Cedar Creek Nursing And Rehabilitation Center

F 0583

Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interviews, and record review, the facility failed to ensure the resident's right to secure and confidential personal and medical records for one (unknown resident) of 31 residents. The facility failed on 12/20/25 to ensure the privacy of unknown residents by not locking the laptop screen on medication cart (1 of 2), so the residents' information could not be seen and/or accessed by someone walking by. This failure puts residents at risk for confidential health information exposure, psychosocial harm and decreased quality of life. The findings included: Interview and observation on 12/20/25 at 01:12 PM, RN B left her computer screen on her medication cart unlocked and unsupervised with unknown resident information while entering a resident's room during medication pass. She revealed she was supposed to lock her screen for resident privacy. Interview on 12/21/25 at 03:08 PM, the ADM and DON revealed the laptop on the medication cart needed to be locked due to HIPAA and to protect resident's medical information. Record review of facility's policy RESIDENT RIGHTS, undated, reflected Privacy and confidentiality- The resident has a right to personal privacy and confidentiality of his or her personal and medical records. 3. The resident has a right to secure and confidential personal and medical records.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Creek Nursing and Rehabilitation Center

159 Montague Ave Bandera, TX 78003

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Regarding Resident #4, the DON revealed blister packs for narcotics should not be taped. She revealed that if the blister pack was punctured, the narcotic should be wasted and witnessed by 2 nurses. The DON revealed this was important to ensure all narcotics were accounted for. Record review of facility's policy, Medication Administration and General Guidelines, dated 2025, reflected . 9. Except for single unit dose packet distribution systems, only the licensed or legally authorized personnel who prepare a medication may administer it. This person then records the administration on the residents MAR at the time the medication is given. At the end of each medication pass, the person administering the medications reviews

the MAR to ascertain that all necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.Record review of facility's policy, Medication Storage in the Facility, dated 2025, reflected .13.

Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists. (sp) Record review of facility's policy Medication Administration Procedures, dated 2003, reflected . If a controlled medication is wasted it must be documented on the controlled accountability sheet for the medication and witnessed by nurses. Both staff members must sign on the accountability sheet verifying the drug was wasted.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Creek Nursing and Rehabilitation Center

159 Montague Ave Bandera, TX 78003

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, interviews, and record review the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 8 residents (Resident #2). The facility failed to ensure RN B did not leave Resident #2's medications inside the resident's room for the resident to take unsupervised on 12/20/25. This deficient practice could affect residents who received medications for treatments and could result in less potent or an adverse effects and drug diversion. The findings included: Record review of Resident #2's admission Record, dated 12/21/25, reflected resident was a [AGE] year-old male initially admitted [DATE REDACTED] and re-admitted [DATE REDACTED] with diagnoses to include dementia (group of symptoms affecting memory, thinking, and social abilities, which interfere with daily life) and cortical age-related cataract (an area of the lens of the eye loses transparency). Record review of Resident #2's quarterly MDS assessment, dated 10/10/25, reflected Resident #2 had a BIMS score of 11 out of 15, reflecting moderate cognitive impairment. Record review of Resident #2's Order Summary Report, dated 12/21/25, reflected resident's order summary included Prolensa Opthalmic Solution 0.07% . Instill 1 drop in left eye one time a day for CATARACT SURGERY.

With start date 12/08/25. Record review of Resident #2's care plan, undated, reflected Resident has impaired visual function, has DX of cataracts, resident wears glasses, initiated 05/29/24, with intervention to include Review medications for side effects which affect vision. PRN, revised 07/19/24. Interview and

observation on 12/20/25 at 01:12 PM, RN B revealed Resident #2 had his prescribed eye drop medication at bedside. RN B revealed Resident #2 was not supposed to have his eye drops at bedside even though he may be able to administer them himself. RN B further revealed it could be possible that a resident could overdo their eye drops medication but this resident was aware so this would not happen. Interview on 12/21/25 at 03:08 PM, the DON and ADM revealed they were not aware if Resident #2 could self-administer his medications. (It was asked if they could find this care planned or if there was an assessment that he could self-administer his medications, but no records were identified.) The DON revealed if Resident #2 could not self-administer his medication, they needed to keep these medications on

the medication carts and doctor's orders needed to be followed. Record review of facility's policy, Medication Administration and General Guidelines, dated 2025, reflected . 9. Except for single unit dose packet distribution systems, only the licensed or legally authorized personnel who prepare a medication may administer it. This person then records the administration on the residents MAR at the time the medication is given. At the end of each medication pass, the person administering the medications reviews

the MAR to ascertain that all necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Creek Nursing and Rehabilitation Center

159 Montague Ave Bandera, TX 78003

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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Daily Food Temperature Control, dated 2012, reflected Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges. Record Review of facility's policy Food Storage and Supplies, dated 2012, did not reflect dating food products with an expiration date as was reflected in the FDA Food Code 2022. Record Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S.

Department of H&HS, revealed, 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposited to splash, dust, or other contamination. Record review of the FDA Food Code 2022 reflected, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3- 403.11(E) may be held at a temperature of 54 C (130 F) or above; or (2) At 5 C (41 F) or less. Record review of the FDA Food Code 2022 reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. Open and hold cold (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and. Record review of the FDA Food Code 2022 reflected, 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from:. (d) Frozen, commercially processed and packaged raw animal FOOD may be stored or displayed with or above frozen, commercially processed and packaged, ready-to-eat food.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cedar Creek Nursing and Rehabilitation Center

159 Montague Ave Bandera, TX 78003

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 0813

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

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 enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 1 resident reviewed, in that: The facility failed to maintain the temperature of Resident #1's personal refrigerator was at or below 41 degrees F 12/1/25 to 12/4/25 and was documented 12/5/25 to 12/19/25. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included:Record review of Resident #1's admission record, dated 12/21/25, reflected resident was a [AGE] year-old female admitted [DATE REDACTED] with diagnoses to include constipation, protein-calorie malnutrition, and nausea. Record review of Resident #1's quarterly MDS assessment, dated 12/02/25, reflected Resident #1 had a BIMS score of 12 out of 15, reflecting moderate cognitive impairment. Interview and record review on 12/20/25 at 03:55 PM revealed Resident #1's Refrigerator Temperature log, dated December 2025, reflected temperatures on days 1 to 4 were 43 degrees Fahrenheit and temperatures for days 5 to 19 were not documented. Resident #1 revealed she had never gotten sick from her foods in her refrigerator. Interview on 12/20/25 at 05:20PM, the ADM and the CDM revealed the ADM instructed the ambassadors (persons in management that visited residents every morning and checked the temperatures of their refrigerators, about ensuring the residents' refrigerator temperatures should be 41 degrees Fahrenheit or less. They revealed the ambassadors will be doing a sweep on Monday of all the refrigerators to ensure all the refrigerators are within the appropriate temperature range. Record Review of facility's policy Personal Refrigerators Policy, dated 2012, reflected

The refrigerator compartment should be maintained at a temperature of 35-41 degrees (Fahrenheit).

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet