came in. She said the cream would not come in from the pharmacy if the order was not put in the system. She said the facility had over-the-counter Nystatin but facility staff would not know to apply it if the order was not put into the system. Interview on 3/5/2024 with Resident #202's family member, she said Resident #202 had redness on his scrotum since 2/23/2024. Resident #202's family member said she had been at the facility since 8:15 AM that day and the staff had not provided Resident #202 with any incontinence care. Resident #202's family member said she did not know if he was incontinent at that time, but no one had come to check on him. Resident #202's family member said the staff brought him medication, but no one had checked for his incontinence. Resident #202's family member said the redness near Resident #202's scrotum had extended to his rectum. Resident #202's family member said the staff put a barrier cream on the area, but the medication the physician ordered had not come in yet. Resident #202's family member said when the WCD was present he said Resident #202 had a yeast infection from the antibiotics he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 6 of 31 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 03/07/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some received. Resident #202's family member said she expected the medications to be delivered to the facility either Saturday 3/2/2024 or Sunday 3/3/2024. Resident #202's family member said when the medication did not arrive during the weekend, she expected the medication to be delivered on 3/4/2024. Resident #202's family member said she wanted Resident #202 to receive the medication to alleviate his pain and distress. Resident #202's family member said Resident #202 reported the pain at an eight on a scale of one to ten. Interview on 3/5/2024 at 12:00 PM with Resident #202's family member, she said the wounds on Resident #202's buttocks were not deep, located on both buttocks and had taken six months to heal. Resident #202's family member said Resident #202 currently had redness, excoriation, and large purple areas on both buttocks. Resident #202's family member said if Resident #202 sat on his buttocks for extended periods of time, the areas darkened. Resident #202's family member said no one repositioned Resident #202 that morning. Resident #202's family member said she was at the facility from approximately 8:00 AM to 4:00 PM daily, and during that time she had not observed Resident #202 be repositioned. Resident #202's family member said the facility informed her of the importance of repositioning for Resident #202. Resident #202's family member said Resident #202 was most comfortable on his back. Interview on 3/5/2024 at 1:23 PM with the TN, she said she could not recall who informed her of Resident #202's redness in the brief area. The TN said she recalled becoming aware of the redness on 3/1/2024 when she was completing rounds with the WCD . The TN said she forgot to put in the order for Resident #202's order for Nystatin cream because she had many other duties when the physician created the orders. The TN said the order was prescribed by the WCD on 3/1/2024 at approximately 3:30 PM. The TN said she obtained Resident #202's Nystatin cream from the facility's electronic medication dispensation system. The TN said she did not know the electronic medication dispensation system had Nystatin cream stocked. The TN said she provided Nystatin powder to Resident #202's red areas on 3/4/2024. The TN said she had not put in Resident #202's Nystatin order on 3/1/2024 at any time. The TN said she typically did not treat rashes, but the floor nurses did. The TN said she would check a rash if requested, and that was what occurred on 3/1/2024 with Resident #202. Interview on 3/5/2024 at 3:23 PM, the DON said she did not know when Resident #202's Nystatin was ordered and did not know why the order was not put in the system by the nurse. She said the pharmacy would not be alerted about the need for the medication until the order was put into the system. She said she was notified on Friday 3/1/2024 when the WCD was in the building that the resident had redness with possible yeast but did not know what the treatment plan was. In a telephone Interview on 03/06/2024 at 2:37PM, CNA DD stated Resident #202's skin on 03/06/2024 at 7:15AM looked the same as it did at 03/06/2024 at 12:00PM when the Corporate RN applied the Nystatin cream. CNA DD stated the resident's skin was pinkish/red with purple blotches on the brief area and that 033/06/2024 was the first time she had worked with Resident #202. CNA DD stated she did not notify the nurse about the condition of Resident #202's skin and thought someone already knew about it because there was clear cream on the skin. CNA DD stated if there was no cream on the skin then she would have notified her nurse. In an interview on 03/07/2024 at 1:55 PM, the Administrator stated it was the responsibility of the nurses and CNAs to check resident skin and for the CNA to report changes to the charge nurse. The Administrator stated, now it had been included that the DON would be notified as well. The Administrator stated it appears someone may not have seen the wounds prior to 2/29/2024 when they were identified and that it was not for lack of checking. The Administrator stated maybe when the skin was checked, the wound/skin issues were easier to identify. The Administrator stated the staff were working (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 7 of 31 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 03/07/2024 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 0684 as hard as they could. She stated her expectations were the residents be repositioned every 2 hours. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy and procedure for Notification of Changes, dated 05/2023, read in part: .the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions or b. Clinical complications . Residents Affected - Some Record review of the facility's policy and procedure for Skin Assessment, dated 11/2023, read in part: .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 2. Procedure .h. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers and lesions .5. considerations for a bariatric resident .c. Thoroughly inspect each surface of a skin fold .7. Documentation of skin assessment: .b. Document observations .c. document type of wound .d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) Record review of the facility's policy and procedure for Wound Treatment Management, dated 11/2023, read in part: .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse .7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound Record review of the facility's policy and procedure for Pressure Ulcer/Skin Injury Management and Prevention, dated 01/08/2023, read in part: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . Policy Explanation and Compliance Guidelines .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .7. Assessment of Pressure Injury Risk .e. Nursing assistants will inspect skin during bath or pericare and will report any concerns to the resident's nurse immediately after the task .9. Monitoring: a. The treatment nurse, unit manager, or designee will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record. b. the attending physician will be notified of: i. the presence of a new (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 8 of 31 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 03/07/2024 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 0684 pressure injury upon identification. 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 9 of 31 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 03/07/2024 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for six of 9 residents (Resident #31, #66, #90, #37, #72 and #11) reviewed for pressure sores. Residents Affected - Some -The facility failed to ensure Resident #31 received wound care treatment for 38 days, did not evaluate, and obtain orders for wound care upon admission when the resident was noted to have an open wound to the buttocks. The right heel had a pressure ulcer that was not identified for further preventative treatment by the discharging hospital, and deteriated after admission - this wound was unavoidable per Wound Care MD. -The facility failed to ensure Residents #66's re-opened sacrum ulcer, #90's stage 4 ulcer to the foot, #37's stage 3 (full thickness tissue loss, open area) sacrum ulcer, #72's DTI (pressure ulcer as a [NAME] area with intack skin) to the left heel, and #11's DTI to the left heel were assessed, monitored, and treated. An Immediate Jeopardy (IJ) situation was identified on 03/01/2024 at 3:00 PM. While the IJ was removed on 03/06/2024 at 3:25 PM, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for a delay in treatment, pain, a decline in health, hospitalization or a significant decline in health. Findings include: Resident #31 Record review of Resident #31's face sheet, dated 2/29/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), hypertension (elevated blood pressure), malnutrition (condition that results from lack of sufficient nutrients in the body), dementia (group of symptoms that affects memory, thinking and interferes with daily life), thyroid disease (a medical condition that keeps the thyroid from making the right amount of hormones), need for assistance with personal care, sepsis (infection of the blood stream), obesity (condition characterized by abnormal or excessive fat accumulation) due to excess calories, Alzheimer's Disease (type of brain disorder that causes problems with memory, thinking and behavior), chronic kidney disease stage 3 (condition characterized by a gradual loss of kidney function) and osteoarthritis (long term degenerative joint