Inspection·August 19, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety related to: Pneumonia. An approach was to Administer oxygen as ordered. Observe oxygen precautions.; Resident had episodes of anxiety and was at riskor fluctuations in moods. An approach was to monitor and record any abnormal behaviors and or moods. Review of Resident #1's consolidated physician orders revealed he had an order for oxygen, 2-5 Liters per minute for shortness of breath/SATs below 90% as needed. Residents Affected - Few Review of SBAR report for Resident #1, dated 8/1/24, revealed there was concern for mental status changes related to Resident #1 stating he doesn't feel right. The summary read, Resident had been complaining of not feeling well. He reported that he had some SOB concentrator hooked up at 2l per min and resident reported feeling much better. After a few minutes resident was seen running to front office where he fell. DON/ADON and regional nurse at his side. At later time this Ln called 911. Resident was then admitted to hospital for further eval. Review of Resident #1's hospital discharge report, dated 8/8/24, revealed Resident #1 was discharged with an order for Nicotine patch 7 mg/24 hr. 1 patch for smoking cessation. Review of Resident #1's admission nursing assessment dated , 8/8/24, completed by LVN A revealed Resident #1 was re-admitted to the facility. The document included he returned as a non-smoker, used a walker for ambulation and would receive oxygen. Further review revealed there was no indication LVN A asked Resident #1 if he had smoking materials in his possession. Review of incident/accident report, dated, 8/13/2024, revealed at 6:15 PM Resident #1 told LVN A he started a fire in his room with his oxygen. He told LVN A that he was hearing voices that told him to burn down the building and he could not control himself. Interview on 8/16/24 at 10:20 AM with the ADON, who assessed Resident #1 after the incident on 8/13/24, stated she did not know where Resident #1 obtained a lighter. Resident #1 did not tell her, and she did not ask him. The ADON stated upon Resident #1's return from the hospital on 8/8/24, he had orders for a nicotine patch to help him quit smoking. Interview on 8/16/24 at 10:45 AM with the ADM and ADON revealed prior to the incident with Resident #1, nursing staff would review the smoking policy with residents during the admission process but would not have them sign the policy. The ADM stated they did not have a process in place to ensure smoking residents returning from the hospital did not have smoking materials on their possession. Nursing staff would not ask the residents if they had smoking items. Interview on 8/16/24 at 11:15 AM with the ADON revealed she had a conversation with Resident #1's family member about the incident but did not think to ask if she knew how Resident #1 obtained a lighter. She did not ask the Resident #1 either. Interview on 8/16/24 at 12:42 PM with the DON revealed the ADM called her and told her about the incident involving Resident #1. She stated she was in shock because Resident #1 did not have a history of mental illness. She stated she was grateful nothing major happened because Resident #1's oxygen was on. Interview on 8/16/24 at 2:06 PM with Resident #2 revealed residents were not able to have cigarettes or lighters but his roommate would have a cigarette in his possession during smoke breaks. He also stated staff would not stay with them for the entire smoke break like they were supposed to stay. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 2 of 10 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 08/19/2024 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 0689 Resident #2 presented as being alert and oriented to person, place and time. Level of Harm - Immediate jeopardy to resident health or safety Review of Resident #2's smoking assessment dated , 8/14/24, revealed his General Awareness and Orientation- Including Ability to Understand the Facility Safe Smoking Policy was rated as no problem. Further review revealed Resident #2 was a safe smoker. Residents Affected - Few Telephone interview on 8/16/24 at 2:20 PM with LVN A revealed Resident #1 walked up to the nurse's station and told her he did not know what he was doing and started a fire in his room. She stated she was walking down the hall towards Resident #1's room as a CNA was walking up the hall yelling out fire. She stated when she arrived, to Resident #1's room, there was a burnt piece of paper on the floor in front of the nightstand. It was smoldering and the front of the nightstand was black in color but not burned through the wood. She stated she and the CNA stomped the embers out without the use of an extinguisher. LVN A stated she turned Resident #1's oxygen tank off at this time. LVN A stated the CNA did not