Inspection·May 22, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Resident #1's significant change MDS assessment dated 01/24/'2025 reflected the resident scored a 9 out of 15 on her BIMS which indicated the resident had moderate cognitive impairment and could understand others and be understood. The resident used a used a manual wheelchair for mobility. She was dependent on staff for ADLs and required two or more persons to transfer her from chair to bed or bed to chair. Record review of Resident #1's [NAME] dated 01/2025 reflected TRANSFERS: Requires maximum assistance of 2 staff with mechanical lift. Record review of Resident #1's Active Orders As of: 05/20/2025 reflected she had 3 orders of narcotic pain medications prior to the fracture of her right humerus which she was prescribed by hospice on 02/02/2024 listed as the following: 1.Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 2 hours as needed for mild pain/dyspnea. Phone Active 02/02/2024 2. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.5 ml by mouth. every 2 hours as needed for moderate pain/dyspnea. Phone Active 02/02/2024 3. Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 1 ml by mouth every. 2 hours as needed for severe pain/dyspnea. Phone Active 02/02/2024 Record review of the facility PIR dated 01/23/25 reflected on 01/19/2025 during a transfer from wheelchair to bed (Resident #1), CNA A heard a pop sound. LVN B (Charge Nurse on the unit) assessed, and Resident #1 told the nurse her right arm hurt. An assessment done by hospice RN C reflected she called the family, and the family did not want Resident #1 to go to the ER. The family requested she have an orthopedic appointment and to keep her comfortable. A sling was applied to stabilize her right arm and routine hospice pain medications were given. The Administrator spoke with Resident #1 and her family in Resident #1's room on 01/20/2025 at 10:00 am. Resident #1 stated she was not in pain, and she was comfortable. Treatment was provided in house and the resident stated she felt safe. CNA A was suspended pending investigation. Staff member stated she did not touch Resident #1's arm during the transfer. CNA A stated she did not use a mechanical lift and did not check the [NAME]. X-ray results were positive for a fracture the same day and Resident #1's family refused the orthopedic appointment later. Record review of Resident #1's progress note dated 01/19/2025 at 3:30 am written by LVN B reflected; resident was climbing out of bed earlier in the shift. CNA A got Resident #1 up in a wheelchair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455618 If continuation sheet Page 2 of 8 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 455618 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Home 631 Lakeview Blvd New Braunfels, TX 78130 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 0689 Level of Harm - Immediate jeopardy to resident health or safety and brought her to the dining room for snacks. CNA A transferred Resident #1 back to bed and came and told him (LVN B) Resident #1's arm popped during transfer. LVN B entered the room and found Resident #1 lying in bed with a gait belt on and she complained of pain in her right arm. He wrote he did not see any obvious deformity and Resident #1 stated she would not move her arm. LVN B notified hospice, her vital signs were within normal limits and he did not attempt ROM. LVN B medicated Resident #1 with morphine sulfate, .5 ml sublingually (under the tongue) and he wrote the resident was calm. Residents Affected - Few Record review of progress note written by RN C dated 01/19/2025 at 10:00 am reflected Hospice nurse came in to evaluate Resident #1 due to possible injury. Right shoulder is clearly swollen, and Resident #1 has pain to the touch. Unable to move arm without it hurting. X-ray completed. Record review of the Radiology Results Report dated 01/19/2024 at 9:55 am reflected Findings: Displaced humeral neck fracture of the right shoulder. Record review of Resident #1's progress note dated 01/20/25 written by the FNP reflected the family had 3 options: 1. send the resident to the ER. 2. call orthopedic office on Monday for further recommendation. 3. Keep the resident on hospice and control pain. The FNP's assessment of Resident #1 included: she was not in pain, had a sling in place, required maximum assistance and was mostly bed bound. Record review of Resident #1's progress note dated 01/21/25 at 2:25 pm written by RN C reflected hospice talked with orthopedic office and discussed with family who decided to keep Resident #1 in the facility and comfortable. A new order for morphine Contin 15 mg bid was provided. No pain currently. Record review of progress note written by RN C dated 01/19/2025 at 10:00 am reflected Hospice nurse came in to evaluate Resident #1 due to possible injury. Right shoulder is clearly swollen, and Resident #1 has pain to the touch. Unable to move arm without it hurting. X-ray completed. Record review of the Radiology Results Report dated 01/19/2024 at 9:55 am reflected Findings: Displaced humeral neck fracture of the right shoulder. Record review of Resident #1's progress note dated 01/20/25 written by the FNP reflected the family had 3 options: 1. send the resident to the ER. 2. call orthopedic office on Monday for further recommendation. 