condition). Record review of Resident #31's admission MDS, dated [DATE], with an ARD of 1/24/2024, reflected a BIMS score of 5, which indicated significant cognitive impairment. She had no impairment of either her upper or lower extremities, and she used a wheelchair for mobility. Resident #31 required assistance or was totally dependent on staff for all ADL's except eating. She was always incontinent of bowel and bladder. Section M of the MDS revealed she had no pressure injuries but was at risk of developing pressure injuries. She utilized a pressure reducing device for her bed and received application (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 10 of 31 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 03/07/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some of ointments and/or medications other than to feet. Resident #31 was administered anticoagulant, antiplatelet, and hypoglycemic medications during the assessment period. She received OT, PT and ST services. Record review of Resident #31's care plan, dated 1/29/2024, reflected a focus on her ADL self-care deficit with interventions which included OT, PT, and ST services as ordered, use of task segmentation, assistance with PODUS boots to both lower extremities, and assistance with all ADL's except eating. The note related to the PODUS (soft boot to relieve heel pressure) boots to BLE as tolerated for elevating the heels, was added on 2/29/2024. A focus on her incontinence with interventions which included assisting with dressing and hygiene during the toileting process, frequent checking for incontinence care and perineal care, use of a barrier cream and weekly skin check with showers and PRN. The resident was at risk for skin breakdown r/t decreased mobility, incontinent care and diabetes. The interventions included assist with turning and repositioning during rounds as needed and notify MD for ulcers that are deteriorating as needed. A focus on Resident #31's unstageable pressure injury (severe damage of the heel) of the right heel with interventions which included a dietary consultation, monitoring for signs of infection, use of a nutritional supplement, treatment and wound care per physician's orders, and turning and repositioning every two hours. The focus on Resident #31's heel injury was dated 2/28/2024. A focus on her type 2 diabetes mellitus with interventions which included medication administration and monitoring for skin changes. Focus: The resident was at risk for pain and discomfort r/t generalized discomfort, diabetes and osteoarthritis. The interventions included administer pain medication as ordered. The focus did not include pain associated with pressure ulcers. Focus: The resident was diabetic and at risk for pressure/venous/stasis ulcers. The interventions included monitor skin for changes-redness, circulatory problems, breakdown and report to MD/RP. Focus: the resident had impaired immunity r/t recent osteomyelitis, history of COVID-19, sepsis and flu. The interventions included the resident was at risk for infection and keep environment clean. Further review of the care plan did not include resident refusal of care or refusal of repositioning. Record review of Resident #31 2023 TAR revealed an order for weekly skin assessments every Saturday day shift. The skin assessments were completed on 2/3/2024, 2/10/2024, 2/17/2024, and 2/24/2024. Resident #31 received an order related to an unstageable DTI of the right heel, and the heel was to be cleansed with normal saline, patted dry, have betadine applied, and covered with an antibacterial pad and Kerlix gauze roll. The order was written on 2/26/2024 An order for Resident #31 had an unstageable DTI of the right heel to be cleansed with saline, patted dry, betadine applied, and covered with an antibacterial pad and a Kerlix gauze roll written on 2/29/2024. Record review of resident #31's nurses notes dated 1/17/2024 at 7:23 PM, written by LVN EE, reflected the resident had an open wound to the right buttocks region, the size pencil eraser and an opening to the right heel. The note read in part .MD was notified with orders verified. Record review of Resident #31's baseline care plan, dated 01/18/2024, indicated the resident had no wounds. Record review of Resident #31's skin observation tool, dated 1/25/2024, written by LVN C, indicated the skin was intact and no new issues noted. Record review of Resident #31's skin observation tool, dated 2/14/2024, written by LVN HH, indicated there were no new skin issues noted. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 11 of 31 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 03/07/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #31's skin observation tool, dated 2/21/2024, written by LVN HH, indicated the skin was intact and no new skin issues were noted. Record review of Resident #31's skin observation tool, dated 2/26/2024, written by the TN indicated the right heel had unstageable DTI measuring 8cm x 7cm and the RP and MD were aware of the current treatment plan. Residents Affected - Some Record review of Resident #31's notes revealed a clinically unavoidable skin condition pressure ulcer to the right heel, dated 2/28/2024, and signed by TN, and the physician. Record review of Resident #31's active physician's orders report, dated 2/29/2024, reflected an order, dated 2/26/2024, related to an unstageable DTI of the right heel. The order called for the wound base to be cleansed with normal saline, patted dry, betadine applied, and covered with an antibacterial pad and Kerlix gauze roll. Record review of Resident #31's active physician's orders report, dated 2/29/2024, reflected an order, dated 2/29/2024, related to an unstageable DTI of the left heel. The order called for the wound base to be cleansed with normal saline, patted dry, betadine applied, and covered with an antibacterial pad and Kerlix gauze roll Record review of Resident #31's initial wound evaluation and management summary reflected the resident was seen by the WCD on 3/1/2024. The resident had arterial wounds of the right and left heel. Interview on 2/28/2024 at 9:10 AM, the TN said she was first notified of Resident #31's right heel wound on 2/26/2024 and that was when wound care treatment began. During wound care observation and interview on 2/29/2024 at 11:00 AM, Resident #31 had soft boots to both feet and both feet were propped with pillows. The TN removed the boots. The right heel had a dressing wrapped with gauze. The TN removed the dressing. The heel had thick, dark, black, dry scab, approximately 2-3 inches in length covering the entire right heel. When the betadine-soaked dressing was removed there was a foul odor. There was no drainage noted. The surrounding skin was pink with large patches of dry flaky skin. The TN completed wound care to the right heel. The resident winced during wound care. The TN re-applied the soft boots and did not inspect the left heel until the State Surveyor questioned the discoloration to the outer edge of the left heel. The left heel had thick dry flaky skin and large dark purple areas. The skin to the left heel was intact. Resident #31 said she did not like to be turned d/t fear of falling and the staff would turn her slightly as much as she could tolerate then she stayed in the same position on her back most of the time. The TN said the left heel was clear on 2/26/24 and on 2/28/24. The TN stated Resident #31 was up in the wheelchair yesterday (2/28/2024) which could contribute to the discoloration. The TN said the pressure ulcer would have happened d/t not repositioning and offloading the feet. The TN said she would notify the MD to get a doppler study (non-invasive test to measure blood flow). The TN said the wound could develop rapidly for diabetic residents' d/t poor blood flow. Observation on 3/4/2024 at 10:57 AM revealed Resident #31 was admitted to a local hospital and was receiving care. Interview on 2/29/2024 at 12:15 PM, LVN HH said she only recently learned of Resident #31's wounds and when she did the skin assessment on 2/21/2024 there were no skin wounds. LVN HH assumed the wounds to Resident #31 were not new and the treatment nurse was taking care of it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 12 of 31 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 03/07/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Attempted interview on 2/29/2024 at 12:35 PM with Resident #31's RP was unsuccessful. No call back was received by the end of the Survey. Interview on 03/01/2024 at 9:53 AM, CNA L said she was aware Resident #31 would be receiving wound care on 2/29/2024 so she left her in bed and the resident had skin irritation to the buttocks d/t runny stools. CNA L said she applied skin barrier to the redness on the buttocks but there were no open wounds. CNA L said she rounded on Resident #31 by 10:30 AM on 2/29/24 and the resident was sitting up in bed on her bottom, she then changed her brief and left her sitting up in bed with a wedge under the left arm. CNA said after lunch she changed her brief and sat her back up on her bottom in bed. CNA L said the reason for repositioning was to prevent bedsores and stiffness would be a risk to the resident. CNA L said the resident refused repositioning off her back. Interview on 03/01/2024 at 12:35 PM, the WCD said this was the first time he had been to the facility to see any of the residents. The WCD said eschar (a collection of dry, dead tissue within a wound, commonly seen with pressure ulcers) could develop in 24 hours depending on the resident's status. The WCD said it first began as an open wound, then drainage occurred, then slough (yellow tissue) and scarred over just like a regular cut would scab over. The WCD said Resident #31's whole foot was in jeopardy and it might be an arterial injury d/t her pain and was more of