Inspection·April 5, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a PASRR Level 1 screening dated 10/20/21 indicated Resident #7 had no evidence or indicators of mental illness. The level 1 screening indicated Resident #7 had no evidence or indicators of intellectual disability. The level 1 screening indicated Resident #7 had no evidence or indicators Resident #7 had a developmental disability. During an interview on 4/5/2023 at 11:00 a.m., the MDS nurse said Resident #7 had not been diagnosed with schizophrenia or psychosis when the level 1 PASRR screening was completed on 10/20/21. The MDS nurse said she had not completed a form 1012 since he had the new diagnosis. During an interview on 4/5/2023 at 1:53 p.m., The MDS nurse said a form 1012 was done to correct a PASRR or when a resident received a new diagnosis. The MDS nurse said the form alerted PASRR to do an assessment. The MDS nurse said it was important this was completed to establish if the resident was PASRR positive or negative and if positive to have a meeting and determine if the resident needed or wanted any services for his behaviors. The MDSD nurse said she was usually alerted when a resident received new diagnosis so that the PASRR could be updated as needed. She said she was not sure why she had not done the 1012 form. The MDS nurse said she would submit a form 1012 for Resident #7 today considering his diagnosis. During an interview on 4/5/23 at 1:56 p.m., the ADON said the MDS nurse was responsible for ensuring PASRR evaluations were completed and updated. During an interview on 4/5/223 at 2:05 p.m., the DON said PASRR evaluations and updates were the responsibility of the MDS nurse. The DON said PASRR should be updated if a resident received any new qualifying diagnosis. The DON said this was important to ensure residents were receiving all the services they were entitled to. During an interview on 4/5/2023 at 2:15 p.m., the administrator said the MDS Coordinator was responsible for completing and updating PASRR evaluations. She said the regional resource team looked over and checked to ensure these were being completed on admission and as needed. The administrator said this was important to identify any residents needing PASRR services. 2. Record review of Resident #15's face sheet dated 4/5/23 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #15 had diagnoses of schizoaffective disorder (mental health disorder with a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar), suicidal ideations (thinking about or planning to take their own life), major depressive disorder (mental health disorder characterized by persistent depressed mood or loss of interest in activities, causing impairment in daily life), and anxiety (feeling of worry, unease). Record review of Resident #15's admission MDS dated [DATE] revealed she had a BIMS of 00, indicating she was severely cognitively impaired. Resident #15 required extensive to total assistance of 1-2 persons for most ADLs. Resident #15 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Resident #15 had active diagnoses of depression and schizoaffective disorder. Record review of Resident #15's hospital records dated 1/23/23 revealed she was admitted to the hospital for intracranial hemorrhage (brain bleed-stroke) and had an active problem list that included suicidal ideations, major depressive disorder, anxiety, brief psychotic disorder (sudden onset of psychotic behavior that lasts less than a month followed by complete remission with possible future relapses), hallucinations, and schizoaffective disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676477 If continuation sheet Page 2 of 12 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 676477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Springs Wellness & Rehabilitation 501 Yates Street Mount Vernon, TX 75457 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #15's PASRR Level I Screening completed by the MDS Coordinator, dated 1/27/23, indicated Resident #15 had no evidence or indicators of Mental Illness, Intellectual Disability, or Developmental Disability. Record review of Resident #15's corrected PASRR Level I Screening, completed by the MDS Coordinator, dated 4/4/23 indicated Resident #15 had Mental Illness. During an interview on 4/4/23 at 2:38 PM, the MDS Coordinator said she was responsible for ensuring the PASRR screenings were completed accurately and coordinating with the local authority. The MDS Coordinator said most residents' Level I PASRR Screenings were completed by the referring facility prior to the resident admitting to the facility. The MDS Coordinator said she would then review the PASRR Level I Screening and the resident's records to ensure the PASRR Level I Screening was completed accurately and the resident did not have any diagnoses that would prompt the need for the Level II PASRR evaluation. The MDS Coordinator said Resident #15 did not have a PASSR Level