Inspection·January 13, 2024

F 0580 Status related to cognitive impairment, lack of coordination and muscle weakness with a start date of 8/24/2023. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's physician orders dated December 2023 revealed Resident #1 was administered the following medications: Residents Affected - Few *clopidogrel, tablet, 75 mg, 1 tablet daily (blood thinner) and *aspirin, tablet, chewable, 81 mg, 1 tablet daily (blood thinner). In a record review of a written statement dated 12/18/2023, CNA E stated she observed Resident #1 with blood on the bridge of his nose and immediately reported it to LVN A & B during shift change on 12/17/2023 at 6:00 a.m. (Note: Resident #1 was on blood thinners.) Record review of Resident #1's clinical record revealed no SBAR or head-to toe assessment was for Resident #1 on 12/17/23. Record review of Resident #1's Progress Notes revealed a late entry entered on 12/19/23 at 8:48 AM by LVN A for 12/17/23 5:38 AM of observed superficial abrasion approx[imately] 1.5 cm in legth[sic] .cleaned the dry blood from his nose and place a dressing on top to keep it clean from dirt and debri[sic]. Will inform oncoming nurse. [LVN B] Record review of Resident #1's Progress Notes revealed entry on 12/17/23 at 6:33 PM by LVN B that upon arrival of shift [12/17/23 6:00 AM] resident was found to [sic] bleeding from forehead and bridge of nose. No explanation given as to what occurd[sic] .Resident c/o [complained of] headache and face pain. Record review of Resident#1's Nurse Note dated 12/18/23 at 11:24 PM, authored by LVN C, read Off going nurse [LVN B] reported resident was found this morning with bleeding to his face. When I went to assess resident it was observed that he has nasal swelling and right facial swelling as well as abrasions to his [forehead]. Resident was at baseline for resident which is alert to self and able to follow very basic instruction. When asked resident if was in pain he stated yes and touched his nose. I could hear him trying to breathe through his nose. I asked if it was difficult to breathe through his nose and he stated yes. VS 133/81, 105, 95% room air, 21, 99.1. Resident ambulated throughout unit per his usual routine. Call placed to . Physicians expressing concern and they gave orders to send him out to . ER to be evaluated . Ambulance was called, and he is pending transport. Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 12:45 AM by LVN C observed that he has nasal swelling and right facial swelling as well as abrasions to forehead . Further documentation indicated resident stated yes when asked if he was in pain and yes to difficulty breathing through nose. Resident transferred to local emergency room on [DATE] at 12:46 AM. Record review of Resident #1's ER CT Scan of the Head without intravenous contrast, dated 12/18/23 at 2:25 AM, revealed an acute subdural hemorrhage throughout the left supratentorial (upper part of brain) brain and along the left greater than right tentorial (brain fold) leaflets .Punctate intraparenchymal (blood in tissue of brain) in the left occipital lobe (visual processing area of the brain) .Mild diffuse left cerebral edema. No midline shift. Review of CT Maxillofacial [related to the upper jaw, face, and neck] dated 12/18/2023 at 2:25 AM, revealed Nondisplaced right nasal bone fracture. Sharp angulation of the bony nasal septum. No other acute facial fractures. soft tissue swelling (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 2 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few overlying the nose. Intracranial hemorrhage better evaluated on same day CT head. Review of CT Chest/Abdomen/Pelvis dated 12/18/2023 at 2:25 AM, revealed acute left posterolateral [back and side] 7th, 8th, 9th, 10th, and 11th left rib fractures. Record review of Resident #1's admitting hospital record dated 12/18/23 revealed reason for admissions was fall and rib fracture and SDH (subdural hematoma). Admitting diagnosis was SDH: sent to the ICU for SDH monitoring and treatment. Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 5:53 AM by the ADON that resident was transferred to higher acuity facility, due to subdural hematoma [bleeding inside the skull, but outside the actual brain tissue], large intraparenchymal hemorrhage [bleeding in the brain tissue], nasal fracture [broken bones], and multiple left rib fractures. Further documentation indicated telephone line to on-call physician service was not working properly, and the nurse notified resident's responsible party. Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 11:46 AM by Nurse F, PCP made aware of resident's [Resident #1's] transfer to higher level acuity facility. Record review of written statement authored by LVN B revealed that, on 12/17/23 at 6:00 AM, Resident #1 was still bleeding from his nose; first aide applied; sitting in a chair in the hallway. Resident#1 removed the bandaged off nose multiple times. Resident complained about a headache. At the end of her shift 6:00 PM, he was stable. Resident #1 stated he felt better. Record review of an email from LVN B dated 12/19/23 8:08 PM, LVN B stated the overnight nurse LVN A did not provide information on what happened to Resident #1 prior to the start of LVN B's shift on 12/17/23 at 6:00 AM. In an interview on 12/20/2023 at 2:00 PM, CNA E stated at the start of her shift on 12/17/2023, shortly after 6:00 AM, she alerted the overnight nurse, LVN A, and the oncoming nurse, LVN B, that Resident #1 was bleeding from the bridge of his nose. CNA E stated she was asked to clean Resident #1 up so that he could be better assessed by LVN B. CNA E stated Resident #1 ate breakfast like his normal self, but after breakfast stated he was not feeling well. CNA E stated she reported to LVN B that Resident #1 vomited, and wanted to lay down after breakfast, which was not his normal. CNA E stated Resident #1 did not eat lunch or dinner and wanted to sleep most of the day. CNA E stated throughout the day Resident #1 was found in the sleeping TV area, Dining area and once curled up in a fetal position in the hallway. CNA E stated she reported that information to LVN B as it occurred. CNA E stated, on occasion Resident #1 would not sleep well during the night and would nap during the day. CNA E stated it was not his normal to be sleeping in common areas. In an interview on 12/20/2023 at 4:35 PM, LVN B stated that the aide told her Resident #1 was bleeding from the bridge of his nose. LVN B stated she applied pressure for 15 minutes to stop the bleeding. LVN B stated the resident was on multiple blood thinners that made it difficult for the bleeding to stop completely. LVN B stated Resident #1 also had a known behavior of skin picking and was restless frequently. LVN B stated she applied a dressing to the wound, but Resident #1 removed it within 15 minutes. LVN B stated she put an alarm on her phone to remind her to check up on Resident #1 every 45 minutes to an hour. LVN B stated she instructed the aides to round more frequently on Resident #1. LVN B stated she did not recall any staff member alerting her to a change in Resident #1. LVN B stated when she assessed him that morning [12/17/2023] she had a suspicion the residents' nose was broken due to the change in the shape of the nose and the sound of his breathing. LVN B stated there (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 3 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was some bruising under the jaw from a fall earlier in the week. LVN B stated she did not assess his chest or back for further injuries. LVN B stated when the night