a circulatory type of wound. The WCD said failure to reposition the resident may not have contributed to the wound development. The WCD said she may need to go to the ER and he would be speaking with the NP. The WCD said it would be hard to say how fast the wound could get worse and once an arterial wound clotted it could be rapid. The WCD said the left foot was also in jeopardy. Interview on 03/01/24 at 2:30 PM, LVN C said he may have assessed Resident #31's skin when she first admitted but could not recall what the skin looked like. LVN C said he worked regularly on the 100 Hall and Resident #31 lived in the 200 Hall. LVN C said when he performed skin assessments, he would first ask the CNAs on shower days if a resident had any changes to the skin. He said he would follow up after the shower and conduct a head-to-toe assessment. He said he looked at the back of the head, back of the body, stomach, under female breasts, groin, legs, checked toes and heels. LVN C said it was important to catch skin changes early, unfortunately changes could be missed and when that happened the facility would be proactive and address appropriately. LVN C said it was good to have extra eyes on any changes and communication was important. In a telephone interview on 03/05/24 at 1:00 PM, LVN EE saidshe was the admitting nurse and did not notify the MD of Resident #31's open wound to the buttocks and open wound to the right heel. LVN EE said normally she would make a note of it and report to Tx nurse, but it was on the 24-hour report. LVN EE said she thought the wound care nurse would see the 24-hour report and would follow up with all new Admissions and their wounds. LVN EE said she communicated the report to the oncoming shift but could not remember who the report was given to. LVN EE said she probably should have verified her observations of the wounds with another nurse d/t she cannot stage wounds. Interview on 3/4/2024 at 11:09 AM the Hospital RN P said Resident #31 was admitted to the hospital for a pressure injury of the right heel skin. Hospital RN P stated Resident #31 received wound care, had blood labs drawn, was receiving electrolyte replacement therapy and the nephrology department was consulted d/t the resident's low potassium levels. Hospital RN P said the podiatry department reported the resident would need surgical care of the pressure wound. Hospital RN P said the pressure wound to the right heel was unstageable as it was covered with necrotic (dead) tissue. Hospital RN P said Resident #31 had a small sacral pressure wound as well. Hospital RN P said the heel wound could have occurred quickly if it was due to arterial injury, but in her opinion the injury was likely (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 13 of 31 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 03/07/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some present for between one and two months if there was no arterial injury. Hospital RN P said Resident #31's heel wound did not have any infection which would lead to an amputation, but lab results were still pending. Hospital RN P said if the labs indicated a serious infection it could lead to an amputation of the foot. Interview on 03/05/2024 at 1:23 PM, the TN said the 24-hour report was not too familiar with it and was not something she reviewed daily. The TN said new admits were discussed with her during daily nurse meetings and when stop and watch tools (an early warning communication tool) were used for change in condition. The TN said if she was in the building, she would do the skin assessments for the new admits and if the skin assessments were already completed, she would trust the nurse would tell her if there were any areas of concern. The TN ssaid during evening admits the charge nurse would do the skin assessments. The TN said on 2/26/2024 the Agency Nurse notified her of Resident #31's right heel, she did not remember the name of the nurse. The TN stated the resident's left heel was pink and soft and she conducted a focused assessment on the heels only. The TN said no one notified her of any skin issues to the sacral or buttocks. The TN stated, had she been notified upon Resident #31's admission of the skin issues to the right heel she would have assessed it, notified the MD and RP then put a treatment plan in place. The TN said if there were skin issues the nursing staff should have made her aware. The TN said ultimately, she was responsible to address the wounds. Interview on 03/05/2024 at 3:00 PM, the DON said she was not the DON when Resident #31 was admitted on [DATE] and therefore was not aware of the wounds if they were on the 24-hour report. The DON said the 24-hour report would be reviewed during morning meetings and admissions, readmissions and discharges would be reviewed. The DON said she began as acting DON on 01/18/2024 and was in and out of the building periodically. The DON said when a wound was identified she expected the nurse would call the doctor, document, notify the treatment nurse and the RP. The DON expected it would be written on the 24-hour report and reviewed by the treatment nurse. The DON said she probably did attend the morning meeting but did not recall hearing about Resident #31's wounds. The DON said the expectation would be to address the wounds at the time of the meeting and if the nurse was unsure of the presentation of the skin that another nurse would be consulted. Interview on 03/06/2024 at 11:10 AM, the MD said she was notified of Resident #31's wounds to the heels by TN on 2/26/2024 and not before that date. Record review of Resident #31's hospital clinical records reflected she was admitted on [DATE] and the chief complaint was for wound check at the request of the physician for concern about venous ulcers to bilateral heels. The clinical records included pressure injury limited to skin breakdown on the left lower buttocks and on the right lower buttocks and based on clinical presentation Resident #31 was at risk for PAD (peripheral artery disease), pressure wounds, osteomyelitis (infection of the bone,) and nutritional deficits. The clinical records read in part: .External Record Review .inpatient record from another hospital admission on [DATE]. It appears the patient was discharged with pressure wound to right heel. It appears this has worsened and become bilateral since discharge to rehabilitation facility . The Emergency Department Clinical Summary indicated the final diagnoses was: pressure injury of skin of right heel, pressure injury of skin of left heel, skin ulcer of buttock. The pressure injury to the dorsal right of the foot was purple, with moderate serous drainage, blistered and the patient stated both of my feet are bothering me the patient was complaining of pain to both feet and there was blood filled blister present on the left heel. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 14 of 31 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 03/07/2024 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 0686 Resident #66 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #66's face sheet, dated 02/28/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia (a group of symptoms that affect memory, thinking and interferes with daily life), Chronic Obstructive Pulmonary Disease (persistent respiratory symptoms such as breathlessness and cough), bipolar disorder (a mental condition, with extreme mood swings), osteochondropathies of the left ankle and foot (disease of the bone and cartilage), HTN (elevated blood pressures), osteoarthritis, depression, cachexia (unintentional weight loss) and contractures to both hands. Residents Affected - Some Record review of Resident #66's annual MDS, dated [DATE], reflected a BIMS score of 14 out of 15, which indicated intact cognition. She was dependent on staff for toileting, bathing, lower body dressing. She required substantial assistance with upper body dressing and personal hygiene. She required partial assistance from staff when rolling side to side in bed, sitting to lying and lying to sitting on side of bed. She required substantial assistance from staff when sitting to standing and transfers. She was always incontinent of bowel and bladder. She had progressive neurologic conditions. She was at risk of pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. She required pressure reducing device for the bed and applications of ointments/medications other than to feet. She was administered high-risk drug classes: antipsychotic, antidepressant and anticoagulant during the assessment period. She was receiving physical therapy. Record review of Resident #66's, undated, care plan reflected: Focus - Resident #66 had ADL self-care performance deficit, dated 02/21/2024. Interventions included: the resident was bedfast all or most of the time; the resident required skin inspections, observe for redness, open areas, cuts, bruises and report changes to the Nurse, dated 12/08/2022. Focus - Resident #66 was resistive to care, revision date 2/15/2024. Interventions included: if resident resists, leave and return 5-10 minutes later and try again, dated initiated 07/06/2023. Focus - Resident #66 at risk for skin breakdown d/t decreased mobility, incontinence and malnutrition. Interventions included: assist resident with turning and repositioning during rounds and as needed. Weekly skin assessment, notify MD for ulcers that were deteriorating as needed. Focus - Resident #66 had skin impairment (damage/pressure ulcers) and at risk for further skin breakdown, date initiated 03/01/2024 (after Survey entrance). Interventions included: assess skin and record findings in clinical records, notify MD and RP, perform treatments per order, notify MD/RP if no improvement. Record review of Resident #66's active orders, as of 2/28/2024, reflected an order for weekly skin