3. Keep the resident on hospice and control pain. The FNP's assessment of Resident #1 included: she was not in pain, had a sling in place, required maximum assistance and was mostly bed bound. Record review of Resident #1's progress note dated 01/21/25 at 2:25 pm written by RN C reflected hospice talked with orthopedic office and discussed with family who decided to keep Resident #1 in the facility and comfortable. A new order for morphine Contin 15 mg bid was provided. No pain currently. In an observation and interview on 05/20/25 at 08:45 a.m. Resident #1 was lying in bed. Resident #1 was on a low bed with a fall mat beside the bed on the floor. She stated she had a small amount of pain in her right arm but was provided pain medication. In an interview on 05/20/2025 at 08:47 am with LVN E who was Resident #1's charge nurse, she who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455618 If continuation sheet Page 3 of 8 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 455618 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Home 631 Lakeview Blvd New Braunfels, TX 78130 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 0689 stated Resident #1 required a mechanical lift transfer with 2 people. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 05/20/2025 at 08:50 am with CNA F who was assigned to work with Resident #1, he stated he had been at the facility for over a year and Resident #1 had always required a mechanical lift and 2 people for transfer. Residents Affected - Few In an interview on 05/20/2025 at 3:00 pm with LVN B, he who stated Resident #1 was climbing out of bed and he asked CNA A to go get her up in a wheelchair and take her to the dining room for some snacks. He stated he knew how to check the [NAME], and he said Resident #1 never got up on the nightshift. He said he realized when CNA A told him Resident #1's arm popped during transfer something was wrong. He stated he entered Resident #1's room and she complained of pain, and he assessed her, medicated her, and notified the hospice of the potential injury. He stated he was accountable as the charge nurse and nursing staff received training right after that on abuse and neglect and checking the [NAME]. In an interview on 05/21/2025 at 03:09 pm with CNA A, she who stated Resident #1 did not usually get up on nightshift. She said Resident #1 had a low bed with a mat but had a fall a few nights prior and seemed to be restless, so LVN B asked her to get Resident #1 up and give her some snacks. She admitted she never had to get Resident #1 up prior to 01/19/2025. She stated she saw a gait belt sitting in a wheelchair in the resident's room and assumed she was a one-person transfer. She stated getting the resident up was no problem, but when she went to put Resident #1 back to bed, the resident jerked back, and she heard a crack or popping sound from Resident #1's right shoulder. She stated she was trained during on-boarding to check the [NAME] in PCC or to ask the nurse what type of transfer the resident needed. She stated she was trained on how to do mechanical lift transfers and needed 2 people for the transfer. She said not checking the [NAME], or asking the nurse about the right type of transfer can result in injury or harm. In an interview on 05/22/2025 at 10:03 am with the DON, she shoshe stated CNA A made a mistake and was suspended pending investigation. She stated training of all staff started the very next day. She had the Physical Therapist train staff on transfers. She stated staff received an on-boarding training with one person and they demonstrate how to do everything, and checking a resident's [NAME] is one of the items they have training on. She stated the importance of knowing the right transfer of a resident provides safety for the resident and the staff or they could get hurt. She stated CNA A received 1:1 training by the Physical Therapist on transfers prior to being allowed to work. She stated CNA A was retrained on how to access and use PCC for the [NAME], but later she resigned for other reasons . Record review of Rehabilitation Training dated 01/20/2025 provided to CNA A by the Physical Therapist reflected she had remedial training on transfers. In an interview on 05/20/2025 at 04:23 pm with CNA D who was the facility trainer revealed when staff on-board, training included the CNA would sign into PCC, then click on their station and would be able to access a resident [NAME] to check their type of required transfer. She stated she trained CNA A, and the backup plan was to ask the nurse or herself. Record review of CNA As orientation training record titled Nurse Aide Floor On-Boarding dated 09/20/2024 reflected she was trained on How to identify residents transfer ability on PCC, and mechanical lift transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455618 If continuation sheet Page 4 of 8 