Inspection·May 29, 2025

F 0759 with the other medications, mixed it with pudding and administered it to Resident #22. Level of Harm - Minimal harm or potential for actual harm In an interview on 5/14/25 at 8:57 a.m., MA V said she crushed the potassium chloride but could not crush any enteric coated medication or potassium chloride. She then said Potassium chloride could be crushed. She said there was a list of medications that could not be crushed in a binder for reference. MA V retrieved the list and said Potassium chloride was listed on the sheet and could not be crushed. She said Potassium Chloride ER was long acting and it would not be the same if it were crushed. Residents Affected - Few In an interview on 5/15/25 at 10:47 a.m. the DON said Potassium Chloride ER should be dissolved in water and not crushed because it would get into the system faster which could affect the heart rhythm and muscle function. She said if the order did not correlate, staff should stop and notify the nurse and MD for a medication change. Record review of Meds That Should Not Be Crushed dated 4/2025 and provided by the facility revealed Potassium Chloride Klor-Con tablet was listed due to modified-release. 2. Record review of Resident #68's face sheet dated 5/15/25 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included cerebral infarction, nutritional deficiency, and gastrostomy status (presence of an artificial opening to the stomach). Record review of Resident #68's discharge-return anticipated MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired. She required assistance from staff with ADL care. Record review of Resident #68's care plan revealed she had a nutritional problem or potential nutritional problem. Interventions were to administer medications as ordered, date initiated 2/5/24. Record review of Resident #68's Physician orders for May 2025 revealed an order for Multivitamin tablet give 1 tablet enterally one time a day related to nutritional deficiency, order date 4/13/25. In an observation on 5/14/25 at 9:04 a.m., LVN B prepared Resident #68's medication for administration via g-tube. She prepared multivitamin with minerals (instead of without minerals), along with eight additional medications and administered them to Resident #68. In an interview on 5/14/25 at 9:35 a.m. LVN B said the medication listed on the eMAR was Multivitamin (without minerals), but she would clarify the order with the MD. In an observation and interview on 5/14/25 at 9:42 a.m. of the medication room revealed Multivitamin (without minerals) was available. LVN B said the multivitamin without minerals might not be crushable but she would clarify Resident #68's order with the MD. In an interview on 5/15/25 at 10:47 a.m. the DON said she expected nursing staff to follow the MD order. She said Multivitamin and Multivitamin with minerals were two different medications. She said the MD would specify if the order should contain minerals depending on different factors like lab work. She said staff should look at each individual medication one at a time to ensure the bottle, blister pack, and dosage are correct. She said the Consultant Pharmacist came once a month and walked with nursing staff to ensure they were administering medications appropriately. She said medication administration skills were checked annually and on hire. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 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 In an interview on 5/15/25 at 12:58 p.m. the Administrator said nursing staff should follow the physician orders and the 7 rights of medication administration. Record review of the facility's Medication Administration policy reviewed/revised 1/2025 read 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 and in accordance with professional standards of practice, in a manner to prevent contamination or infection . 10. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation .17. Administer medication as ordered in accordance with manufacturer specifications .c. Crush medications as ordered. Do not crush medications with do not crush instructions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #68) reviewed for infection control. Residents Affected - Few -LVN B did not wear appropriate PPE when administering medication via peg-tube (PEG tubes allow you to receive nutrition through your stomach) to Resident #68 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) on 5/14/25. This failure could place residents at risk of infection. Findings included: Record review of Resident #68's face sheet dated 5/15/25 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included cerebral infarction, nutritional deficiency, and gastrostomy status (presence of an artificial opening to the stomach). Record review of Resident #68's discharge-return anticipated MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were severely impaired. She had a feeding tube and required assistance from staff with ADL care. Record review of Resident #68's Physician orders for May 2025 revealed an order for Multivitamin tablet give 1 tablet enterally one time a day related to nutritional deficiency, order date 4/13/25. Record review of Resident #68's care plan revealed she required enhanced barrier precautions to reduce risk of MDRO transmission. She was at risk for infection due to current use of indwelling device, g-tube. Interventions were to maintain EBP - staff to use gown and gloves during high contact care activities, date initiated 4/17/24. In an observation on 5/14/25 at 9:04 a.m. there was an orange sign on Resident #68's door that read, STOP Enhanced Barrier Precautions, everyone must: clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and gown for the following high contact resident care activities . device care or use . feeding tube .' There was PPE in a cart in front of the door. LVN B prepared Resident #68's medication for administration via g-tube. She donned (put on) gloves but did not don a gown. She entered Resident #68's room and administered the medication to her via g-tube. In an interview on 5/14/25 at 9:34 a.m. LVN B said she wore gloves but forgot to put on the gown when she administered Resident #68's medication via g-tube. She said the sign on the doorway notified staff that the resident was on enhanced barrier precautions due to an open orifice such as a g-tube, wound or IV. She said the purpose of wearing a gown when caring for residents with g-tubes was to prevent any type of fluid exchange. In an interview on 5/15/25 at 10:57 a.m. the DON said residents on enhanced barrier precautions were immune compromised. She said enhanced barrier precautions policies and protocol were for staff to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676467 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Creek Rehabilitation and Healthcare Center 13600 Birdcall Lane Cypress, TX 77429 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few have on a gown and gloves during personal high contact activities such as medication administration through g-tube, wound care, dressing changes, and showers. She said there could be a risk of giving the resident an infection if the proper PPE was not worn. She said the orange sign on the doorway indicated for staff to wear gown and gloves. In an interview on 5/15/25 at 12:58 p.m. the Administrator said she expected staff to adhere to the CDC guidance and wear appropriate precautions which included a gown and gloves. Record review of the facility's Enhanced Barrier Precautions policy reviewed/revised April 2024 read in part, . It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . 4. High-contact resident care activities include a. Dressing, b. Bathing, c. Transferring d. Providing hygiene e. Changing briefs or assisting with toileting, f. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, g. Wound care . Record review of the facility's Infection Prevention and Control Program reviewed/revised 1/2024 read in part, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676467 If continuation sheet Page 5 of 5