shift nurse, LVN C, arrived on 12/17/2023 at 6:00 PM, LVN B insisted on walking rounds to give report on Resident #1. LVN B stated it took a few minutes to find Resident #1, as he was not in his designated room, and was actually standing in the last, empty room at the end of the hall with out the lights on. LVN B stated he laughed at them when she told him they were looking for him. LVN B stated Resident #1 could be heard to audibly be breathing through his nose, but it was labored. LVN B stated facial swelling and discoloration was now visible and that Resident #1 stated, it kind of hurts. LVN B stated she explained to LVN C that the previous overnight shift nurse, LVN A, did not provide an explanation as to what happened to Resident #1. In an interview on 12/20/2023 at 5:22 PM, LVN C stated that upon arrival to her shift on 12/17/2023 at 6:00 PM, LVN B requested that the two of them go look at Resident #1 for shift report. LVN C stated it looked like Resident #1 had a broken nose, and he admitted to some pain when asked. LVN C stated she told LVN B that she would be sending Resident #1 out to the emergency room because he didn't look right. LVN C stated she did not assess his chest or back for further injuries. LVN C stated she believed Resident #1 left via ambulance around 11:30 PM. LVN C stated she prioritized the evening medications on the secured unit for the men's hall, and the secured unit for the women's hall over sending Resident #1 out. LVN C stated that normally there was a certified medication aide, but that night [12/17/2023] there was not. LVN C stated on the few occasions there was not medication aide on the shift, it made the shift very hectic when she had to pass her own medications. LVN C stated she contacted the on-call physicians' group but was unable to leave a message. LVN C stated she contacted the residents responsible party and was also unable to leave a message. LVN C stated she called the ADON at that time but did not leave a message. LVN C stated she contacted the emergency room at the end of her shift [12/18/2023 at 6:00 AM] for an update on Resident #1 and was informed he was being transferred to a higher level of care [the local emergency room is free standing and does not have the ability to admit residents as there is no associated hospital with it]. LVN C stated it was after that phone call that she alerted the facility management to the situation. During an interview in Spanish on 01/11/24 at 11:56 AM, NA D stated he found Resident #1 ambulatory on Hall A on 12/17/23 at 2:00 AM and informed LVN A and returned to his duties. NA D stated that Resident #1 provided him with no explanation on the cause of the bleeding to the nose. During an interview on 01/11/24 at 11:35 AM, the ADON stated Resident#1 was found in A Hall, standing up and ambulatory, on 12/17/ 23 AM at 2:00 AM by NA D. The Nurse on duty was LVN A (agency) and she described in her Nurse Notes dated 12/17/23 at 5:38 AM that Resident #1 had superficial abrasion approximately 1.5 cm to the bridge of the nose. LVN A provided first aide. There was no description from NA D or LVN A on how the injury occurred on 12/17/23. Resident #1's BIMS score was 3 (severely impaired) and the resident did not state he had an injury. Resident, previous to the incident on 12/17/23, had a fall on 12/12/23 with injury to the bridge of the nose. On 12/12/23, the resident was not sent to the ER per recommendation by the physician. During an interview on 01/11/24 at 12:18 PM, the ADON stated: per nursing practice, if a head injury was suspected, neuro checks were started immediately. Neuro checks were done for 72 hours; namely, 15 minutes X4, 30 minutes X4; hourly X4 Q shift until 72 hours are completed. The ADON stated, no neuro checks were done on 12/17/23, she stated the bleeding to the nose was an old scab and nurses assumed it was an old injury from fall on 12/12/23 as stated in the nurses' notes . The ADON stated x-ray results on 12/18/23 from the ER (local hospital) revealed a non-displaced right rib fracture, sharp angulation of boney nasal septum reflected the resident's normal anatomy rather than a fracture, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 4 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and no blood inside of nose. However, the ADON stated CT scan revealed an acute subdural hemorrhage throughout the left side of the head. Resident #1 did not return to the facility. The ADON stated the assumption was that the resident scratched his scab on 12/17/23 and neuro checks for the fall on 12/12/23 revealed no neuro issues. An attempted telephone interview on 01/11/24 at 12:39 PM to LVN B. LVN B's telephone would not accept messages. During a joint interview on 01/11/24 at 2:24 PM, with the ADON and the Director of Quality (Corporate), the Director of Quality (Corporate) stated: on the day of the incident 12/17/23 LVN C (Agency) did an SBAR on 12/17/23 at 10:00 PM. Resident #1 had right facial swelling and the resident complained of pain and had difficulties breathing through his nose. LVN A did not do an SBAR at 2:00 AM on 12/17/23 - she state the reason why the SBAR was not completed was unknown. The ADON stated she had no explanation as to why an SBAR was not done at 2:00 AM. The Director of Quality and the ADON stated no head-to-toe assessment was required based on history of fall with existing abrasion. They state there was no documented vitals taken on 01/17/23 at 2:00 AM. During a telephone interview on 01/11/24 at 2:35 PM, LVN A stated that she did not do a head-to-toe assessment or SBAR on the incident involving Resident #1 on 12/17/23 at 2:00 AM because the resident only had bleeding to the bridge of the nose and first aid was applied. LVN A stated she was aware Resident #1 had a fall on 12/12/23 and neuro checks were done for 72 hours. LVN A stated she did vital signs but could not remember whether the vital signs were documented. LVN A stated she did not communicate with the physician on 12/17/23 at 2:00 AM and did not seek a physician order to initiate neuro checks. During a telephone interview on 01/11/24 at 3:45 PM, the facility MD stated: if there was no evidence of a fall on 12/17/23 at 2:00 AM, there was no requirement that vitals or neurological checks be done since there was no evidence of trauma or change of condition. The MD stated what was given to Resident #1 was standard care rather than best care which would have involved vitals or neurological checks. The MD stated he nor the on-call physician were notified of the bleeding on 12/17/23 at 2:00 AM. The MD stated that during the delay of 22 hours standard care did not require vitals or neuro checks be done. The MD stated that a significant change, SDH, could have been occurring during the gap of 22 hours (01/17/23 at 2:00 AM to 01/18/23 at 12:46 AM). During a telephone interview on 01/11/24 at 4:45 PM, LVN A stated there was no evidence Resident #1 vomited on 12/17/23 or had a fall or change of condition. LVN A stated vitals and assessments were done but not documented because there was a shift change at 6:00 AM and the facility did not pay Agency Nurses for documentation after the shift change. LVN A stated that she was aware of Resident #1's fall on 12/12/23 and that 72 hour neurological checks had been completed on 12/15/23. LVN A stated that the physician was not notified on 12/17/23 at 2:00 AM or at the end of her shift at 6:00 AM. During an interview on 01/11/24 at 4:05 PM, the Director of Quality stated: given the circumstances LVN A fully assessed Resident #1 on 12/17/23 at 2:00 AM. LVN A did not document a change of condition in the resident, and vitals and neurological checks were not done for a period of 22 hours by nursing staff because Resident #1 did not reveal signs of a change of condition. During joint interview on 01/11/24 at 5:00 PM, the Director of Quality and the Administrator stated overtime was permitted for agency staff to document in the clinical record. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 5 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of Abuse Prevention Program revised January 2011, revealed, policy statement: residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Under step 3.) Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect .b.) Mandated staff training/ orientation programs that include such topics as abuse prevention, identifying and reporting of abuse . Record review of Preventing Resident Abuse policy revised November 2010 revealed under step 3j.) assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3p.) ensure that the needs of each resident are met; 3q.) report any signs or suspected incidents . Record review of Abuse and Neglect: Clinical Protocol revised April 2013, revealed the nurse will assess the individual and document related findings. under Step 2.) The nurse will report findings to the physician . Record review of Reporting Abuse to Facility Management, revised December 2013, revealed policy statement, it is the responsibility of our employees .etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management. Definitions provided of injuries of unknown source: 1.) Source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2.) the injury is suspicious because of a.) the extent of the injury, b.) the location of the injury. Neglect defined as: failure to provide goods and services necessary to avoid physical harm . Record review of Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2012, revealed policy statement, facility will not condone any form of resident abuse or neglect .report any signs and symptoms of abuse/neglect to their supervisor .immediately. Examples of abuse/neglect provided included: inadequate provision of care, caregiver indifference to residents' care and needs. The Administrator was given the IJ template and was notified of the Immediate Jeopardy (IJ) on 01/12/2024 at 12:05 PM and a plan of removal (POR) was requested. On 01/12/2024 at 5:44 PM, the POR was accepted. It was documented as follows: Plan to remove immediate jeopardy. The facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed for receiving nursing services in that: Facility staff failed to respond appropriately when Resident #1 had a bleeding to the bridge of the nose on 12/17/2023 at 2:00 a.m. for documented assessment, vital signs and communications with the physician for a period of 18 hours when the resident had a change of condition; requiring an ER visit.

F580 On 01/12/2024 the Administrator notifies Medical Director of immediate jeopardy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 6 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 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 0580 On 01/12/2024 resident #1 no longer resides in the facility. Level of Harm - Immediate jeopardy to resident health or safety On 01/12/2024 all residents in the facilities will be assessed by Director of Quality/RN Designee for any changes in condition. Any findings will be communicated to the Medical Director for further interventions/orders and Resident/RP will be notified. Residents Affected - Few On 01/12/2024 DOQ (Director of Quality, RN) completed one-on-one in-service with Assistant Director of Nursing on Changes in Condition, including timely assessment, physician notification, and follow physician recommendations. On 12/22/2023 Assistant Director of Nursing/Designee completed 100% in-service training on Notification to Management (IDT Team) of Any Injury or Change of Condition, training on Abuse/Neglect, training on Appropriate Assessments of Residents will be done in a Timely Manner on any Change of Condition or Injuries, and training on Notification to MD of any Injury or Change of Condition. Starting on 01/12/2024 the Assistant Director of Nursing/Designee initiated in-service with nurses on changes in condition, including timely assessment, physician notification, and follow physician recommendations. Education to be completed on 01/12/2024. Any staff that is not available will be trained prior to their next scheduled workday, including PRN and Agency staff. Ad-Hoc QAPI meeting was held on 01/12/2024, with the Medical Director, NHA (Nursing Home Administrator), Director of Quality, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Change in condition and timely reporting was reviewed on 01/12/2024 by the NHA (Nursing Home Administrator), Assistant Director of Nursing, DOQ (Director of Quality), and Medical Director. Starting on 01/12/2024, IDT (Interdisciplinary team), including Administrator, Assistant Director of Nursing, and MDS Coordinator will review any changes in condition and events daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if timely notification and assessment was completed due to changes in condition. The findings will be immediately brought to the Administrator for further action, if necessary. On 01/12/2024 the RNC (Regional Nurse Consultant)/DOQ (Director of Quality) will start reviewing Events/Changes in Condition for validation of thorough assessment and timely notification weekly for four (4) weeks followed by monthly for 2 months. The Administrator/designee will monitor compliance by completing audit of five (5) residents per week for four (4) weeks. This was initiated on 01/12/2024. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 01/12/2024. The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Verification of the Plan of Removal: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 7 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 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 0580 Level of Harm - Immediate jeopardy to resident health or safety In an interview on 01/13/24 at 9:35 AM, the ADON stated there were three residents who had a recent change in their condition in the past week. Record review of the 3 residents who were identified with a change in their condition revealed each resident had been assessed by the nurse, the physician was notified, orders received were initiated and a SBAR was completed. Residents Affected - Few Record review of facility's nurse staffing revealed: total of 27 (24 NAs, 3 LVNs). Record review of the 4 in-services on 12/22/23 revealed 59 signatures with a completion rate of 100%. During an interview on 01/11/24 at 11:10 AM, the ADON stated an in-service was conducted on 12/22/23 for 59 staff, the in-services as follows: *Notification to Management of Any Injury or Change of Condition, *Abuse and Neglect for 59 staff, *Appropriate Assessment Done in a Timely Manner, and *Notification too MD for 59 staff. Interviews on 01/13/24 10:24 AM to 4:00 PM with 3 of 5 facility nurses (3 LVNs) who worked on the 6 AM to 6 PM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations. Interviews on 01/13/24 from 10:24 AM to 4:00 PM with 3 of 6 agency nurses (3 LVNs) who worked on the 6 PM to 6 AM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations. In an interview on 1/13/24 at 11:07 AM, the Regional Nurse Consultant (RNC) stated she assisted the DOQ with assessing all the residents on 01/12/24. The RNC stated she assessed the 2 secured units and the DOQ assessed the residents on the other side of the building. RNC stated there were 2 residents whom she noticed there was a change from their normal baseline, which the floor nurse had already identified earlier in the day, the residents' physicians had been notified and she made sure an SBAR had been completed for those residents. The Regional Nurse Consultant stated she participated in the Ad Hoc QAPI meeting held on 01/12/24 with the Administrator, ADON, DOQ present in person and the Medical Director present via telephone. In a telephone interview on 01/13/24 at 2:05 PM, the Medical Director stated he was informed of the IT situation on 01/12/24, he participated via telephone in the Ad Hoc QAPI meeting held in the late afternoon on 01/12/24, and he approved the measures the facility was going to implement. The Medical Director stated the policy about Change in Condition and Timely Reporting was reviewed with him during the Ad-Hoc QAPI meeting. In an interview on 01/13/24 at 2:52 PM the RNC stated she would weekly run a report in the electronic charting system to see which residents had a new SBAR completed to identify residents who had a change in their condition and would do this for two months to monitor residents who had a change in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 8 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 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 0580 their condition. Level of Harm - Immediate jeopardy to resident health or safety In an interview on 01/13/24 at 2:58 PM, the ADON stated all the residents were assessed on 01/12/24 by the DOQ and RNC. The ADON stated she was in-serviced by the DOQ on change of resident's condition, timely notification to the physician, following the physician recommendations and on Abuse & Neglect. The ADON stated she had in-service all 12 nurses on changes in condition, timely assessment, physician notification, following physician recommendations and abuse and neglect. The ADON said an Ad Hoc QAPI meeting was held on 01/12/24 in the afternoon; she, the RNC, the DOQ and administrator were present, and the Medical Director attended via phone. The ADON stated the policy pertaining to Change in Condition and Timely reporting was reviewed during the ad-hoc QAPI meeting held on 01/12/24. ADON said on weekends, the Manager on Duty would monitor any changes in condition to the residents; and during the week the IDT would do the monitoring. The ADON stated if there was a change in the resident's condition the resident would be assessed, the physician would be notified, new orders received would be implemented and the resident's RP would be notified. The ADON stated she completed the monitoring of changes in resident's condition on 01/13/24, using a Daily Census Sheet, for the weekend Manager on Duty, any new findings would be assessed by the nurse and the Daily Census sheet was placed in the facility's POR white binder. Residents Affected - Few In an interview on 01/13/24 at 3:15 PM, the Administrator stated all the residents were assessed by the RNC and the DOQ on 01/12/24, and the medical director was notified on 01/12/24 after the facility was informed of the IT. The Administrator said the DOQ conducted an in-service with the ADON on Changes in Condition, timely assessment, physician notification and following physician recommendations and 100% of the nurses were in-serviced by the ADON on 01/12/2024 on Notification to Management of any injury or change of condition, appropriate assessments of residents being done in a timely manner, notify the physician of change of condition, following physician recommendations, and abuse and neglect. The Administrator stated an Ad Hoc QAPI meeting was held on 01/12/24 after the facility's POR had been accepted with the Medical Director via phone, and the RNC, ROQ and ADON in person. The Administrator said the policy pertaining to Change in Condition and Timely Reporting was reviewed during the AD Hoc QAPI meeting. The Administrator stated changes in a residents' condition would be monitored by the IDT during the morning meeting; the facility activity report would be printed to show progress notes written in the past 24-hours; the nurses would attend the morning meeting and report on residents who had a change in their condition. He stated on the weekends the Manager on Duty would review the report for any changes of condition and notify the ADON or the Administrator if a resident had a change in their condition. The Administrator stated he would audit the activity report weekly to see if there was an event or change in a resident's vital signs, then he would review the resident's clinical record to see if it was a change in the residents' condition and notify the ADON. The Administrator said the COO would be consult the RNC and ROQ for monitoring of residents' change of condition, there would be weekly calls with the COO and the COO would visit the facility monthly to monitor the facility and his progress. Record review of the Daily Census Report dated 01/13/24 revealed Resident #1 was no longer in the facility. Record review of the facility's white binder with the POR documents revealed the following: *a Training In-Service Sign-in Sheets, dated 12/22/23, revealed 59 of 59 employees had been in-serviced by the ADON on Notification to MD of Any Injury or Change of Condition, Notification to Management (IDT Team) of Any Injury or Change of Condition, Appropriate Assessments of Residents Will be Done in a Timely Manner on Any Change of Condition or Injuries, and Abuse and Neglect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 9 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 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 0580 Level of Harm - Immediate jeopardy to resident health or safety * an Ad Hoc QA Meeting Sign-in Sheet dated 01/12/24 was in the binder with the signature of the Administrator, ADON, Director of Quality, and the Regional Nurse Consultant. The Medical Director was listed as being in attendance via telephone. * a Census Report dated 01/13/24 with each residents' name highlighted to indicate the residents had been monitored for a change of their condition and was signed by the ADON at the bottom of the sheet. Residents Affected - Few * an undated Review Change of Condition and Timely Notification of Assessments monitoring form had been created * a Daily Census Report dated 01/12/24 with each resident's name checked off and a copy of the progress note from the Director of Quality or the Regional Nurse Consultant for each resident assessed. Record review of the Training In-Service Sign-in Sh[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 10 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed for nursing services, in that: Residents Affected - Few Facility staff failed to respond appropriately when Resident #1 had a bleeding to the bridge of the nose on 12/17/23 at 2:00 AM. The facility staff did not document an assessment, vital signs, and communications with the physician for a period of 22 hours when the resident had a change of condition. Resident #1 was taken to the ER on [DATE] at 12:46 AM and diagnosed with a subdural hematoma. An Immediate Jeopardy was identified on 01/12/24 at 12:05 PM. While the Immediate Jeopardy was removed on 01/13/24 at 5:10 PM., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for serious injury, harm, impairment, or death. The findings included: Record review of Resident #1's ER CT Scan dated 12/18/23 revealed an acute subdural hemorrhage throughout the left supratentorial (upper part of brain) brain and along the left greater than right tentorial (brain fold) leaflets .Punctate intraparenchymal (blood in tissue