pull the alarm. She stated they immediately put the fire out, but protocol required he pull the alarm when there was a fire. LVN A stated Resident #1 did not have a history of behaviors and had never done anything similar. She stated Resident #1's behavior was new onset and totally out of character. LVN A stated Resident #1 was discharged from the facility on the same date on an emergency detainment. Telephone interview on 8/16/24 at 4:33 PM with LVN A revealed she readmitted Resident #1 on 8/8/24 and did not ask him about having smoking paraphernalia because he returned as a non-smoker with orders for a nicotine patch even though he had been a daily smoker up to the date of discharge to the hospital, 8/1/24. LVN A stated she did not usually receive residents after being out on pass and had not been instructed to ask residents upon their return if they had smoking paraphernalia. Interview on 8/16/24 at 5 PM with the ADM and ADON revealed they reiterated they did not know where or when Resident #1 obtained a lighter. They stated he had not been out on pass, was hospitalized from [DATE] to 8/8/24 and then he started the fire on 8/13/24. The ADM and ADON were asked about safeguards in place to prevent families/residents from bringing paraphernalia into the facility. The ADON stated staff reviewed the smoking policy with residents and family members upon the resident's admission and as needed and they had never had a problem. The ADM stated staff was not asking the residents or family members upon re-entering the facility if the resident had smoking paraphernalia on them. The ADON stated family members were also allowed to visit, sit outside and smoke with residents at any time during their visit. She stated again they had not had a problem. The ADM and ADON stated they did not have a process in place to ensure residents did not have smoking paraphernalia during readmissions and upon returns from being out on pass. The ADM stated Staff could not frisk the residents upon their return to the facility, but stated staff was not required to ask residents if they had paraphernalia in their possession either. Interview on 8/17/24 at 11:19 AM with agency RN B revealed the charge nurse would provide her with the resident's status during shift change. However, stated she was new to the facility and not familiar with smokers. RN B stated after outings families would sign residents back into the facility in the sign on their Out on Pass Log and would return medications to the charge nurse. She stated she was not instructed to ask the families and residents if they had smoking paraphernalia on them. Interview on 8/17/24 at 11:32 AM agency LVN C revealed she had worked at the facility twice including on this date. She stated she received an in-service on this same date regarding the facility smoking policy but was not provided with a list of smokers. She stated she did not know who they were and had not seen a list anywhere. LVN C stated she had not supervised residents during a smoking break (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 3 of 10 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 08/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few and had not completed documentation for a new admission. LVN C stated she had not received any residents coming back in from an outing and had not received any instructions related to the processes in place. She had not been instructed to ask residents if they had smoking paraphernalia on their possession. Interview on 8/17/24 at 12:08 PM with RN D revealed he provided RN weekend coverage but was not a supervisor. He stated he was not in charge of orienting agency nurses to the facility and not been involved in admitting a resident to the facility. He stated he had supervised residents during smoke breaks. He commented, You can tell them all you want but residents will not always give up their cigarettes or lighters. He stated he did not ask residents if they had paraphernalia on them and had not asked families or residents about having paraphernalia upon returning from pass. RN D stated he was not sure if there was a list of smokers. Interview on 8/17/24 at 12:44 PM with Resident #1's family member revealed Resident #1 had been out on pass with her multiple times. She had bought Resident #1 cigarettes and offered to buy him a lighter in the past, but he declined. She stated she did not know about the facility's smoking policy and staff had never talked with her about it. The family member stated she did not provide Resident #1 with a lighter while he was hospitalized , 8/1/24 to 8/8/24. She stated she did not know how he obtained the lighter and had not talked to Resident #1 since his discharge from the facility. Resident #1's family member stated facility staff was also still trying to figure out how Resident #1 obtained