I Screening upon admission to the facility from an outside facility. The MDS Coordinator said she completed Resident #15's PASRR Level I Screening and she just missed Resident #15 had diagnoses of schizoaffective disorder, suicidal ideation, anxiety, and major depressive disorder. The MDS Coordinator said Resident #15's PASRR Level 1 should have indicated the resident had severe mental illness and a referral should have been sent to the local authority for the Level II PASRR evaluation. The MDS Coordinator said when the surveyor requested copies of Resident #15's PASRR on 4/04/23, she realized she missed the mental illness on the PASRR Level I Screening. The MDS Coordinator said she then completed a corrected PASRR Level I Screening dated 4/04/23 and sent the referral to the local authority. During an interview on 4/5/23 at 2:44 PM, the DON said she was still learning about PASRR, but she knew it indicated if a resident had mental illness, intellectual disability, or development disability and determined if the resident would qualify for addition services and/or equipment. She said the MDS Coordinator was responsible for ensuring the PASRRs were completed accurately regardless of if the PASRR was completed outside the facility or completed within the facility. The DON said if the residents' PASRR Level I Screenings was not completed accurately, the resident could miss out on additional services and/or equipment to meet their mental illness, intellectual and developmental disability needs. During an interview on 4/05/23 at 3:13 PM the Administrator said PASRR Screenings were completed to determine if residents with mental illness, intellectual disabilities, and/or developmental disabilities qualified for additional services through the local authority. The Administrator said the MDS Coordinator was responsible for ensuring the PASRR Screenings were completed accurately to ensure residents with mental illness, intellectual and developmental disabilities received the necessary services to improve their quality of life. Record review of a policy revised on 5/10/21 titled Pre-admission Screening and Resident Review (PASRR) indicated its purpose was to identify residents with mental illness, intellectual disability or developmental disability / related conditions and to ensure they are properly placed, where in the community or in a nursing facility and to ensure they receive the services they require for their mental illness, or intellectual disability/developmental disability. The policy indicated a nursing facility could convene an interdisciplinary team more often than on admission and annually. Reasons for significant changes can include: the resident experiences a serious health decline and the services previously agreed to may have to be modified or deleted. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676477 If continuation sheet Page 3 of 12 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 676477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Springs Wellness & Rehabilitation 501 Yates Street Mount Vernon, TX 75457 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission including the minimum healthcare information necessary to properly care for 1 of 5 residents reviewed for new admissions (Resident #28) The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #28. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review Resident #28's face sheet dated 2/16/23 revealed he was an [AGE] year-old male, who admitted to the facility on hospice services on 2/28/23. Resident #28 had diagnoses of congestive heart failure (heart does not pump blood as well as it should), Alzheimer's (progressive mental deterioration that could occur in middle or old age, due to generalized degeneration of the brain), and atherosclerotic heart disease of native coronary artery (plaque buildup in the walls of the blood vessels that supply blood to the heart). Record review of Resident #28's admission MDS revealed it had not been completed at time of his death/discharge on [DATE]. Record review of Resident #28's Physician Orders indicated he had wounds to his coccyx (tailbone), right buttock, left buttock, both knees, both wrists, and left upper arm for which he received wound care. He had orders for a fall mat while in bed and a pressure reducing cushion to his wheelchair. Resident #28 required oxygen as needed for shortness of breath and comfort measures. Resident #28 had a DNR order. He was on a regular diet. Resident #28 had orders for Tylenol, morphine, and tramadol for pain, along with lorazepam for anxiety (feeling of worry, nervousness, or unease about an imminent event or uncertain outcome). Record review of Resident #28's baseline care plan revealed it had been completed on 3/06/23. Record review of Resident #28's progress notes ranging from 2/28/23-3/10/23 revealed the resident was admitted to the facility from home for respite care (temporary institutional care of