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 455618 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Home 631 Lakeview Blvd New Braunfels, TX 78130 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 0689 Level of Harm - Immediate jeopardy to resident health or safety In an interview on 05/20/2025 at 1:12 p.m. with the ADM, she who stated she was the abuse and neglect prevention coordinator. She stated CNA A was suspended pending investigation. She stated residents must feel safe at the facility. She ADM stated staff were trained immediately after the incident and she made the report. She ADM stated she was accountable for quality of care at the facility. She stated the incident was discussed in QAPI and continued to be monitored. She ADM stated 9 residents in the facility required mechanical lift transfers. Residents Affected - Few Record review of the facility policy titled Abuse Prevention/Neglect or Exploitation dated 03/16/2022 reflected It is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident's property. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury of harm. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of the facility policy and procedure titled No Lift Concept dated 10/23/13 reflected requires all employees to adopt a No Lift Concept. Employees are expected to use the aid of equipment when lifting objects or residents. An educational in-service relating to safety practices and lifting is required of all employees at least one time and/or as needed. Procedure: 2. Nursing staff are required to use mechanical lifts (Hoyer, Sit-To-Stand), gait/transfer belts, sliding boards, bed scales and bed repositioning devices on residents when appropriate after being trained in their use. It was determined the failure placed Resident #1 in an IJ situation on 05/21/25. The ADM was notified on 05/21/2025 at 03:26 pm, that a PNC IJ had been identified due to the above failure. The facility implemented the following interventions: 1. CNA A was suspended pending investigation and when she returned provided 1:1 instruction for transfer and re-educated on the [NAME] and use of [NAME] prior to resident care. She later resigned. 2. On 1/20/2025 MDS coordinators completed a full audit on all residents [NAME]'s to ensure accuracy of transfer information. 3. The DON in-serviced all staff on 1/20/25 for ANE, checking the [NAME] in PCC for transfer information on residents and staff were not allowed to work until training was completed. 4. Review of new nursing staff on-boarding reflected 100% were trained in checking the [NAME] in PCC and transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455618 If continuation sheet Page 5 of 8 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 455618 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Home 631 Lakeview Blvd New Braunfels, TX 78130 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 0689 5. Level of Harm - Immediate jeopardy to resident health or safety All new nursing staff continue to be in-serviced during orientation with the on-boarding checklist. Residents Affected - Few 6. An Ad hoc QAPI meeting was called at 09:00 am on 01/19/2025 to discuss the incident and plan of correction. The physician was called at 6 am and the hospice RN on call was notified at 4 am. It will be discussed in quarterly QAPI meeting with the Medical Director on 05/28/2025. Observation on 05/21/2025 at 10:18 am of CNA F and CNA I perform a mechanical lift transfer for Resident #3 revealed no issues with safety and no issues with CNA F signing into PCC to check the residents [NAME]. Record review of Resident #2 and #3's MDS's, Care Plans and [NAME]'s reflected they were mechanical lift 2 person transfers. Observation on 05/21/2025 at 10:25 am of CNA J and LVN K perform a mechanical lift transfer for Resident #2 revealed no issues with safety and no issues with CNA J signing into PCC to check the residents [NAME]. Record review of training titled Checking [NAME] and Resident Transfers dated 01/20/2025 reflected 64 staff signatures. Signatures were compared to a nurse staff roster for 01/19/2025 and 100% were highlighted as had training. Record review of a notarized statement dated 05/21/25 which reflected On 01/20/2025 MDS coordinators completed a full audit on all residents [NAME]'s to ensure accuracy of transfer information. MDS coordinators continue ongoing auditing by reviewing each resident's [NAME] with every MDS completed. Signed by MDS L and MDS M. Record review of AD HOC QAPI sign in sheet dated 01/19/2025 reflected the ADM, DON, MDS M, Director of Therapy and the ADON attended. Interviews on 05/21/2025 from 10:00 am to 1:45 pm with 12-day shift nursing staff and 9-night shift nursing staff to total 20 out of 88 nursing staff employed revealed they received training after the incident on abuse and neglect, checking the [NAME] in PCC and resident transfers. In an interview on 05/21/2025 at 12:27 pm with MDS L (Day Shift), she who stated training occurred after Resident #1's incident. Staff were trained on abuse and neglect, checking the [NAME] and making sure the resident is