the lighter. She stated a staff member called her earlier on this date. 2. Observation and interview during a walk through the smoking area outside on 8/16/24 at 12:29 PM with the MS revealed there was not a smoking sign or ashtrays. There were three visible aluminum trash cans: two under the eve upon exiting the facility and one in the covered patio area. Interview with the MS revealed the SW would supervise the residents during smoke breaks and would store the ashtrays in her office after smoke breaks. She would then bring them back out for smoke breaks. Observation and interview on 8/16/24 at 3 PM revealed about 8 Residents smoking outside in the courtyard. There was not a smoking sign leading to the courtyard and there was not a sign outside in the smoking area. There were also no ashtrays. The ADON was supervising the smoke break and stated someone went inside to get the ashtrays because they also noticed there were no ashtrays. The ADON stated she did not notice there was not a smoking sign. Further observation revealed a staff member brought 2 glass ashtrays for the smokers to use. Interview on 8/16/24 at 3:10 PM with the ADM and Regional Consultant revealed they had not noticed there was not a smoking sign. The ADM stated he had never taken the residents out for smoke breaks and did not know what type of ash trays were available but knew they should be metal. Observation and interview on 8/16/24 at 3:20 PM revealed a glass ashtray on top of a small table under the eve right outside the door and a second glass ashtray on top of a picnic table under the covered patio. Further observation revealed a cigarette butt on the ground between a chair and the cigarette butt trash can under the eve. Interview with the ADM revealed he stated there was a cigarette butt on the ground and should be disposed in the cigarette butt trash can for safety precautions. He stated he understood if the cigarette butt was not completely turned off it could start a fire. Interview on 8/16/24 at 3:38 PM with the SW revealed she would take residents out for a smoke break on M, W, F at 11 AM. The SW stated she was not sure about what type of ashtrays the residents used. She stated there were metal trash cans available for the residents' use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 4 of 10 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 08/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of facility Smoking Policy, dated October 2022, read This facility shall establish and maintain safe resident smoking practices. 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is not allowed inside the facility under any circumstances. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 7. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. 13. Lighters, including matches are prohibited to be kept in patients' rooms. Review of facility policy, [ Code Red], dated July 2024 read: POLICY: To ensure the safety of the residents, this policy provides instructions for staff to know and follow in the event of a fire. RESPONSIBLE PERSONS: Every employee is responsible to understand and to follow these procedures. PROCEDURE: Upon finding a fire staff must: 1) Yell CODE RED and the location of the fire, remove any residents from immediate danger. 2) Remove any residents in immediate danger. 3) Pull the alarm. 4) Use the overhead paging system and announce, 'CODE RED, and give a brief description of the location of the fire. 5) Contain the fire by closing doors, and/or windows. 6) Extinguish Fire if possible. 7) Close all doors in the area, checking bathrooms. 8) Close remaining windows and doors on the floor. 9) Do Not cross the fire area. 10) Visitors will not be permitted to enter floors. They will be permitted to remain in the lobby until the fire emergency is cleared. Remember RACE >>> R = Rescue/Remove resident from fire location and yell out CODE RED. A = Alarm: pull the fire alarm and tell someone to overhead page CODE RED. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 5 of 10 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 08/19/2024 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 0689 C = Contain: close all doors in the area. Level of Harm - Immediate jeopardy to resident health or safety E = Extinguish: while removing residents from the area. This was determined to be an Immediate Jeopardy (IJ) on 08/17/2024 at 4:59 PM and the Administrator was notified. The Administrator was provided with the IJ template on 08/17/2024 at 4:59 PM. Residents Affected - Few The following Plan of Removal was accepted on 08/18/2024 at 12:20 PM and it included: 8/13/2024 Residents #1 was assessed by ADON and resident was not a smoker and had a nicotine patch in place, police were notified and in building at this time. Resident was Emergency discharged to [hospital]. MD notified and aware of ED. There were no new orders obtained. Affected resident responsible party was notified by ADON of the alleged incident and plan of correction. 