a sick, elderly, or disabled person, providing relief for their usual caregiver) on hospice services. Resident #28 was at risk for falls and needed frequent reminders to use the call light to prevent falls. He had a fall mat at his bedside for safety. Resident #28 had oxygen for low oxygen levels. The admission assessment/baseline care plan summary was dated 3/06/23 at 2:59 PM. During an interview on 4/05/23 at 2:12 PM, RN B said the admission nurse was responsible for completing the Admission/readmission evaluation documentation within 24 hours of the admission and the baseline care plan was part of the Admission/readmission evaluation. RN B said she believed the DON had to sign off on the Admission/readmission evaluation/baseline care plan before it could be completed. RN B said their computer system would not let the admission nurse complete and lock the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676477 If continuation sheet Page 4 of 12 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 676477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Springs Wellness & Rehabilitation 501 Yates Street Mount Vernon, TX 75457 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Admission/readmission evaluation/baseline care plan until the DON reviewed it. RN B said the purpose of the baseline care plan was to outline the resident's care specific to the resident. RN B indicated if a baseline care plan was not completed timely, it could place the resident at risk of not having their needs met if the proper care interventions were not put in place. During an interview on 4/05/23 at 2:27 PM, the ADON said the admitting charge nurse was responsible for completing the baseline care plan. The ADON said the baseline care plan was part of the Admission/readmission evaluation and should be completed within 24 hours of admission. The ADON said Resident #28 was admitted to the facility on [DATE] and the baseline care plan was completed on 3/06/23. The ADON said the baseline care plan was outside the required timeframe and should have been completed within 24 hours of admission. The ADON indicated the purpose of the baseline care plan was to guide the care of the resident and implement interventions to meet the resident's needs. The ADON said the care and needs of the resident would not be met if the baseline care plan was not completed timely. During an interview on 4/5/23 at 2:44 PM, the DON said the admission nurse was responsible for completing the Admission/readmission evaluation and the baseline care plan was part of that evaluation. The DON said she reviewed the Admission/readmission evaluation and baseline care plan after the admitting nurse to ensure it included all the needed care areas for the resident and then she signed off on it. The DON said the baseline care plan should be completed within 48 hours of admission. The DON indicated the purpose of the baseline care plan was to meet the needs of the resident, it showed what the risks were for the resident, and what interventions were needed to meet the resident's needs. The DON said if the baseline care plan was not completed timely, the interventions may not have been put in place to keep the resident safe and properly meet the resident's needs. The DON said Resident #28's baseline care plan was late because she was out of the facility at a training, and she was unable to sign off and complete the baseline care plan until she returned. The DON said she was going to implement training other RNs in the facility to review and sign off on the baseline care plans in her absence to ensure the baseline care plans would be completed timely going forward. During an interview on 4/5/23 at 3:13 PM, the Administrator said the baseline care plan was completed by the admission nurse and the DON and ADON followed up on it. The Administrator said the purpose of the baseline care plan was to determine the base level of care needed to meet the resident's needs until the comprehensive care plan was completed. The Administrator indicated if the baseline care plan was not completed timely, it would not communicate the needs of the resident to all the care staff. She said the baseline care plan should be completed within 48 hours of the resident admitting to the facility. Record review of the facility Care Plans-Baseline Process dated 3/2020 revealed . it was the policy of the center to create a baseline plan of care to meet the resident's immediate needs and shall be developed for each resident within forty-eight hours of admission . the baseline care plan would be started by the admitting nurse . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676477 If continuation sheet Page 5 of 12 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 676477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Springs Wellness & Rehabilitation 501 Yates Street Mount Vernon, TX 75457 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 respiratory care was provided consistent with professional standards of practice for 2 of 14 residents reviewed for respiratory care. (Resident #12 and Resident #18). Residents Affected - Few The facility failed to properly store Resident #12 and Resident #18's respiratory equipment. The facility failed to change the oxygen humidifier bottle for Resident #12 in a timely manner. These failures could place residents at risk of respiratory infections. Findings included: 1. Record review of the face sheet dated 04/05/23 revealed Resident #12 was [AGE] years old and admitted on [DATE] with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), shortness of breath, and acute respiratory failure with hypoxia (results from acute or chronic impairment of gas exchange between the lungs and the blood causing low oxygen levels). Record review of Resident #12's physician's orders dated 04/04/23 revealed an order dated 12/16/22 for oxygen at 2 L (liters) via nasal cannula to maintain oxygen saturation above 92%. The orders did not indicate an order for changing oxygen tubing or humidifier bottles. Record review of a quarterly MDS dated [DATE] revealed Resident #12 had a BIMS of 15, which indicated no cognitive impairment. Resident #12 required supervision to limited assistance with ADLs. The MDS indicated Resident #12 received oxygen therapy and had shortness of breath on exertion and while at rest. Record review of a care plan dated 02/24/23 indicated Resident #12 had cardiac disease and altered respiratory status/difficulty breathing with an intervention to administer oxygen as ordered per physician. Record review of a Nursing Medication Administration Record for Resident #12 dated March 2023 did not indicate any orders for changing respiratory equipment. Record review of a Nursing Medication Administration Record for Resident #12 dated April 2023 indicated an orde r dated 04/05/23, Change nasal cannula and humidifier every week on Sundays. Date tubing and humidifier when changing The record indicated the nasal cannula or humidifier were not changed on Sunday, 04/02/23. During an observation and interview on 04/03/23 at 10:57 a.m., Resident #12's nasal cannula wrapped around the oxygen concentrator handle with a tissue wrapped around the nasal part of the cannula. There was no bag for storage present. She said she does not always wear her oxygen. She said she wore her oxygen when she took naps or felt short of breath. Resident #12 said she did not have a bag to store her tubing in. Resident #12 said she kept the nasal part wrapped in tissue to keep it clean. She said sometimes it ended up on the floor, so she kept it wrapped up in the tissue. The humidifier bottle was dated 3/20/23. There was no date on the nasal cannula. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676477 If continuation sheet Page 6 of 12 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 676477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Springs Wellness & Rehabilitation 501 Yates Street Mount Vernon, TX 75457 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 0695 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/04/23 at 3:26 p.m., the DON said the facility did not have a policy concerning how to store nasal cannulas or nebulizers when not in use. She said the facility did not have a policy concerning how often the tubing or humidifier bottles should be changed. She said each resident had a doctor's order for storage and changing tubing. She said when oxygen tubing was not in use it should be stored in a bag and tubing should be changed weekly. Residents Affected - Few During an interview on 04/05/23 at 10:55 a.m., CNA A said the nurses change out the nasal cannulas every Sunday on the 10 - 6 shift. She said when nasal cannulas were not in use, they should be stored in a bag. During an interview on 04/05/23 at 11:16 a.m., RN B said oxygen tubing was changed on the night shift once a week and as needed. She he said nasal cannulas and humidifier bottles should both be changed once a week and dated when changed. She said this was documented on the nursing medication administration record. She said if Resident #12 did not have an order for changing the tubing it would not be on the administration record. She said there should have been a bag in the room for Resident 12's nasal cannula. She said she did not think Resident 12 would have kept it in a bag. She said if the humidifier bottle was dated 3/20/23, it should have been changed before 04/03/23. During an interview on 04/05/23 at 1:20 p.m., the ADON said she was also the Infection Prevention Nurse. She said there was usually an order on nursing medication administration record for tubing to be changed on Sundays. She said Resident #12 was very OCD (obsessive compulsive disorder). She said the date on the humidifier bottle of 3/20 indicated the bottle and tubing should have been changed on 4/2/23. She said oxygen tubing not being stored properly or