assessment, complete head to toe. Start date 6/30/2023. An order for Zinc Oxide, external paste 25%, apply to sacrum topically every shift for redness. Start date 06/23/2023. Record review of Resident #66's skin assessment, dated 2/29/2024, by TN, reflected an open pink area to the sacrum and white on the inside, wound measurements were 0.7cm x 0.4cm x 0.1cm. The resident was complaining of pain, denied having anything for pain, repositioned on her side for offloading. Record review of Resident #66's active physician orders, as of 03/01/2024, reflected an order, dated 2/29/2024, to cleanse the sacrum wound bed with NS, pat dry and apply alginate calcium and cover with foam dressing. Record review of Resident #66's weekly skin assessments, dated 12/29/23, reflected the previous wound to sacrum was healed and skin barrier cream was applied. Skin assessment, dated 1/5/24, 1/12/24, 1/19/24, 1/26/24, 2/2/24, reflected intact skin. Skin assessment, dated 2/14/24, reflected healed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 15 of 31 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 03/07/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some sacrum wound. Skin assessment, dated 2/21/24, reflected redness to sacrum was present. Skin assessment, dated 2/23/24, noted redness to the sacrum and treatment was in place. Observation and interview on 2/27/2024 at 10:05 AM revealed Resident #66 was in bed lying on her back with the HOB elevated. She stated she preferred to stay in her room. Observation on 2/28/2024 at 3:15 PM revealed Resident #66 was in bed lying on her back with the HOB elevated. Observation and interview on 2/28/2024 at 3:30 PM revealed Resident #66 was in bed sitting up with the HOB elevated. She stated she did not want to get up today. Observation on 2/28/2024 at 4:04 PM revealed Resident #66 was lying in bed on her back. Observation on 03/01/2024 at 8:42 AM revealed Resident #66 was lying on her right side propped with a pillow with the HOB slightly elevated. Observation and interview on 2/29/2024 at 1:45 PM during skin assessment rounds with the TN revealed Resident #66 was lying in bed on her back with the HOB elevated, there were no pillows under her back. Resident #66 had a small open area on the sacrum. There was no redness or drainage noted. The TN cleansed the area and applied Alginate and a dry dressing. Resident #66 stated she was not turned throughout the day then she said sometimes they did turn her onto her sides. The TN stated this was the first time she saw the sacral wound and it was open. The TN stated it was time to in-service the CNAs on reporting skin changes. The TN stated the nursing staff should have reported this to her. The TN left the room, returned, and stated she spoke with CNA L. The TN stated CNA L told her she was aware of the sacral wound and did not report it to TN d/t she was putting zinc ointment on it. Interview on 2/29/2024 at 2:20 PM, CNA L said Resident #66 had the spot on her bottom for a while, since last week maybe. CNA L saidshe would apply cream from the zinc packets to the area. When asked who gave her the zinc packets and whether she applied it to the open wound, CNA L stated she put it on the open wound to heal the wound. When asked why she did not report the wound to the nurse, she stated the resident would tell her to just put the cream on it. Interview on 2/29/2024 at 4:07 PM, the DON said Resident #66 would refuse to turn. When asked why a CNA would apply cream onto an open wound, the DON stated that was the best they knew, and they were instructed to check for redness and to use skin barrier cream. The DON said she did not know why CNA L did not notify the nurse. The DON said if the cream was not appropriate for the wound, then it would not heal or help the open area depending on the state and nature of the resident. The DON said CNAs were responsible to notify the charge nurse as soon as possible when they noticed skin changes and the opportunities for CNAs to assess skin were: during peri care, bathing or showering three times per week and during dressing and undressing the residents. The DON said the skin changes could be communicated by verbal means or the use of stop and watch forms. The DON expected the CNAs to report open areas and obvious changes that may not have been on the resident the day before. The DON said skin changes should be reported because they could get bad or worse and open wounds could get infected, deeper or worse. She said the charge nurse, unit manager and treatment nurses continued to communicate well and she conducted staff in-services regarding notifying the treatment nurse no matter what the issue may be. The DON said she did not know why there was a wound to Resident #66's toe and did not know if the CNA would have recognized it as an issue to report. The DON said the admitting nurse was responsible for the skin assessments upon admit and the next day the treatment nurse would (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 16 of 31 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 03/07/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some be responsible as well. The DON said she expected the nurse conducting the skin assessment to make sure it was complete and some nurses were not so good with making immediate decisions. She said the skin assessment should be a head-to-toe evaluation and more detailed if needed to better identify any skin issues. She said the unit managers and ADON were responsible to ensure the skin assessments were complete and accurate. The DON said skin issues would be communicated during morning meetings or during one-on-one nurse reporting. The DON said if skin issues were identified a day before then it would be brought to the IDT meetings for discussion, the MD and wound care physician would be notified. She said it would also be discussed during care plan meetings, QAPI meetings along with weekly weight meetings. The DON said she would want to make sure the facility had what was needed to heal the skin issues. Interview on 03/01/2024 at 8:59 AM, LVN S said she expected CNAs to reposition residents every 2 hours to prevent sores and to apply barrier cream during incontinent care. LVN S said it was the CNAs and nurses responsibility to do skin assessments and CNAs had the opportunity to see skin during showers/baths and brief changes. LVN S said she expects the CNAs to notify the nurse of any skin changes. Interview on 3/01/2024 at 9:53AM, CNA L said Resident #66 stays in bed by her choice, and sometimes she would scream. CNA L said she changed the resident's position about 3 times during her shift and said she did this for Resident #66 yesterday (2/29/2024). CNA L said she left Resident #66 sitting up in bed at the resident's request. CNA L said when the red spot on Resident #66's sacrum started to look open about one week ago, she reported it to evening CNA F. CNA L said she thought CNA F reported it to the nurse, but she did not. CNA L said she now realized she reported it to the wrong person. Observation and interview on 03/01/2024 at 11:44 AM, with the TN and the WCD, revealed Resident #66 had a PU to her coccyx. There was a lot of redness surrounding the open area, but there was only a small open area. Per the WCD, it was a stage 3 PU (full thickness, open wound) to her coccyx that was 1cm x0.5cm x0.1cm and due to it having some drainage he was going to treat it with collagen and alginate. He said she had a PU there before and it re-opened. Interview on 03/01/2024 at 12:35 PM, the WCD said the zinc cream would not have damaged Resident #66's wound but it would not have helped it either. The WCD said not repositioning and not turning the resident could cause pressure ulcers to the sacrum. Interview on 03/03/2024 at 9:38 AM, LVN U saidshe started orientation on 2/27/2024 and was assigned to residents which included Resident #66. LVN U said she was still getting familiar with the residents and did not know all the details about Resident #66's wound. LVN U said the areas on the body that were more susceptible to pressure injures included the heels and buttocks. LVN U said residents who were at higher risk of developing pressure injuries were residents who were immobile and any time a resident had a history of wounds. LVN U said closed wounds could be treated and if not identified then the risk to the residents would be worsening of wounds. LVN U said, in general, wound prevention would include off loading and repositioning. LVN U said all nursing staff were responsible to help prevent pressure injuries. LVN U said she received in-services which included wound care, repositioning, reporting and neglect on 03/02/2024 and in-services were ongoing for her since 2/27/2024. LVN U said she was responsible to ensure the aides repositioned the residents and notified the nurses about any changes to the resident. LVN U said the aides could use barrier creams and the nurses were responsible to administer treatments as ordered by the physician. LVN U said communication took place typically during morning clinicals, reports and walking rounds with the night nurse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 17 of 31 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 03/07/2024 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interview on 03/03/2024 at 11:45 AM, CNA V said Resident #66 did not have skin issues or wounds weeks ago. CNA V said the CNAs were responsible to report skin changes to the nurse as they were the ones who would see the skin especially during bathing. CNA V said some people just had different work ethics and all aides went to the same CNA school. CNA V said some aides just didn't do what they were supposed to do. Interview on 03/03/2024 at 10:20 AM, CNA W, was assigned to Resident #66 and stated the resident had a dressing over the sacrum today. CNA W said not reporting wounds to the nurse or the treatment nurse was probably d/t nursing not paying attention. CNA W said wounds could occur from not turning, or repositioning, from not getting up out of bed or not using pillows for propping. Interview on 03/03/2024 at 2:42 PM, CNA F said she did work with Resident #66 sometime last week but did not remember the exact date. CNA F stated Resident #66 had the red area to the sacrum from the time she was first admitted . CNA F said sometime during the week of 2/19/2024 to 2/23/2024, she noticed a small area on the sacrum that was not too open and reported it to an Agency Nurse. CNA F said she did not remember the Agency Nurse's name. CNA F said she recalled talking to CNA L about different things but could not recall if they discussed the sacral wound. Resident #90 Record review of Resident #90's face sheet, dated 02/28/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included urinary tract infection, dementia (group of symptoms that affects memory, thinking and interferes with daily life) diabetes (a long-lasting health condition that affects how your body turns food into energy), osteoarthritis (a type of joint disease), resistance to beta lactam antibiotics (infection becoming less affected by a group of commonly pres[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 18 of 31 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 03/07/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 (Resident #53, Resident #8, and Resident #42) out of 20 residents reviewed for incontinent care. -CNA M failed to change Resident #53's brief for over 5 hours. -CNA J failed to change Resident #8's brief for over 8 hours. -CNA N failed to change Resident #42's brief for over 5 hours. These failures could place residents at risk for dignity issues, skin breakdown, infection, and hospitalization. Findings include: Resident #53 Record review of Resident #53's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses of hemiplegia/hemiparesis (paralysis and weakness on one side) following cerebral infarction (stroke) affecting right dominant side, unspecified dementia, cerebral infarction (stroke), aphasia (trouble speaking), history of falling, schizophrenia (people interpret reality abnormally), and bipolar (unusual shifts in mood, ranging from extreme highs to lows). Record review of Resident #53's care plan dated 1/23/24, revealed a Focus: Resident has an ADL self-care performance deficit r/t activity intolerance, confusion, dementia, fatigue, hemiplegia (paralysis on one side), impaired balance, limited mobility, limited ROM, musculoskeletal impairment (Initiated: 2/21/23, Revised on: 2/21/23). Goal: The resident will maintain current level of function through the review date (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Interventions: Personal Hygiene- The resident requires total to extensive assistance by 1 staff with personal hygiene and oral care (Initiated: 2/21/23, Revised: 2/21/23). Toilet UseThe resident is totally dependent on 1 staff for toilet use (Initiated: 2/21/23, Revised: 2/21/23). Focus: Resident is at risk for skin breakdown r/t decreased mobility, incontinence, poor PO intake (Initiated: 2/21/23, Revised: 2/21/23). Goal: Will show granulation (new skin) and reduction in size through review date (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Pressure injury will be free from signs and symptoms of infection (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Will remain free of pressure injury(s) through the next review date (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Interventions: Assist resident with turning and repositioning during rounds and as needed (Initiated: 2/21/23). Provide/offer incontinent care during rounds and as needed (Initiated: 2/21/23). Focus: Resident #53 is totally incontinent of B/B requires assistance r/t self-care deficit (Initiated: 2/21/23, Revised: 2/21/23). Goal: Reduce the risk for skin breakdown through the next review (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Promote dignity by keeping resident clean, dry and free from odor every shift through the next review (Initiated: 2/21/23, Revised: 1/23/24, Target: 4/22/24). Interventions: Assist with dressing and hygiene during the toileting process. Be sure resident is kept clean, dry, every shift. Monitor for any skin breakdown-Report immediately. Use incontinent products, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 19 of 31 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 03/07/2024 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 0690 skin barrier, every shift and as needed. Weekly skin check. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #53's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 5 out of 15, which indicated severely impaired cognition. The resident had impairment on one side of her upper and lower extremities and used a wheelchair. According to the MDS the resident was substantial/maximal assistance with eating, oral hygiene, upper body dressing, and personal hygiene. She was totally dependent with toileting hygiene, shower/bathes, lower body dressing, and putting on/taking off footwear. The MDS revealed Resident #53 was substantial/maximal assistant with rolling left and right, sit to lying, and lying to sitting on side of bed. She was dependent with chair/bed to chair transfer, and tub/shower transfers. Resident #53 was always incontinent of bowel and bladder and was not on a toileting program. The MDS indicated the resident was at risk of developing pressure ulcers/injuries but did not have any that were unhealed at that time. Residents Affected - Some Record review of Resident #53's medical record revealed a form for B&B-Bladder Documentation for the past 30 days. On 2/29/24 at 7:21am it was documented that Resident #53 was incontinent of urine by CNA M. In an observation on 2/29/24 at 8:52am Resident #53 was sitting up in her wheelchair in her room. The room smelled strongly of urine. In an interview with CNA M on 2/29/24 at 10:07am, she said she worked with Resident #53. She said she arrived at the facility at 6:30am and started making rounds. She then started changing everyone, performing showers, and getting everyone up for breakfast. Then she said she checked/changed residents again. She said she would then give more showers, took a break at 10am, checked again, went to lunch, and more rounds. She said since Resident #53 was in a wheelchair she had to get her into a Hoyer lift with a teammate and put her into bed to check/change her and then put her back into the wheelchair with the Hoyer lift. She said she had not changed Resident #53 yet that morning because she had not gotten to her yet and the last time she was changed was whenever the night shift changed her. In an interview with CNA M on 2/29/24 at 2:25pm, she said she did not change Resident #53 until around 11:45am. In an interview on 3/5/24 at 11:53am with CNA KK, she said she last changed Resident #53 at 10:00am and was about to go and change her again. Resident #8 Record Review of Resident #8's undated face sheet, revealed a [AGE] year-old woman admitted on [DATE] with diagnoses of cerebral infarction (stroke), type 2 diabetes mellitus (condition results from insufficient production of insulin causing high blood sugar), morbid obesity (health condition resulting from an abnormally high body mass), immunodeficiency (immune system's ability to fight infections and cancer is compromised) due to drug use, hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness), overactive bladder (a frequent and sudden urge to urinate that may be difficult to control), pseudobulbar effect (nervous system disorder that causes inappropriate involuntary laughing and crying), epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), hypertension (high blood pressure), and heart failure. Record review of Resident #8's annual MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15 which indicated no cognitive impairment. The MDS documented she had impairments to both upper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 20 of 31 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 03/07/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and lower extremities, and she utilized a wheelchair for mobility. Per the MDS, Resident #8 required maximum assistance or was totally dependent on staff for all ADL's. The MDS revealed she was always incontinent of bladder and bowel, and she was not on a toileting program. The MDS documented she did not receive any OT, PT, and/or ST services. Record review of Resident #8's care plan dated 12/21/2024 revealed a Focus: Resident #8 has an ADL self-care performance deficit r/t activity intolerance, fatigue, hemiplegia (paralysis on one side), limited mobility, stroke (Initiated: 12/20/21, Revised: 12/20/21). Goal: The resident will maintain current level of function through the review date (Initiated: 12/20/21, Revised: 12/12/23, Target: 12/18/23). Interventions: The resident is totally dependent on (2-5) staff to provide bath/shower. The resident requires total assistance by (2-5) staff to turn and reposition in bed as necessary. The resident requires extensive to total assistance by (1-2) staff with personal hygiene and oral care. The resident is totally dependent on (1-3) staff for toilet use. Focus: The resident is totally incontinent of B/B requires assistance r/t self-care deficit (Initiated: 12/20/21, Revised: 12/20/21). Goal: Reduce the risk for skin breakdown through the next review (Initiated: 12/20/21, Revised: 12/12/23, Target: 12/18/23). Promote dignity by keeping resident clean, dry & free from odor every shift through the next review (Initiated: 12/20/21, Revised: 12/12/23, Target: 12/18/23). Interventions: Assist with dressing and hygiene during the toileting process. Be sure