of brain) in the left occipital lobe (visual processing area of the brain).Mild diffuse left cerebral edema. No midline shift. Review of CT Maxillofacial [related to the upper jaw, face, and neck] dated 12/18/2023 at 2:25 AM, revealed Nondisplaced right nasal bone fracture. Sharp angulation of the bony nasal septum. No other acute facial fractures. Soft tissue swelling overlying the nose. Intracranial hemorrhage better evaluated on same day CT head. Review of CT Chest/Abdomen/Pelvis dated 12/18/2023 at 2:25 AM, revealed acute left posterolateral [back and side] 7th, 8th, 9th, 10th, and 11th left rib fractures. Record review of Resident #1's admitting hospital record dated 12/18/23 revealed reason for admissions was fall and rib fracture and SDH (subdural hematoma). Admitting diagnosis was SDH: sent to the ICU for SDH monitoring and treatment. Record review of Resident #1's Face Sheet printed 12/21/22 revealed Resident #1 was a [AGE] year-old male admitted on [DATE] and discharged to the ER on [DATE]. Resident #1's diagnoses included: cerebral infarction (stroke), lack of coordination, dementia with agitation, cognitive communication deficits, and essential hypertension (primary). The RP was listed as a family member. Record review of Resident #1's physician orders dated December 2023 revealed: clopidogrel, tablet, 75 mg, 1 tablet daily (blood thinner) and aspirin, tablet, chewable, 81 mg, 1 tablet daily (blood thinner). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed his primary reason for admission was coded as Other Neurological Conditions related to cerebral infarction [a brain lesion in which a cluster of brain cells die when they do not get enough blood; stroke]. Other active (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 11 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few diagnosis included non-Alzheimer's vascular dementia [a group of symptoms that affects memory, thinking and interferes with daily life]. Resident #1 had a BIMS summary score of 3, indicative of severe cognitive deficits. Resident #1 had one fall since admission with a non-major injury. Resident #1 was coded as walking 50 feet with set-up assistance only and coded as contact guard assistance for walking 150 feet. Record review of Resident #1's Care Plan, undated, revealed he had a problem area in the category of Falls with a start date of 12/07/23; with the following interventions: refer to therapy, edited 12/12/23; attempt to discover cause and resolve reason for falls, created 12/08/2023; fall assessment per policy, created 12/08/2023. Additional problem area of Falls with a start date of 8/24/2023, with the following interventions: call light in reach at all times, created 8/25/2023; fall risk assessment per policy, created 8/25/2023; monitor routines, habits, tendencies preferences, behavior, ADL deficits, created 8/25/2023. Record review of Resident #1's clinical record revealed no SBAR, or head-to toe assessment done on Resident #1 by LVN A at 2:00 AM. [No documented evidence showed that vitals were taken or that the physician was notified on 12/17/23 at 2:00 AM.] Record review of Resident #1's Nurse Note dated 12/17/23 at 5:38 AM, authored by LVN A, reflected: Resident #1 was bleeding from his nose; assessed which revealed a superficial abrasion; appeared that he scratched some form of scab. First Aide was provided, and she (LVN A) would inform the on-coming nurse (LVN B). [No evidence existed that the physician was notified.] Record review of Resident #1's Progress Notes revealed entry on 12/17/23 at 6:33 PM by LVN B that upon arrival of shift [12/17/23 6:00 AM] resident was found to [sp] bleeding from forehead and bridge of nose. No explanation given as to what occurd[sp] .Resident c/o [complained of] headache and face pain. [No evidence existed that the physician was notified.] Record review of Resident#1's Nurse Note dated 12/18/23 at 11:24 PM, authored by LVN C, read Off going nurse [LVN B] reported resident was found this morning with bleeding to his face. When I went to assess resident, it was observed that he has nasal swelling and right facial swelling as well as abrasions to his [forehead]. Resident was at baseline for resident which is alert to self and able to follow very basic instruction. When asked resident if was in pain he stated yes and touched his nose. I could hear him trying to breathe through his nose. I asked if it was difficult to breathe through his nose and he stated yes. VS 133/81, 105, 95% room air, 21, 99.1. Resident ambulated throughout unit per his usual routine. Call placed to . Physicians expressing concern and they gave orders to send him out to . ER to be evaluated . Ambulance was called, and he is pending transport. Record review of Resident #1's Progress Notes revealed a late entry entered on 12/17/23 at 8:48 AM by LVN A for 12/17/23 5:38 AM of observed superficial abrasion approx. 1.5 cm in legth[sp] .cleaned the dry blood from his nose and place a dressing on top to keep it clean from dirt and debri[sp]. Will inform oncoming nurse. [No evidence existed that the physician was notified.] Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 12:45 AM by LVN C of observed that he has nasal swelling and right facial swelling as well as abrasions to forehead . Further documentation indicated resident stated yes when asked if he was in pain and yes to difficulty breathing through nose. Resident transferred to local emergency room on [DATE] at 12:46 AM. [Timeline (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 12 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 was 22 hours.] Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's Progress Notes revealed entry on 12/18/23 at 5:53 AM by ADON that resident was transferred to higher acuity facility, due to subdural hematoma [bleeding inside the skull, but outside the actual brain tissue], large intraparenchymal hemorrhage [bleeding in the brain tissue], nasal fracture [broken bones], and multiple left rib fractures. Further documentation indicated telephone line to on-call physician service was not working properly, and the nurse notified resident's responsible party. Residents Affected - Few Record review of Resident #1's Progress Notes by Nurse F revealed entry on 12/18/23 at 11:46 AM that PCP made aware of resident's [Resident #1's] transfer to higher level acuity facility. In a record review of a written statement dated 12/18/2023, CNA E stated she observed Resident #1 with blood on the bridge of his nose and immediately reported it to LVN A & B during shift change on 12/17/2023 at 6:00 a.m. (Note: Resident #1 was on blood thinners.) In a record review of an email from LVN B dated 12/19/23 8:08 PM, LVN B stated the overnight nurse LVN A did not provide information on what happened to Resident #1 prior to the start of LVN B's shift on 12/17/23 at 6:00 AM. [No evidence existed that the physician was notified.] Recorded as Late Entry on 12/19/23 8:48 AM and authored by LVN A read Entry missing from 12/17 This nurse was informed by the aide that this resident was bleeding from his nose. This nurse went to assess the resident and observed a superficial abrasion approx[imately] 1.5cm in length [sic] to his nose which looked as perhaps he scratched off some of the formed scab that was there. This nurse cleaned the dry blood from his nose and placed a dressing on top to keep it clean from dirt and debri [sic]. Will inform oncoming nurse. Record review of statement on 12/29/23 authored by LVN B revealed that, on 12/17/23 at 6:00 AM, Resident #1 was still bleeding from his nose; first aide applied; sitting in a