not being changed once a week was an infection control issue. During an interview on 04/05/23 at 1:37 p.m., the DON said oxygen tubing and humidified bottles should be changed every 7 days on Sunday. She said the bag for Resident 12's nasal cannula could have been in her drawer. She said the oxygen tubing should have been stored in a bag when not in use. During an interview on 04/05/23 at 2:15 p.m., the Administrator said oxygen tubing and humidifier bottles should be changed every 7 days. She said the nasal cannula for Resident #12 should have been changed on 04/02/23 by the 10 - 6 nurses. She said, typically, any oxygen tubing would be stored in a bag when not in use. 2. Record review Resident #18's face sheet dated 4/03/23 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #18 had diagnoses of anemia (deficiency of red blood cells in the blood), chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing), cerebral infarction (caused from disruption of blood flow to the brain due problems with the blood vessels that supply the brain), dementia (progressive or persistent loss of intellectual functioning, impairment in memory, thinking, personality change caused by disease of the brain), hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (plaque buildup in the walls of the blood vessels that supply blood to the heart), and paroxysmal atrial fibrillation (irregular, often rapid heart rate that causes poor blood flow). Record review of Resident #18's quarterly MDS dated [DATE] revealed she had a BIMS of 13, which indicated she was cognitively intact. Resident #18 required limited to extensive assistance of one person for most ADLs. Resident #18 required oxygen therapy. Record review Resident #18's undated Physician Orders revealed she received levalbuterol HCL 0.63mg (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676477 If continuation sheet Page 7 of 12 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 676477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Springs Wellness & Rehabilitation 501 Yates Street Mount Vernon, TX 75457 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few per 3ml by nebulized inhalation every six hours as needed for shortness of breath. Resident #18 had orders to change or replace humidifier bottle, date and initial, and change oxygen tubing, date and initial, every Sunday on night shift. There was not an order specific to changing the storage bag of the nebulizer mask and tubing. Record review of Resident #18's Nursing MAR dated 3/01/23-3/31/23 revealed she had received 11 breathing treatments of levalbuterol HCL 0.63 mg in 3 ml (1 vial) inhalation by nebulizer from 3/11/23-3/31/23. Record review of Resident #18's Nursing MAR dated 4/01/23-4/30/23 revealed she had received 2 breathing treatments of levalbuterol HCL 0.63 mg in 3 ml (1 vial) inhalation by nebulizer on 4/2/23. During an observation and interview on 4/03/23 at 11:21 AM Resident #18 revealed the facility staff changed her oxygen tubing, humidifier bottle, nebulizer mask and tubing weekly. Resident #18's oxygen tubing, humidifier bottle, and oxygen tubing storage bag was dated 4/03/23. Resident #18's nebulizer mask and tubing were dated 4/03/23, but the storage bag it was stored in was dated 3/05/23. During an observation on 4/04/23 at 11:04 AM revealed Resident #18's nebulizer mask and tubing continued to be stored in a storage bag dated 3/05/23. During an observation on 4/05/23 at 10:50 AM revealed Resident #18's nebulizer mask and tubing continued to be stored in a storage bag dated 3/05/23. During an interview on 4/05/23 at 2:12 PM, RN B revealed the 10 PM to 6 AM nursing staff were responsible for discarding and replacing all the oxygen supplies weekly and was usually done on Sundays. She said the storage bags of the nebulizer mask and tubing should also be changed at that time to prevent respiratory infections. She said it did not make sense to place clean supplies in a dirty storage bag and defeated the purpose of replacing the clean nebulizer masks and tubing. She said placing the clean nebulizer mask and tubing in a dirty storage bag would place the resident at increased risk for respiratory infections. During an interview on 4/05/23 at 2:27 PM the ADON, who was also the Infection Preventionist, revealed the nursing staff were responsible for changing the oxygen equipment/nebulizer masks & tubing weekly and was usually changed on Sundays. She said the storage bags of the oxygen equipment/nebulizer masks & tubing should also be changed at that time to prevent respiratory infections. The ADON revealed a storage bag that had not been changed in a month could lead to a resident developing respiratory infections and defeated the purpose of changing the oxygen equipment/nebulizer masks & tubing weekly. During an interview on 4/05/23 at 2:44 PM the DON revealed oxygen supplies should be changed every week and stored in a bag and a date placed on the tubing, mask & storage bags. The DON revealed a nebulizer mask & tubing storage bag dated 3/05/23 indicated someone was lazy and did not change the storage bag when they changed the nebulizer mask and tubing. The DON revealed a clean nebulizer mask and tubing placed in a month-old dirty storage bag would place the resident at increased risk of developing respiratory infections. During an interview on 4/05/23 at 3:13 PM the Administrator revealed she would expect staff to change the storage bag weekly when new oxygen equipment/nebulizer masks and tubing were changed to prevent respiratory infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676477 If continuation sheet Page 8 of 12 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 676477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Springs Wellness & Rehabilitation 501 Yates Street Mount Vernon, TX 75457 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of an Oxygen Safety facility policy dated May 2011 indicated, .Use plugs, caps and plastic bags to protect equipment not in use from dust and dirt . Review of an Oxygen Administration facility policy dated October 2010 indicated, .After completing the oxygen setup or adjustment, the following information should be recorded .the date and time that the procedure was performed . Event ID: Facility ID: 676477 If continuation sheet Page 9 of 12 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 676477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Springs Wellness & Rehabilitation 501 Yates Street Mount Vernon, TX 75457 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. 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 provide food that was palatable and served at an appetizing temperature for 3 of 14 residents reviewed for palatable food. (Residents #1, Resident #6, Resident #12) Residents Affected - Some The facility failed to provide palatable food served at an appetizing temperature to Residents #1, Resident #6, Resident #12 who complained the food was served cold. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: Record review of Resident Council Minutes dated 02/10/23 indicated, Dietary - Is the food hot when you get it? Occasionally cold when we receive on halls. Record review of Resident Council Minutes dated 03/10/23 indicated, Dietary - Is the food hot when you get it? Cold on halls. 1. Record review of the face sheet dated 04/05/23 revealed Resident #1 was [AGE] years old and admitted on [DATE] with diagnoses including stroke, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and diabetes (a disease that results in too much sugar in the blood). Record review of a quarterly MDS dated [DATE] revealed Resident #1 had a BIMS of 15, which indicated no cognitive impairment. Resident #1 required supervision to extensive assistance with ADLs. Record review of a care plan dated 01/20/23 indicated Resident #1 had diabetes and may be at risk for unstable blood glucose level. During an interview on 04/03/23 at 10:44 a.m., Resident #1 said the food was always cold and when he does not like what they are serving they give him a ham sandwich. He said he gets tired of ham sandwiches. 2. Record review of the face sheet dated 04/05/23 revealed Resident #6 was [AGE] years old and admitted on [DATE] with diagnoses including muscle weakness, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and difficulty in walking. Record review of a quarterly MDS dated [DATE] revealed Resident #6 had a BIMS of 9, which indicated Resident #6 was moderately cognitively impaired. She required supervision to limited assistance with all ADLs. Record review of a care plan dated 03/16/23 indicated Resident #6 was ordered a regular diet with a goal to eat 75% of meals through 06/02/23. During an interview on 04/03/23 at 11:36 a.m., Resident #6 said she did not always like the food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676477 If continuation sheet Page 10 of 12 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 676477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Springs Wellness & Rehabilitation 501 Yates Street Mount Vernon, TX 75457 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She said at times her cream of wheat was lumpy, but she ate it anyhow. She said the food was cold sometimes. 