the resident is kept clean, dry every shift. Check with resident during rounds and as needed, assist to toilet, and as needed. Give incontinent care during rounds and as needed. Give peri care (washing the genitals and anal area) with facility protocol/policy. Record review of Resident #8's medical record revealed a B&B-Bladder Documentation for the past 30 days. On 2/29/24 at 5:55am it was documented that Resident #8 was incontinent of urine. Record review of Resident #8's progress notes revealed a nurse's note from 2/29/24 at 1:31pm from LVN OO that read, Resident stated that she had not been rounded on during the entire shift. Record review of Resident #8's progress notes revealed a nurse's note from 2/29/24 at 8:37pm from the DON that said resident stated, ' .They always come and change me at 3:00am .' Interview and observation on 2/27/2024 at 9:44am with Resident #8, she said the staff did not change her incontinence briefs during the night shift until 3:00am and they did not change her when they first came on shift. She said the staff arrived between 10:30pm and 11:00pm. Resident #8 said the staff did not change her until 3:00am every night. Interview and observation on 2/29/2024 at 12:59pm with Resident #8, she said the staff did not want to change her during the evening shift from 2:00pm to 10:00pm. Resident #8 said she had not been changed at all on 2/29/24. Interview on 2/29/24 at 1:06pm with LVN C, he was not aware that Resident #8 was not changed yet during the shift. Interview on 2/29/2024 at 2:14pm with LVN C, he said he had spoken with CNA J and CNA K about Resident #8 not receiving incontinence care that day. LVN C said he determined Resident #8 had not received incontinence care during the day shift that day. LVN C said the CNA's reported they were busy and did not have time to provide Resident #8 with incontinence care. LVN C said he assisted the CNA's with providing incontinence care and that that was her first incontinence care performed on 2/29/24 during the 6:30am to 2:30pm shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 21 of 31 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 03/07/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 2/29/24 at 2:41pm with CNA J, she said she checked Resident #8 at 6:45am that day and she was dry. CNA J said she assumed the 10:30pm to 6:30am shift had changed her at shift change. CNA J said she checked Resident #8 again after breakfast and she was dry. She said then CNA K also checked on the resident during the day. Interview on 2/29/24 at 2:53pm with CNA K, she said she provided Resident #8 incontinence care on 2/29/2024 at approximately 1:50pm. She said she had not provided Resident #8 incontinence care at any other time on 2/29/2024. CNA K said she never checked Resident #8's incontinence brief to determine if it was soiled on 2/29/2024 because she was not the resident's CNA. She said the Resident #8 was not assigned to her and was assigned to CNA J. CNA K said she checked in on Resident #8 during the day on 2/29/2024, but she never checked her incontinence brief to determine if it was soiled. Interview on 3/1/2024 at 3:51pm with Resident #8, she said she was doing well that day. She said on 2/29/2024 when the facility staff did not provide her with incontinence care during the day, she felt neglected and bad. Resident #8 said she felt that because it took more than one person to assist her with incontinence care, the staff ran away from her call lights. She said when she did not receive incontinence care timely in the past, she felt neglected and sad. Resident #8 said she wished the staff would treat her the way they would like to be treated if they were in her position. Resident #42 Record review of Resident #42's undated face sheet revealed she was [AGE] years old, admitted on [DATE] with an original admission date of 9/1/20. She had diagnoses of dementia, traumatic subarachnoid hemorrhage (bleeding in the brain), chronic respiratory failure, HTN (high blood pressure), and abnormalities of gait and mobility. Record review of Resident #42's Quarterly MDS dated [DATE], revealed a BIMS score of 3 out of 15 which indicated severely impaired cognition. This MDS did not mention her ADLs. She was always incontinent of bowel and bladder and was not on a toileting program. The MDS revealed Resident #42 was dependent with toileting hygiene, shower/baths, lower body dressing, and putting on/taking off footwear. She was substantial/maximal assistance with oral hygiene, upper body dressing, and personal hygiene. Resident #42 was at risk of pressure ulcers/injuries but did not have any at the time. She had a pressure reducing device for bed and applications of ointments/medications other than to feet. Record review of Resident #42's care plan dated 1/24/23, revealed a Focus: Resident has an ADL self-care performance deficit r/t dementia, weakness, and deconditioning (Initiated: 5/28/21, Revised: 5/28/21). Goal: She will be clean, dry and well groomed (Initiated: 5/28/21, Revised: 1/24/24, Target: 4/23/24). Interventions: The resident is bedfast all or most of the time. The resident requires extensive assistance of 1 for personal hygiene. The resident requires total assist of 1-2 for toilet use. Focus: Resident has total incontinence of B/B requires assistance r/t self-care deficit. Goals: Promote dignity by keeping resident clean, dry & free from odor every shift through the next review (Initiated: 6/11/21, Revised: 1/24/24, Target: 4/23/24). Reduce the risk for skin breakdown through the next review (Initiated: 6/11/21, Revised: 1/24/24, Target: 4/23/24). Interventions: Assist with dressing & Hygiene during the toileting process. Be sure resident is kept clean dry, every shift. Monitor for any skin breakdown-Report to MD. Provide incontinent/peri care (washing the genitals and anal area) as needed; use incontinence products, apply skin barrier every shift and as needed. Weekly skin check with showers and prn. Focus: Resident is at risk for Decubitus Ulcer/Pressure Ulcer r/t Incontinence decreased mobility (Initiated: 9/25/20, Revised: 5/28/21). Goals: The resident will have intact skin, free of redness, blisters or discoloration by/through review date (Initiated: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 22 of 31 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 03/07/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 9/25/20, Revised: 1/24/24, Target: 4/23/24). Skin will remain clean, dry and intact without evidence of breakdown through the next review (Initiated: 9/25/20, Revised: 1/24/24, Target: 4/23/24). Interventions: If Incontinent, give Incontinent care Q2 hours and as needed. Weekly skin assessment, notify MD for Ulcers that are deteriorating, as needed. In an observation on 2/28/24 at 9:29am Resident #42 was laying on her back in bed while CNA W and CNA J put her in a Hoyer lift to weigh her. The resident's diaper was observed to be soaked with urine and the CNAs did not change her and only weighed her and left the room. In an observation on 2/29/24 at 8:45am, Resident #42 was asleep on her side in bed. She smelled strongly of urine. Interview on 2/29/24 at 9:06am, CNA N said she took care of resident #42. She said she got to work at 6am and started to get everyone up, out of bed, and showered. Then she took them to breakfast and helped feed them. After that she said she would start changing residents around 8am. She said she had not changed Resident #42 yet and she still needed to get another resident up and showered, so it would be a little while before she could change her. Interview on 2/29/24 at 2:04pm with CNA N, she said she did not change Resident #42 until about 11am and she was not changed before that, since whenever the night shift had changed her. In an interview on 3/5/24 at 11:50am with CNA JJ, she said she last changed Resident #42 at about 11:30am and before that she changed her at about 8:50am-9:00am. Interview with the ADON on 2/29/24 at 9:00am, she said the CNAs rounded on the residents at least every 2hrs or more often if necessary and changed the residents at that time if they needed it. Interview with the DON on 2/29/24 at 1:55pm, she said her expectations were that the staff changed the residents when they got to the facility and every 2hrs and PRN. She said however, that the staff had a tough schedule. Interview with the DON on 3/4/24 at 10:00am, she said she ensured the CNAs were changing residents by performing Angel rounds. She said Angel rounds were when department heads were responsible for a hall, and they went through and checked the residents and spoke with them to ensure they were being taken care of and changed. She also said it was up to the nurses to ensure the aides were changing the residents. Interview with the DON on 3/4/24 at 10:30am, she said the facility was staffed well enough to keep residents clean and dry, unless they had a high number of call ins. She said incontinent care should be done every 2hrs and as needed. She said consequences of not providing timely care could appear neglectful and could have negative consequences to the resident. She also said nurses were in-serviced on going into the resident's rooms during shift change and asking the resident's how they were, checking for odors and changing them if they needed it. Interview with the Wound Care Nurse on 3/4/24 at 12:00pm, she said turning/repositioning and incontinence care every 2hrs and PRN, was a part of pressure injury management. Interview with LVN II on 3/4/24 at 1:01pm, she said residents needed to be turned/repositioned every 2hrs and incontinent care needed to be done every 2hrs as well. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 23 of 31 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 03/07/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with the Administrator on 3/7/24 at 2:15pm she said she expected staff to change residents every 2-3hrs and as needed. She was not sure why they were not being changed like they were supposed to be. She did not think any staff left the residents soiled intentionally. Record review of the facility's policy and procedure for Activities of Daily Living (ADLs) (revised 2/2023) read in part: .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; .3. Toileting .Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Record review of the facility's policy and procedure for Perineal Care (revised 1/2024) read in part: It is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown . Record review of the facility's Job Description for Certified Nursing Assistant (revised 1/1/18) read in part: Certified Nursing Assistant's (CNA) perform routine tasks and care in accordance with established policies and procedures under the supervision of nursing to assure that the highest degree of quality resident care can be maintained at all times .Essential Job Functions: Provides and promotes resident's rights during resident care .Perform satisfactorily nursing care and activities of daily living (bathing, transfers, walking, bed mobility, eating, brace/splint care, bowel & bladder, toileting, vital signs, etc.) in a very caring and safe manner . Record review of the facility's Job Description for Charge Nurse (Registered Nurse/Licensed Vocational Nurse) (revised 1/1/18) read in part: The Charge Nurse is responsible for staff assignments and providing the overall supervision of resident care activities. Responsible for performing a variety of duties to provide quality nursing care to resident and to coordinate total nursing care for residents; implementing specific procedures and programs; participating with the Director of Nursing and the Assistant Director of Nursing in establishing specific goals; determining work procedures and expediting work flow; insuring compliance with all operating policies and procedures and Texas Department of Aging and Disability Services regulations and Federal Health Care Administration and Centers for Medicare and Medicaid Services .Essential Job Functions: .Assume the authority, responsibility and accountability for directing assigned unit/staff . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 24 of 31 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 03/07/2024 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 - Some 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 assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 of 2 residents (Residents #8 and #352) reviewed for pharmacy services. The facility failed to ensure LVN A administered Oxycodone-Acetaminophen (a controlled medication used to treat moderate to severe pain) and Lorazepam (a controlled medication that treats anxiety) to Resident #8 in accordance with physician's orders. The facility failed to ensure MA A administered Oxycodone-Acetaminophen to Resident #8 in accordance with physician's orders. The facility failed to ensure LVN I destroyed two of Resident #8's Oxycodone-Acetaminophen tablets and one of Resident #352's Oxycodone tablets with a witness according to facility policy. These failures could place residents at risk of medication error and drug diversion. Findings included: Resident #8 Record review of Resident #8's face sheet dated 2/27/24 revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnosis included hemiplegia and hemiparesis following cerebral infarction (paralysis or weakness on one side following a stroke), chronic pain, generalized anxiety order, and major depressive disorder. Record review of Resident #8's annual MDS assessment, dated 12/11/23, revealed a BIMS score of 15 out of 15, which indicated no cognitive impairment. She was dependent on staff for ADL care. Record review of Resident #8's care plan dated 12/19/23 revealed she used an anti-anxiety medication related to anxiety disorder and pseudobulbar affect (emotional incontinence). The interventions were to administer anti-anxiety medication as ordered by the physician and monitor for side effects and effectiveness. She was at risk for pain and discomfort. Interventions were to administer pain medications as ordered. Record review of Resident #8's Physician Orders for February 2024 revealed orders for: Lorazepam 0.5 mg give 1 tablet by mouth two times a day related to generalized anxiety, order date 12/20/23 and Percocet 5-325 mg (Oxycodone-Acetaminophen) give 1 tablet by mouth every 8 hours for pain, order date 4/11/23. There were no active prn (as needed) orders for Lorazepam or Oxycodone-Acetaminophen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 25 of 31 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 03/07/2024 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 - Some Record review of Resident #8's Controlled Substance Disposition Record for Lorazepam dated 2/17/24 revealed directions to take 1 tablet by mouth twice daily. LVN A administered one Lorazepam tablet to Resident #8 on 2/20/24 at 3 a.m. Lorazepam was also administered by MA B on 2/20/24 at 7 a.m. and MA A on 2/20/24 at 7 p.m. for a total of three Lorazepam pills in one day. Record review of Resident #8's Medication Administration Record for February 2024 revealed Lorazepam 0.5 mg was scheduled twice a day (one in the morning and one at bedtime). There were no active prn orders for Lorazepam on 2/20/24. Lorazepam was signed off as administered on 2/20/24 for the morning administration by MA B and one tablet for the bedtime administration by MA A. There was no documentation to show LVN A administered Lorazepam to Resident #8 on 2/20/24 at 3 a.m. Record review of Resident #8's Controlled Substance Disposition Record for Oxycodone-Acetaminophen 5-325 mg dated 1/29/24 revealed directions to take 1 tablet by mouth three times per day. LVN A administered one Oxycodone-Acetaminophen tablet to Resident #8 on 2/20/24 at 3 a.m. MA B administered one tablet on 2/20/24 at 7 a.m., MA A administered one tablet on 2/20/24 at 3 p.m. and 7 p.m. and LVN I administered one tablet on 2/20/24 at 11 p.m. for a total of five Oxycodone-Acetaminophen tablets in one day. Further review of the record revealed that LVN I wasted one Oxycodone-Acetaminophen tablet on 2/23/24 at 11 p.m. and one tablet on 2/26/24 at 11 p.m. LVN I signed the record and wrote wasted but there were no additional signatures on those dates to indicate the waste was witnessed. Record review of Resident #8's Medication Administration Record for February 2024 revealed Oxycodone-Acetaminophen 5-325 mg was scheduled three times a day (7:00 a.m., 3:00 p.m., and 11:00 p.m.). There were no active prn orders for Oxycodone-Acetaminophen on 2/20/24. Oxycodone-Acetaminophen was documented as administered on 2/20/24 at 7:00 a.m. by MA B, one tablet on 2/20/24 at 3:00 p.m. by MA A, and one tablet on 2/20/24 at 11 p.m. by LVN I. There was no documentation to show LVN A administered Oxycodone-Acetaminophen to Resident #8 on 2/20/24 at 3 a.m. or that MA A administered one tablet on 2/20/24 at 7 p.m. In a telephone interview on 2/29/24 at 10:45 p.m. LVN I said on 2/23/24 and 2/26/24 Resident #8 dropped her Percocet (Oxycodone-Acetaminophen) pills. She said she (LVN I) put the pills in the pill buster (a Drug Buster uses activated charcoal to quickly neutralize the active ingredients in pills, liquids, controlled substances and transdermal patches) to waste them. She said another nurse did not witness the waste because she got busy and was passing medications. She said she should have stopped right then and there to get another nurse to witness her waste the medication. She said the purpose of a witness was to know the nurse did not take or do something else with the medication. She said after the waste, both nurses signed the controlled count sheet. She said she documented wasted only on the controlled record for 2/29/24 and there were no other nurse signatures for that administration. In an interview on 2/29/24 at 3:14 p.m. the DON said when nursing staff administered a narcotic medication, they should go in the MAR and narcotic/controlled record and document the medication was given. In an attempted interview on 3/1/24 at 11:39 a.m. with LVN A, she was unable to be reached. A voicemail was left requesting a call back. In a telephone interview on 3/1/24 at 12:16 p.m. MA A said she made a medication error when she administered Percocet to Resident #8 on 2/20/24 at 7 p.m. She said Resident #8 always called the nurse for a prn pain pill. She said she was unable to document the administration on the MAR because it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 26 of 31 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 03/07/2024 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 was not highlighted and did not show up as ready to give. She said she did not realize she made a medication error until today. She said when preparing medication for administration she checked the MAR, order, dose, blister pack and directions. She said the resident could get sick or overdose if she received too much medication. Residents Affected - Some In an observation on 3/1/24 at 1:08 pm of Resident #8 revealed she was lying in bed asleep. Interview on 3/1/24 at 1:30 p.m. with the DON she said MA A did not notify her of a medication error on the day of the incident (2/20/24). She said staff should verify the 5 rights when administering medications which include the right resident, medication, route, time, and documentation. She said staff should refer to the MAR prior to administering the medication. She said if the medication was not in the MAR, they did do not give it. Interview on 3/1/24 at 1:50 p.m. the Administrator said she expected nursing staff to read and following the physician orders. Resident #352 Record review of Resident #352's face sheet dated 3/1/24 