transferred safely. In an interview on 05/21/2025 at 1:24 pm with CNA N (Night Shift), she who stated she was recently trained on abuse and neglect, checking the [NAME] in PCC for transfers, and she was trained when she on-boarded. In an interview on 05/21/2025 at 1:29 pm with CNA O (Night Shift), she who stated the ADM was the abuse and neglect coordinator. She was recently trained on abuse and neglect and checking the [NAME] for resident information. In an interview on 05/21/2025 at 1:32 pm with CNA P (Night Shift), she who stated she was recently trained to check the [NAME] for type of care a resident required. She was also trained on abuse and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455618 If continuation sheet Page 6 of 8 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 455618 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Home 631 Lakeview Blvd New Braunfels, TX 78130 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 0689 neglect prevention. She stated if staff was unsure of type of transfer for a resident, to check with the nurse. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 05/21/2025 at 1:35 pm with LVN Q (Night Shift) she who stated she had training on abuse and neglect. How to check [NAME] on PCC and what transfer the resident required and to ask the Charge Nurse. Residents Affected - Few In an interview on 05/21/2025 at 1:38 pm with CNA S (Night Shift), she who stated in January they had training on how to access PCC and to check the [NAME] and see what type of transfer a resident needed. She stated she had training on abuse and neglect, to report an incident immediately and the ADM was the abuse and neglect prevention coordinator. In an interview on 05/21/2025 at 1:40 pm with CNA T (Day Shift), she who stated training on abuse and neglect was scheduled and on-going as needed. She stated the abuse and neglect prevention coordinator was the ADM and to report any incident immediately. She stated she had training in January on how to access the [NAME] in PCC to find out what type of transfer a resident required or to ask the nurse. In an interview on 05/21/2025 at 1:42 pm with LVN U (Day Shift), she who stated staff had recent training on checking PCC for the [NAME] which gives information on a resident such as how to transfer a resident from bed to chair. She stated as a charge nurse she needed to make sure residents are transferred safely and provided quality care. She monitored the care provided by CNAs assigned to her unit. In an interview on 05/21/2025 at 1:43 pm with RN V (Day Shift), she who stated she was one of the MDS nurses and was responsible for keeping [NAME]'s current. She stated staff were trained after the incident with Resident #1 on how to check the [NAME]. Training on abuse and neglect was provided. She stated staff were informed to report an incident right away. In an interview on 05/21/2025 at 1:44 pm with CNA W (Day Shift), he who stated he received training on how to access the [NAME] in PCC to check on a resident's care required such as transfers. He stated training was provided on abuse and neglect, and it was ongoing and as needed. In an interview on 05/21/2025 at 1:45 pm with the ADON (Day Shift), she who stated training was provided in January 2025 on how to check PCC for a resident's care needs by looking at their [NAME]. She stated she had training on abuse and neglect and provided some of the training. She stated after the incident 100% of nursing staff were trained and new people receive training on PCC, [NAME] and abuse and neglect with on-boarding. In an interview on 05/21/2025 at 1:45 pm with CMA X (Day Shift), she who stated she was provided training on signing into PCC, referring to a resident [NAME] and checking what type of care they required such as transfers. She stated she had training on abuse and neglect. In an interview on 05/21/2025 at 1:45 pm with CNA F (Day Shift), he who stated he had the training in January 2025 after the incident with Resident #1 and how to check PCC for the [NAME]. He stated he would ask the nurse if he was unsure about a resident's care. He said training was ongoing and as needed on abuse and neglect. He CNA F said the abuse and neglect prevention coordinator was the ADM. In an interview on 05/21/2025 at 2:10 pm with RN Y (Day Shift), she stated training on abuse and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455618 If continuation sheet Page 7 of 8 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 455618 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eden Home 631 Lakeview Blvd New Braunfels, TX 78130 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 0689 Level of Harm - Immediate jeopardy to resident health or safety neglect was ongoing and as needed. She stated after the incident with Resident #1 in January 2025, all nursing staff were trained on how to check PCC for a resident [NAME] and to find out the care required such as type of transfer. She stated as a charge nurse she monitored the CNAs and resident care. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455618 If continuation sheet Page 8 of 8