3. Record review of the face sheet dated 04/05/23 revealed Resident #12 was [AGE] years old and admitted on [DATE] with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), unspecified protein calorie malnutrition (the state of inadequate intake of food), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder. Record review of a quarterly MDS dated [DATE] revealed Resident #12 had a BIMS of 15, which indicated no cognitive impairment. Resident #12 required supervision to limited assistance with ADLs. Record review of a care plan dated 02/24/23 indicated Resident #12 was ordered a regular diet with a goal to eat 75% of meals through 07/21/23. During an interview on 04/03/23 at 10:57 a.m., Resident #12 said the food was not good. She said the hot food was served cold. She said she had a heart condition, and her diet was a serious issue. An observation on 04/04/23 at 12:18 p.m., revealed food trays were delivered to E Wing along with a sample tray. An observation on 04/04/23 at 12:20 p.m., revealed the first tray being served on E Wing. An observation on 04/04/23 at 12:24 p.m., revealed CNA A left the E Wing to get a salad for a resident. There were no trays being passed on the E Wing at this time. An observation on 04/04/23 at 12:28 p.m., revealed CNA C began passing trays on E Wing. An observation on 04/04/23 at 12:35 p.m., revealed CNA A in a resident's room passing the residents food tray. CNA A took the resident's dinner order before leaving the room. An observation on 04/04/23 at 12:38 p.m., revealed CNA A served the last tray on E Wing. During an interview and observation on at 04/04/23 at 12:40 p.m., the Dietary Manager and three surveyors sampled a lunch tray. The tray consisted of Breaded [NAME], garlic roasted potatoes, carrots and frosted vanilla cake. The Breaded [NAME] was luke warm. The potatoes and carrots were room temperature. The cake was dry. The dietary manager said the food was not warm. During an interview on 04/05/23 at 9:00 a.m., the Dietary Manager said the nurses and aides reported food complaints to the kitchen. She said sometimes the complaints were written on the meal tickets when they were returned to the kitchen. She said she also read notes from Resident Council. She said when the food leaves the kitchen it was the correct temperature. She said she feels the food was not being passed out to the residents timely. She said the tray sampled on 4/04/2023 was not warm when she sampled the tray. She said she really was not sure how to fix the problem if the trays were not being passed timely. She said residents might not eat if the food was cold. During an interview on 04/05/23 at 10:55 a.m., CNA A said she had not heard a lot of food complaints, but she had heard the food was cold or residents just did not like the food. She said when the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676477 If continuation sheet Page 11 of 12 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 676477 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cypress Springs Wellness & Rehabilitation 501 Yates Street Mount Vernon, TX 75457 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents complained she carried the tray back to the kitchen and either got a new tray or got the resident something different. She said she was one of the CNAs that passed the trays on the E wing on 04/04/23. She said she did not feel the trays were passed in a timely manner. She said this was because there was just so much going on. She said other staff were passing trays on another hall and she had to go back to the kitchen to get a resident a salad. She said not passing the trays in a timely manner could cause the food to be cold when served to the residents. During an interview on 04/05/23 at 11:16 a.m., RN B said she did not hear as many food complaints as she used to. She said she had not heard any complaints of the food being cold. She said if the food was cold the residents might not want to eat, and this could lead to weight loss. During an interview on 04/05/23 at 1:20 p.m., the ADON said residents complaining of food being cold had been an issue in the past. She said the issue had been discussed in the morning meetings. She said normally the CNAs passed the trays to those requiring feeding assistance first. She said today (04/05/2023) they passed trays to everyone first and then provided feeding assistance. She said residents might not even want cold food and could cause them weight loss. She said she did feel 20 minutes was too long to pass trays on the E Wing. During an interview on 04/05/23 at 1:37 p.m., the DON said she had not heard any complaints from residents about cold food. She said she did feel food would be cold after sitting 20 minutes on the E Wing. She said cold food could make the residents not eat and could lead to weight loss. During an interview on 04/05/23 at 2:15 p.m., the Administrator said it did take an unusual amount of time for the lunch trays to be passed on the E Wing on 04/04/23. She said normally feeding assistance would be provided and food orders would be taken after meal trays were passed to the other residents. She said residents being served cold food could cause residents not to eat as much and potentially have weight loss. Review of a Food Holding and Service facility policy dated 2018 indicated, .Serve all hot foods at a temperature of 135°F (degrees Fahrenheit) or greater .Adjust the temperature to account for the time the food will be held prior to service on the steam table and on the tray carts . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676477 If continuation sheet Page 12 of 12