8/13/2024 ADON in serviced staff on smoking policy and reporting fire. On 8/13/2024 the Social worker, ADON, and Administrator interviewed all residents in the facility to determine if any other residents experienced any psychosocial harm from the alleged incident. There was no concern identified. The interviews were completed before midnight on 8/16/2024. On 8/14/2024 Administrator reported alleged incident to THHS and initiated an investigation immediately. 8/14/2024 Administrator/designee re-educated residents on smoking policy and letters were emailed/mailed to resident responsible parties who smoke. 8/14/2024 Residents who smoke were re-evaluated on 08/14/2024 using the facility smoking assessment. Ad-Hoc QAPI meeting was held on 8/17/2024 at 5:30 PM, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations) and DON to review the alleged incident, policy and procedure, and the plan for removal of immediacy. On 8/17/2024 in-servicing to all staff on smoking policy and procedure, admission checklist for paraphernalia checks reviewed, and questions when coming back from Out on Pass. Staff will receive Quiz post in-service to ensure understanding of process. 8/17/2024 Safe Surveys conducted. No issues at this time. Any issues will be brought to QAPI. 8/17/2024 Activity Director and Assistant in serviced on signing residents out and back in when out on activities as well as asking about paraphernalia. 8/17/2024 Cognitive Residents in serviced on Signing out and answering all questions on Sign out sheets. The policy pertaining to Smoking and Smoking Assessments were reviewed on 8/17/2024 by the DON, NHA (Nursing Home Administrator) and Medical Director. Starting on 8/13/2024, IDT (Interdisciplinary team), including Administrator, DON, ADON, Activity (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 6 of 10 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 08/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Director, MDS Coordinator, HR, BOM) will meet with residents daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any paraphernalia was obtained. The findings will be immediately brought up to Administrator for further action, if necessary. Grievances will be reviewed during morning meeting with Administrator and IDT team members for any follow up needed. All grievances will be entered into Grievance log by Administrator and investigation form will be filled out accordingly. Residents Affected - Few 8/17/2024 Activities director called RP's of smoking residents to inquire if they had any questions The DON/designee will monitor compliance by completing audit of ten (5) residents per week for four (4) weeks. This was initiated on 8/17/2024. 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. The Administrator will be responsible to ensure this plan is completed on 8/18/2024. The RDO will provide oversight of DON and Administrators to ensure that the items on the plan of removal are reviewed and completed. Verification Process of the POR was initiated on 8/18/24 and completed on 8/19/24: Observation on 8/18/24 at 3 PM in smoking area revealed about 8 residents smoking. The SW was supervising the residents under the eve and the AIT was supervising the 2 residents under the covered patio. There was one metal ash tray at each station including a cigarette butt metal trash can. 1. Interview with the ADON on 8/16/24 at 10:20 AM revealed she in-serviced staff on the smoking policy and reporting a fire. 2. Review of staff sign in, dated 8/16/24, revealed in-service on the smoking policy and reporting a fire was provided on 8/18/24. There were 50 of 50 full time employees and 5 agency staff signatures. 3. Review of 143 resident safe surveys dated from 8/14/24 to 8/17/24 revealed staff conducted resident safe surveys every day. 4. Review of intake worksheet and interview with the ADM on 8/16/24 at 10 AM revealed the ADM reported the incident on 8/14/24. 5. Review of the POR revealed the AD was responsible re-educating residents on the smoking policy. Further review revealed the AD sent a letter with a copy of the smoking policy. She included documentation for each family member she did not reach and left a VM. Documentation also reflected the AD sent out a text message to family members as an additional attempt to make contact. Interviewed AD on 8/18/24 at 4:03 PM. She stated she called family members, left messages and or sent a text to ensure they understood the smoking policy and the amendments they made on the sign in and out document. The AD stated she would follow up and call the family members that she left a voicemail. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 7 of 10 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 08/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 6. Review of smoking assessments revealed 12 Residents were assessed on 8/14/24 and the assessments reflected they were all safe smokers. 7. Review of sign in sheet for Ad-Hoc QAPI meeting held on 8/17/2024 at 5:30 PM revealed the NHA (Nursing Home Administrator), RDO (Regional Director of Operations) and DON signed attesting they reviewed the alleged incident, policy and procedure, and the plan for removal of immediacy. Further review revealed the Medical Director attended via telephone. 8. Review of sign in sheet for in-service, dated 8/17/24, on smoking policy and procedure, admission checklist for paraphernalia checks, and questions staff should ask when residents return from being out on pass. revealed 50 of 50 full time employees and 5 agency staff signatures. Review of signed quizzes by staff and review of text messages staff sent to the ADON revealed all staff completed a quiz with satisfactory results. 9. Review of 143 resident safe surveys from 8/14/24 to 8/17/24 revealed resident safe surveys were conducted every day. Further review revealed any issues would be brought up to the QAPI. 10. Review of in-service, dated 8/17/24, revealed the AD signed attesting she received training on ensuring Residents signed back in to the facility after being out on an activity and she would ask Resident about smoking paraphernalia. 11. Review of a sign in sheet, dated 8/17/24, for a resident in-service revealed instructions for the residents on signing out and answering all questions on the sign out sheet revealed 18 resident signatures who would go out on pass. 12. Interview on 8/18/24 at 3:51 PM with the ADM, DON and Regional Consultant revealed they and the Medical Director reviewed the Smoking and Smoking Assessment policies on 8/17/2024. 13. Interview on 8/18/24 at 3:51 PM with the ADM revealed starting on 8/13/2024, IDT (Interdisciplinary team), including Administrator, DON, ADON, Activity Director, MDS Coordinator, HR, BOM) would meet with residents daily, Monday to Friday, and the Manager on Duty on Saturday and Sunday would meet with residents to determine if any paraphernalia was obtained. The findings would be immediately brought up to him for further action, if necessary. Grievances would be reviewed during morning meetings with himself and the IDT team members for any follow up as needed. He would enter all grievances into the Grievance log and investigation form would be filled out accordingly. The ADM stated these daily checks would continue until staff felt comfortable residents were following the policy by not having paraphernalia on them. Review of a daily checks log revealed from 8/13/24 to 8/15/24 12 smoking residents were asked about smoking paraphernalia. 14. Interview on 8/18/24 at 3:51 PM with the ADM, DON, ADON and Regional Consultant revealed the DON/designee would monitor compliance of the smoking policy by completing an audit of (5) residents per week for four (4) weeks. They stated this was initiated on 8/17/2024. In addition, any identified concerns would be addressed immediately and if trends and patterns were identified, the facility would conduct an Ad-Hoc QAPI meeting to discuss if additional interventions were needed to ensure compliance. 15. Interview at 3:51 PM with ADM, DON, ADON and Consultant revealed nursing staff would continue (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 8 of 10 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 08/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few asking residents daily about paraphernalia. The DON would interview 5 residents a week about any issues and paraphernalia. The ADON stated all staff was quizzed via text sent out; she sent a screen shot of the quiz and staff responded with their answers. Staff would conduct daily checks with residents on C and D halls. Residents on the A and B halls consisted of residents in the memory care units. The ADM and ADON stated none of the residents smoked until most recently Resident #3, in the men's unit decided he wanted to smoke. The ADM stated Resident #3 would join the rest of the residents at regularly scheduled smoking breaks every odd hour beginning at 7 AM with the last smoke break scheduled at 9 PM. Staff would escort him to the courtyard on the days he chose to smoke. The ADM stated he sent out an email, letter re-iterating the smoking P&P with edits including staff asking for paraphernalia after outings with the Residents. Staff followed up with a call to RPs for all smokers. He stated family/residents would have to sign out and back in before residents were allowed back into their room. Nursing staff would complete the admission checklist: nursing staff would ensure they asked the question about smoking and if the resident had smoking materials. Nursing staff would also ask residents if they had smoking materials upon readmissions. The ADM stated 100% of staff was in-serviced on the smoking and fire policies and quizzed including dietary and housekeeping. 