chair in the hallway. Resident#1 removed the bandaged off nose multiple times. Resident complained about a headache. At the end of her shift 6:00 PM, he was stable. Resident #1 stated he felt better. [No evidence existed that the physician was notified.] In an interview on 12/20/2023 at 2:00 PM, CNA E stated at the start of her shift on 12/17/2023, shortly after 6:00 AM, she alerted the overnight nurse, LVN A, and the oncoming nurse, LVN B, that Resident #1 was bleeding from the bridge of his nose. CNA E stated she was asked to clean Resident #1 up so that he could be better assessed by LVN B. CNA E stated Resident #1 ate breakfast like his normal self, but after breakfast stated he was not feeling well. CNA E stated she reported to LVN B that Resident #1 vomited, and wanted to lay down after breakfast, which was not his normal. CNA E stated Resident #1 did not eat lunch or dinner and wanted to sleep most of the day. CNA E stated throughout the day Resident #1 was found in the sleeping TV area, Dining area and once curled up in a fetal position in the hallway. CNA E stated she reported that information to LVN B as it occurred. CNA E stated, on occasion Resident #1 would not sleep well during the night and would nap during the day. CNA E stated it was not his normal to be sleeping in common areas. In an interview on 12/20/2023 at 4:35 PM, LVN B stated that the aide [CNA E] told her Resident #1 was bleeding from the bridge of his nose. LVN B stated she applied pressure for 15 minutes to stop the bleeding. LVN B stated the resident was on multiple blood thinners that made it difficult for the bleeding to stop completely. LVN B stated Resident #1 also had a known behavior of skin picking and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 13 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was restless frequently. LVN B stated she applied a dressing to the wound, but Resident #1 removed it within 15 minutes. LVN B stated she put an alarm on her phone to remind her to check up on Resident #1 every 45 minutes to an hour. LVN B stated she instructed the aides to round more frequently on Resident #1. LVN B stated she did not recall any staff member alerting her to a change in Resident #1. LVN B stated when she assessed him that morning [12/17/2023] she had a suspicion the residents' nose was broken due to the change in the shape of the nose and the sound of his breathing. LVN B stated there was some bruising under the jaw from a fall earlier in the week. LVN B stated she did not assess his chest or back for further injuries. LVN B stated when the night shift nurse, LVN C, arrived on 12/17/2023 at 6:00 PM, LVN B insisted on walking rounds to give report on Resident #1. LVN B stated it took a few minutes to find Resident #1, as he was not in his designated room, and was actually standing in the last, empty room at the end of the hall with out the lights on. LVN B stated he laughed at them when she told him they were looking for him. LVN B stated Resident #1 could be heard to audibly be breathing through his nose, but it was labored. LVN B stated facial swelling and discoloration was now visible and that Resident #1 stated, it kind of hurts. LVN B stated she explained to LVN C that the previous overnight shift nurse, LVN A, did not provide an explanation as to what happened to Resident #1. In an interview on 12/20/2023 at 5:22 PM, LVN C stated that upon arrival to her shift on 12/17/2023 at 6:00 PM, LVN B requested that the two of them go look at Resident #1 for shift report. LVN C stated it looked like Resident #1 had a broken nose, and he admitted to some pain when asked. LVN C stated she told LVN B that she would be sending Resident #1 out to the emergency room because he didn't look right. LVN C stated she did not assess his chest or back for further injuries. LVN C stated she believed Resident #1 left via ambulance around 11:30 PM. LVN C stated she prioritized the evening medications on the secured unit for the men's hall, and the secured unit for the women's hall over sending Resident #1 out. LVN C stated that normally there was a certified medication aide, but that night [12/17/2023] there was not. LVN C stated on the few occasions there was not medication aide on the shift, it made the shift very hectic when she had to pass her own medications. LVN C stated she contacted the on-call physicians' group but was unable to leave a message. LVN C stated she contacted the residents responsible party and was also unable to leave a message. LVN C stated she called the ADON at that time but did not leave a message. LVN C stated she contacted the emergency room at the end of her shift [12/18/2023 at 6:00 AM] for an update on Resident #1 and was informed he was being transferred to a higher level of care [the local emergency room is free standing and does not have the ability to admit residents as there is no associated hospital with it]. LVN C stated it was after that phone call that she alerted the facility management to the situation. During an interview on 01/11/24 at 11:35 AM, the ADON stated: Resident#1 was found in A Hall, standing up and ambulatory, on 12/17/ 23 AM at 2:00 AM by NA D. The Nurse on duty was LVN A (agency) and she described in her Nurse Notes dated 12/17/23 at 5:38 AM that Resident #1 had superficial abrasion approximately 1.5 cm to the bridge of the nose. LVN A provided first aide. There was no description from NA D or LVN A on how the injury occurred on 12/17/23. Resident #1's BIMS score was 3 (severely impaired) and the resident did not state he had an injury. Resident, previous to the incident on 12/17/23, had a fall on 12/12/23 with injury to the bridge of the nose. On 12/12/23, the resident was not sent to the ER per recommendation by the physician. During an interview in Spanish on 01/11/24 at 11:56 AM, NA D stated he found Resident #1 ambulatory in Hall A on 12/17/23 at 2:00 AM and informed LVN A and returned to his duties. NA D stated that Resident #1 provided him with no explanation on the cause of the bleeding to the nose. During an interview 01/11/24 at 12:18 PM, the ADON stated: per nursing practice, if a head injury (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 14 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was suspected, neuro checks were started immediately. She stated Neuro checks were done for 72 hours; namely, 15 minutes X4, 30 minutes X4; hourly X4 Q shift until 72 hours are completed. The ADON stated, no neuro checks were done on 12/17/23 .the bleeding to the nose was an old scab and nurses assumed it was an old injury from fall on 12/12/23 as stated in the nurses' notes . The ADON added that x-ray results on 12/18/23 from the ER (local hospital) revealed a non-displaced right rib fracture, sharp angulation of boney nasal substance reflected the resident's normal anatomy rather than a fracture, and no blood inside of nose. However, the ADON stated CAT Scan revealed an acute subdural hemorrhage throughout the left side of the head. Resident #1 did not return to the facility. The ADON stated the assumption was that the resident scratched his scab on 12/17/23 and neuro checks for the fall on 12/12/23 revealed no neuro issues. Attempted telephone call on 01/11/24 at 12:39 PM to LVN B. LVN B's telephone would not accept messages. During a joint interview on 01/11/24 beginning at 2:24 PM, with the ADON and the Director of Quality (Corporate) stated: on the day of the incident 12/17/23 LVN C (Agency) did an SBAR on 12/17/23 at 10:00 PM. Resident #1 had right facial swelling and the resident complained of pain and had difficulties breathing through his