revealed an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnosis included fracture of shaft of humerus right arm (a long bone in the arm that runs from the shoulder to the elbow), and fracture of right femur (thigh bone). Record review of Resident #352's 5-day MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 which indicated moderate cognitive impairment. She required assistance of staff with ADL care. Record review of Resident #352's care plan dated 2/28/24 revealed she was at risk for pain and discomfort related to generalized discomfort, fracture to right femur and shoulder, muscle spasms. Interventions were to administer pain medications as ordered. Record review of Resident #352's Physician Orders revealed an order for Oxycodone 5 mg give 1.5 tablets by mouth every 6 hours for pain, order date 2/21/24. Record review of Resident #352's Controlled Substance Disposition Record for Oxycodone dated 2/24/24 revealed on 2/29/24 at 1 a.m. LVN I wasted 1.5 Oxycodone tablets and documented that the resident dropped the pill. There were no additional nurse signatures to indicate the waste was witnessed. In an observation and interview on 2/29/24 at 4:59 p.m. of Resident #352 revealed she was lying in bed. She said the facility provided her with pain medication and said she never dropped any of her pills. She said staff would give her the pill and she would put it in her mouth or staff would administer the pill to her with a spoon. In a telephone interview on 2/29/24 at 10:45 p.m. with LVN I, she said Resident #352 had a bad arm and dropped her Oxycodone tablet on the floor in the middle of the night on 2/29/24. She said she placed the pill in the pill buster and forgot to get a coworker to sign. She said she should have stopped to get another nurse to sign with her but did not stop because she was finishing her rounds. She said she was embarrassed she made the mistake and was doing the best she could. She said she signed on the narcotic sheet and wrote LVN after her signature. She said no other nurse signed the controlled record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 27 of 31 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 03/07/2024 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 Interview on 3/1/24 at 1:30 p.m. with the DON, she said two nurses, or a nurse and medication aide were needed to destroy a narcotic with the drug buster. She said both staff would witness the destruction and sign on the narcotic/controlled sheet. She said if that process was not followed the medication could be pocketed, swallowed, or given to someone else. She said the controlled medications process needed to be controlled and complete from beginning to end. Residents Affected - Some Interview on 3/1/24 at 1:50 p.m. the Administrator said the policy, procedure, and expectation was to waste a controlled medication with a coworker. She said the procedure ensured proper handling reporting, and protected the resident, staff, and facility. Record review of the facility's Controlled Substance Administration & Accountability policy dated 5/2023 reflected in part, .It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure . j. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. Spot checks are performed to verify: Controlled substances that are destroyed are appropriately documented . 4.Obtaining/Removing/Destroying Medications . d. Two licensed staff must witness any disposal or destruction of a controlled substance and document same on the Drug Disposition Record, Controlled Drug Record . Record review of the facility's Medication Administration policy, revised 2/2023, reflected in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician .Policy Explanation and Compliance Guidelines . 10. Review MAR to identify medication to be administered. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. 17. Sign MAR after administered . 21. Facility to follow liberalized medication times unless other instructed by the physicians' orders . . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 28 of 31 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 03/07/2024 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 5% based on 2 errors out of 34 opportunities, which involved 2 of 6 residents (Residents #57 and #11) reviewed for medication errors. Residents Affected - Few - MA B administered Carvedilol (a medication used to treat high blood pressure and heart failure) to Resident #57 when it should have been held according to the parameters indicated in the physician's orders. - LVN BB administered insulin to Resident #11 during a meal instead of before a meal as indicated in the physician's orders. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings include: Resident #57 Record review of Resident #57's face sheet dated 2/29/24 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnosis included hypertension (high blood pressure), dementia, diabetes, and cerebral infarction (stroke). Record review of Resident #57's annual MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated no cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #57's care plan dated 1/29/24 revealed she had hypertension. Interventions were to give anti-hypertensive medications as ordered. Record review of Resident #57's order summary report for February 2024 revealed an order for Carvedilol 12.5 mg give 1 tablet by mouth two times a day related to hypertension. Hold for systolic blood pressure less than 110 or Heart Rate less than 60 bpm, order date 7/26/23. Record review of Resident #57's medication aide administration record for February 2024 revealed Carvedilol 12.5 mg was documented as administered on 2/28/24 for the morning dose by MA B. Her blood pressure was 121/69 and heart rate was 53. In an observation on 2/28/24 at 8:50 a.m. with MA B revealed she entered Resident #57's and took her blood pressure which was 121/69 and the heart rate was 53. MA B prepared Resident #57's morning medication which included Carvedilol 12.5 mg - 1 tablet, Klor con 20 mEq, Polyethylene Glycol 3350 17 gm, Senna 8.6 mg 2 tablets, Chewable aspirin 81 mg 1 tablet, Clopidogrel 75 mg 1 tablet, Amlodipine 5 mg, Fluoxetine 20 mg - 1 tablet, Gabapentin 100 mg - 1 tablet, Lisinopril 40 mg - 1 tablet, Metformin 500 mg - 1 tablet, Furosemide 20 mg - 2 tablets, and Refresh Plus Carboxymethylcellulose 0.5% eyes drops. She entered the room and administered the medications to Resident #57. Interview on 2/28/24 at 9:05 a.m. with MA B, she said Resident #57's order for Carvedilol had instructions to hold the medication if the heart rate was less than 60. She said Resident #57's heart (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 29 of 31 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 03/07/2024 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 - Few rate was 53. She said she never saw the heart rate parameter and thought it only applied to Metoprolol. She said the MD put the parameter in, but she did not know why. She said when administering medications, she checked the vital signs and verified that the blood pressure was within the specified parameters. Interview on 2/29/24 at 2:57 p.m. the DON said Resident #57's Carvedilol should have been held because it was a beta blocker and would slow down the heart rate. She said the instructions for when to hold the medication were on the physician orders and the MAR. She said MA B might have been focused on holding the medication if the systolic blood pressure was less than 110. Resident #11 Record review of Resident #11's face sheet dated 2/29/24 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included type 2 diabetes, chronic kidney disease, and Alzheimer's disease. Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care. Record review of Resident #11's order summary report for February 2024 revealed an order for Insulin Lispro inject as per sliding scale . subcutaneously before meals for diabetes, order date 1/18/24. Record review of Resident #11's Medication Administration Record for February 2024 revealed Insulin Lispro subcutaneously before meals was scheduled for 7:30 a.m. In an observation on 2/28/24 at 7:57 a.m. of Resident #11 revealed she was sitting up in bed with approximately 75% of her breakfast eaten. Resident #11 was eating her breakfast sausage and oatmeal. LVN BB took Resident #11's blood sugar which was 190 mg/dL. She prepared and administered 8 units of Humalog Kwik pen to Resident #11. Interview on 2/28/24 at 8:10 a.m. with LVN BB, she said she was supposed to catch the resident before meals because the blood sugar may be high, and the insulin would bring it down. She said after a meal the blood sugar would be elevated. She said she had a window of time to administer the insulin between 7:30 am and 8:30 am. She said administering the insulin at mealtime was sufficient and the resident had not finished eating. Interview on 2/29/24 at 3:04 p.m. with the DON she said short acting, mealtime insulin should be given before meals because they needed to know what the blood sugar was before eating. She said it was very hectic the morning of 2/28/24 and she did not know what happened. She said there were questions on when the insulin should be administered but it would be something the facility would discuss with Quality Monitoring. Interview on 3/1/24 at 1:50 p.m. the Administrator said she expected nursing staff to read and following the physician's orders. Record review of the facility's Medication Administration policy revised 2/2023 read in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 30 of 31 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 03/07/2024 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 this state, as ordered by the physician . Policy Explanation and Compliance Guidelines . b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 31 of 31