16. Interview at 4:03 PM with the AD revealed she and her assistant would ensure residents signed out and back in after taking residents on outings. She stated they would ask Residents what they were taking with them and would ask about smoking paraphernalia upon their return. She stated she and her assistant would also be responsible for ensuring the residents/families signed the resident back in upon their return. She stated they would be quizzing everyone who left the facility about smoking paraphernalia and about the smoking policy. They would let the ADM know right away if residents noted with paraphernalia. The AD stated she called families and made sure they received a letter/email about the smoking policy and edits. She stated she would follow up with families who she left a VM. The AD stated she would also ask resident/families about smoking paraphernalia after returning from smoking breaks during visits. 17. Interview at 4:17 PM with the SW revealed she would be make sure cigarette butts were destroyed (completely put out) and dumped in the metal trash cans after smoke breaks. She would also ensure ash trays were emptied. The SW stated, in addition, she would, be asking relatives/families about paraphernalia. 18. Interview at 4:20 PM with the AIT revealed there was a new sign/in out sheet; staff was to ask residents upon return for paraphernalia. Staff was to continue supervision during smoke breaks. Nurses would inquire about smoking paraphernalia upon readmission. Weekend supervisor would make rounds, in-servicing staff, talking to residents making sure everyone was compliant with the smoking policy. 19. Interview at 4:24 PM with the DM revealed she was in-serviced about staff asking residents for smoking materials upon return from being out on pass. They also reviewed the fire policy. 20. Interview at 4:26 PM with the MS revealed he was in-serviced on checking resident rooms every day and would ask about smoking materials upon return from residents being out on pass. He stated residents who chose not to comply with the smoking policy would get a 30-day notice for discharge. He stated all staff was in-serviced about following the smoking rules during breaks: being more vigilant about ensuring residents did not obtain paraphernalia. The MS stated they would be ordering more ash trays. They would keep the courtyard cleaner by making sure there were not cigarette butts on the ground, emptied ash trays and trash cans daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 9 of 10 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 08/19/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 21. Interview at 4:34 PM with RN B revealed nursing staff would be asking residents for smoking materials anytime they left the facility or upon their return. 22. Interview at 4:37 PM with MA E revealed nursing staff would be asking residents for smoking materials anytime they left the facility and/or upon their return. 23. Interview at 4:41 PM with RN D revealed staff was to ensure residents signed/out and back into the facility; nursing staff was to ensure they asked the questions about smoking materials upon admission. Staff was to reinforce the smoking rules ensuring residents adhered to it to ensure their safety. 24. Interview at 4:47 PM with CNA F revealed she understood the smoking policy and amendments made. She stated nursing staff would be asking residents about smoking materials anytime they left and returned to the facility. 25. Interview at 4:48 PM with CNA G revealed staff was in-serviced about the fire and smoking P&P including changes related to asking residents about smoking materials including new admissions; making sure residents signed out when going out on pass; the sign in and out sheet was updated, and they reviewed resident supervision while smoking in the courtyard. 26. Interview at 4:52 PM with CNA H revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 27. Interview at 5:03 PM with CNA I revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 28. Interview at 5:10 PM [NAME] J revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 29. Interview at 5:14 PM with Dishwasher K revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 30. Interview at 5:25 PM with LVN L revealed she they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 31. Interview at 5:30 PM with RA M revealed they reviewed the smoking and fire P&P and the changes made including asking residents about smoking materials anytime they left and returned to the facility. 32. Interview at 5[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 10 of 10