nose. LVN A did not do an SBAR at 2:00 AM on 12/17/23 -she stated the reason why the SBAR was not completed was unknown. The ADON stated she had no explanation as to why an SBAR was not done at 2:00 AM. The Director of Quality and the ADON stated no head-to-toe assessment was required based on history of fall with existing abrasion. The [NAME] stated, no documented vitals were taken on 01/17/23 at 2:00 AM. During a telephone interview on 01/11/24 at 2:35 PM, LVN A stated that she did not do a head-to-toe assessment or SBAR on the incident involving Resident #1 on 12/17/23 at 2:00 AM because the resident only had bleeding to the bridge of the nose and first aid was applied. LVN A stated she was aware Resident #1 had a fall on 12/12/23 and neuro checks were done for 72 hours. LVN A stated she did vital signs but could not remember whether the vital signs were documented. LVN A stated she did not communicate with the physician on 12/17/23 at 2:00 AM and did not seek a physician order to initiate neuro checks. During a telephone interview on 01/11/24 at 3:45 PM, the facility MD stated: if there was no evidence of a fall on 12/17/23 at 2:00 AM, there was no requirement that vitals or neurological checks be done since there was no evidence of trauma or change of condition. The MD stated what was given to Resident #1 was standard care rather than best care which would have involved vitals or neurological checks. The MD stated he nor the on-call physician were notified of the bleeding on 12/17/23 at 2:00 AM. The MD stated that during the delay of 22 hours standard care did not require vitals or neuro checks be done. The MD stated that a significant change, SDH, could have been occurring during the gap of 22 hours (01/17/23 at 2:00 AM to 01/18/23 at 12:46 AM). During a telephone interview on 01/11/24 at 4:45 PM, LVN A stated there was no evidence Resident #1 vomited on 12/17/23 or had a fall or change of condition. LVN A stated vitals and assessments were done but not documented because there was a shift change at 6:00 AM and the facility did not pay Agency Nurses for documentation after the shift change. LVN A stated that she was aware of Resident #1's fall on 12/12/23 and that 72-hour neurological checks had been completed on 12/15/23. LVN A stated that the physician was not notified on 12/17/23 at 2:00 AM or at the end of her shift at 6:00 AM. During an interview on 01/11/24 at 4:05 PM, the Director of Quality stated: given the circumstances LVN A fully assessed Resident #1 on 12/17/23 at 2:00 AM. LVN A did not document a change of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 15 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few condition in the resident, and vitals and neurological checks were not done for a period of 22 hours by nursing staff because Resident #1 did not reveal signs of a change of condition. During joint interview on 01/11/24 at 5:00 PM, the Director of Quality and the Administrator stated overtime was permitted for agency staff to document in the clinical record. Record review of Abuse Prevention Program revised January 2011, revealed, policy statement: residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Under step 3.) Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect .b.) Mandated staff training/ orientation programs that include such topics as abuse prevention, identifying and reporting of abuse . Record review of Preventing Resident Abuse policy revised November 2010 revealed under step 3j.) assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 3p.) ensure that the needs of each resident are met; 3q.) report any signs or suspected incidents . Record review of Abuse and Neglect: Clinical Protocol revised April 2013, revealed the nurse will assess the individual and document related findings. under Step 2.) The nurse will report findings to the physician . Record review of Reporting Abuse to Facility Management, revised December 2013, revealed policy statement, it is the responsibility of our employees .etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source .to facility management. Definitions provided of injuries of unknown source: 1.) Source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2.) the injury is suspicious because of a.) the extent of the injury, b.) the location of the injury. Neglect defined as: failure to provide goods and services necessary to avoid physical harm . Record review of Recognizing Signs and Symptoms of Abuse/Neglect, revised April 2012, revealed policy statement, facility will not condone any form of resident abuse or neglect .report any signs and symptoms of abuse/neglect to their supervisor .immediately. Examples of abuse/neglect provided included: inadequate provision of care, caregiver indifference to residents' care and needs. The Administrator was given the IJ template and was notified of the Immediate Jeopardy (IJ) on 01/12/2024 at 12:05 PM and a plan of removal (POR) was requested. On 01/12/2024 at 5:44 PM, the POR was accepted. It was documented as follows: Plan to remove immediate jeopardy. The facility failed to ensure that, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #1) reviewed for receiving nursing services in that: Facility staff failed to respond appropriately when Resident #1 had a bleeding to the bridge of the nose on 12/17/2023 at 2:00 a.m. for documented assessment, vital signs and communications with the physician for a period of 22 hours when the resident had a change of condition; requiring an ER (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 16 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 visit. Level of Harm - Immediate jeopardy to resident health or safety On 01/12/2024 the Administrator notifies Medical Director of immediate jeopardy. Residents Affected - Few On 01/12/2024 all residents in the facilities will be assessed by Director of Quality/RN Designee for any changes in condition. Any findings will be communicated to the Medical Director for further interventions/orders and Resident/RP will be notified. On 01/12/2024 Resident #1 no longer resides in the facility. On 01/12/2024 DOQ (Director of Quality, RN) completed one-on-one in-service with Assistant Director of Nursing on Changes in Condition, including timely assessment, physician notification, and follow physician recommendations. On 12/22/2023 Assistant Director of Nursing/Designee completed 100% in-service training on Notification to Management (IDT Team) of Any Injury or Change of Condition, training on Abuse/Neglect, training on Appropriate Assessments of Residents will be done in a Timely Manner on any Change of Condition or Injuries, and training on Notification to MD of any Injury or Change of Condition. Starting on 01/12/2024 the Assistant Director of Nursing/Designee initiated in-service with nurses on changes in condition, including timely assessment, physician notification, and follow physician recommendations. Education to be completed on 01/12/2024. Any staff that is not available will be trained prior to their next scheduled workday, including PRN and Agency staff. Ad-Hoc QAPI meeting was held on 01/12/2024, with the Medical Director, NHA (Nursing Home Administrator), Director of Quality, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Change in condition and timely reporting was reviewed on 01/12/2024 by the NHA (Nursing Home Administrator), Assistant Director of Nursing, DOQ (Director of Quality), and Medical Director. Starting on 01/12/2024, IDT (Interdisciplinary team), including Administrator, Assistant Director of Nursing, and MDS Coordinator will review any changes in condition and events daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if timely notification and assessment was completed due to changes in condition. The findings will be immediately brought to the Administrator for further action, if necessary. On 01/12/2024 the RNC (Regional Nurse Consultant)/DOQ (Director of Quality) will start reviewing Events/Changes in Condition for validation of thorough assessment and timely notification weekly for four (4) weeks followed by monthly for 2 months. The Administrator/designee will monitor compliance by completing audit of five (5) residents per week for four (4) weeks. This was initiated on 01/12/2024. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 01/12/2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 17 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 The COO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Level of Harm - Immediate jeopardy to resident health or safety Verification of the Plan of Removal: Residents Affected - Few In an interview on 01/13/24 at 9:35 AM, the ADON stated there were three residents who had a recent change in their condition in the past week. Record review of the 3 residents who were identified with a change in their condition revealed each resident had been assessed by the nurse, the physician was notified, orders received were initiated and a SBAR was completed. Record review of facility's nurse staffing revealed: total of 27 (24 NAs, 3 LVNs). Record review of the 4 in-services dated 12/22/23 revealed 59 signatures with a completion rate of 100%. During an interview on 01/11/24 at 11:10 AM, the ADON stated: in-service was conducted from on 12/22/23 for 59 staff on (Notification to Management of Any Injury or Change of Condition; In-services for Abuse and Neglect for 59 staff; In service for Appropriate Assessment Done in a Timely Manner for 59 staff; In- service on Notification too MD for 59 staff.; Interviews on 01/13/24 at 10:24 AM to 4:00 PM with 3 of 5 facility nurses (3 LVNs) who worked on the 6 AM to 6 PM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations and knew how to respond to a future change of condition. Interviews on 01/13/24 from 10:24 AM to 4:00 PM with 3 of 6 agency nurses (3 LVNs) who worked on the 6 PM to 6 AM shift revealed they had been in-serviced on 01/12/24 on changes in condition, timely assessment, physician notification, and to follow physician recommendations; and knew how to respond to a change of condition. In an interview on 1/13/24 at 11:07 AM, the Regional Nurse Consultant (RNC) stated she assisted the DOQ with assessing all the residents on 01/12/24. The RNC stated she assessed the 2 secured units and the DOQ assessed the residents on the other side of the building. RNC stated there were 2 residents whom she noticed there was a change from their normal baseline, which the floor nurse had already identified earlier in the day, the residents' physicians had been notified and she made sure an SBAR had been completed for those residents. The Regional Nurse Consultant stated she participated in the Ad Hoc QAPI meeting held on 01/12/24 with the Administrator, ADON, DOQ present in person and the Medical Director present by telephone. In a telephone interview on 01/13/24 at 2:05 PM, the Medical Director stated he was informed of the IJ situation on 01/12/24, he participated via telephone in the Ad Hoc QAPI meeting held in the late afternoon on 01/12/24, and he approved the measures the facility was going to implement. The Medical Director stated the policy about Change in Condition and Timely Reporting was reviewed with him during the Ad-Hoc QAPI meeting. In an interview on 01/13/24 at 2:52 PM the RNC stated she would weekly run a report in the electronic charting system to see which residents had a new SBAR completed to identify residents who had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 18 of 19 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 675371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverview Nursing & Rehabilitation 1102 River Rd Boerne, TX 78006 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few change in their condition and would do this for two months to monitor residents who had a change in their condition. In an interview on 01/13/24 at 2:58 PM, the ADON stated all the residents were assessed on 01/12/24 by the DOQ and RNC. ADON stated she was in-serviced by the DOQ on change of resident's condition, timely notification to the physician, following the physician recommendations and on Abuse & Neglect. ADON stated she had in-service all 12 nurses on changes in condition, timely assessment, physician notification, following physician recommendations and abuse and neglect. ADON said an Ad Hoc QAPI meeting was held on 01/12/24 in the afternoon; she, the RNC, the DOQ and administrator were present, and the Medical Director attended via phone. ADON stated the policy pertaining to Change in Condition and Timely reporting was reviewed during the ad-hoc QAPI meeting held on 01/12/24. ADON said on weekends, the Manager on Duty would monitor any changes in condition to the residents; and during the week the IDT would do the monitoring. The ADON stated if there was a change in the resident's condition the resident would be assessed, the physician would be notified, new orders received would be implemented and the resident's RP would be notified. The ADON stated she completed the monitoring of changes in resident's condition on 01/13/24, using a Daily Census Sheet, for the weekend Manager on Duty, any new findings would be assessed by the nurse and the Daily Census sheet was placed in the facility's POR white binder. In an interview on 01/13/24 at 3:15 PM, the Administrator stated all the residents were assessed by the RNC and the DOQ on 01/12/24, and the medical director was notified on 01/12/24 after the facility was informed of the IJ. Administrator said the DOQ conducted an in-service with the ADON on Changes in Condition, timely assessment, physician notification and following physician recommendations and 100% of the nurses were in-serviced by the ADON on 01/12/2024 on Notification to Management of any injury or change of condition, appropriate assessments of residents being done in a timely manner, notify the physician of change of condition, following physician recommendations, and abuse and neglect. Administrator stated an Ad Hoc QAPI meeting was held on 01/12/24 after the facility's POR had been accepted with the Medical Director via phone, and the RNC, ROQ and ADON in person. Administrator said the policy pertaining to Change in Condition and Timely Reporting was reviewed during the AD Hoc QAPI meeting. Administrator stated changes in a residents' condition would be monitored by the IDT during the morning meeting; the facility activity report would be printed to show progress notes written in the past 24-hours; the nurses would attend the morning meeting and report on residents who had a change in their condition. He stated on the weekends the Manager on Duty would review the report for any changes of condition and notify the ADON or the Administrator if a resident had a change in their condition. Administrator stated he would audit the activity report weekly to see if there was an event or change in a resident's vital signs, then he would review the resident's clinical record to see if it was a change in the residents' condition and notify the ADON. Administrator said the COO would be consult the RNC and ROQ for monitoring of residents' change of condition, there would be w[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 19 of 19