Health inspection·October 18, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 10/16/2024 at 9:14 a.m. Resident #51 was observed sleeping on the bed in his room, and the call light was on the floor, and it was approximately two feet away from the resident's bed. Interview on 10/15/2024 at 10:29 a.m. with CNA-B acknowledged he found Resident #51's call light behind a drawer chest located at the bed side, and Resident #51 was not able to reach the call light. CNA-B said Resident #51 generally did not use the call light, but it should have been within reach for Resident #51 all the time. Interview on 10/16/2024 at 9:14 a.m. with MA-C acknowledged she saw Resident #51's call light was on the floor, and it was approximately two feet away from the resident's bed, so the resident was unable to touch the call light. Further interview with the MA-C said Resident #51 sometimes used the call light for help. Interview on 10/18/2024 at 12:19 p.m. with LVN-D stated CNAs frequently checked Resident #51 because the resident generally did not use the call light, but the call light should have been within reach all the time because Resident #51 could use it for help. Interview on 10/18/2024 at 2:30 p.m. with DON stated Resident #51's call light should have been within reach all the time because some CNAs said Resident #51 could use it for help, DON was responsible for overseeing this, and the potential harm was that Resident #51 might not have assists when the resident needed. Record review of the facility policy, titled Answering the call light, revised 10/2010, revealed . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reached of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 2 of 13 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 10/18/2024 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and safe environment to prevent accidents for 1 of 12 residents (Residents #39) reviewed for environment. There was one used disposable razor found on the sink faucet of Resident # 39's bathroom. This deficient practice cause infection or other physical injuries to residents and even staff. Findings included: Record review of Resident #39's face sheet, dated 10/18/2024, revealed the resident was [AGE] years old male and admitted to the facility 10/08/2021 and re-admitted to the facility on [DATE] with diagnoses of intracranial injury (brain damage), hemiplegia (paralysis to only one side), anxiety disorder (uncontrolled feeling of fear), dementia (gradual decline in cognitive abilities), and muscle wasting and atrophy (loss of muscle tissue and strength). Record review of Resident #39's quarterly MDS, dated [DATE], revealed his BIMS score was 15 of 15 reflecting he had cognitively intact. Further record review of Resident #39's quarterly MDS, dated [DATE], indicated the resident required supervision or touching assistance (helper provides verbal clues or touching assistant) to toilet hygiene, shower, dressing, and partial/moderate assistance (helper does less than half the effort) to personal hygiene. Record review of Resident #39's care plan, edited 10/05/2024, revealed [Resident #39] has limited mobility and activities of daily living function related to hemiplegia, to maintain highest level of mobility thru review date, assist activities of daily livings. Observation on 10/15/2024 at 10:02 a.m. revealed one old disposable razor was on the sink faucets in Resident #39's bathroom. Interview on 10/15/2024 at 10:03 a.m. with Resident #39 refused interviewing with the surveyor by said No. Interview on 10/15/2024 at 10:08 a.m. with LVN-E acknowledged she saw one old disposable razor was on the sink faucet in Resident #39's bathroom. Further interview with the LVN-E stated Resident #39 could not use the razor by himself. Staff might shave Resident #39's beard. Staff had responsibility to discard any used disposable razor to a sharp container after using it to prevent infection and for safety. The potential harm was other confused residents might use it and could cause physical injury or infection. Interview on 10/18/2024 at 2:30 p.m. with the DON stated staff should have discarded the old disposable razor to a sharp container after every use to prevent infection and physical injury. Record review of the facility policy, titled Safety and Supervision of Residents, revised 12/2007, revealed Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 3 of 13 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 10/18/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 residents (Residents #23) of 16 residents reviewed for incontinent care, in that: When CNA-B and CNA-F was providing incontinent care to Resident 23 on 10/17/2024, CNA-F cleaned the resident's genital area with multiple pass of a wipe. These failures could place residents who require incontinent care at risk for cross contamination and infections. The findings included: Record review of Resident #23's face sheet, dated 10/18/2024, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnosis of cellulitis (bacteria infection to the skin), cerebral infarction (blood flow to the brain is blocked), dysphagia (difficulty finding words and speaking slowly), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), muscle wasting and atrophy (loss of muscle tissue and strength), and hyperlipidemia (high levels of lipids or fats in the blood). Record review of Resident #23's quarterly MDS, dated [DATE], reflected his BIMS score was 0 of 15 reflecting he had severe cognitive impairment. Further record review of Resident #23's quarterly MDS, dated [DATE], indicated the resident required substantial/maximal assistance (helper does more than half the effort) to toilet hygiene and dependent (helper does all of the effort) to chair/bed-to-chair transfer, and frequently incontinent to bowel and bladder. Record review of Resident #23's care plan, edited 10/02/2024, revealed The resident had urinary and bowel incontinence; to prevent urinary tract infection or skin breakdown, check at least every 2 to 3 hours for incontinence. Wash, rinse, and dry soiled areas. Change clothing as needed after incontinence episodes. Observation on 10/17/2024 at 11:43 a.m. revealed CNA-B and CNA-F was providing urinary incontinence care to Residencan3, CNA-F grabbed Resident #23's penis and cleaned it with circular motion. Further observation revealed CNA-F cleaned the resident's penis area by multiple passes with one wipe, turned the resident to side and cleaned the buttock area, then put a new brief under the resident's buttock area and closed it. Interview on 10/17/2024 at 12:00 a.m. with CNA-F acknowledged she cleaned Resident #23's penis area by multiple passes with one wipe. Further interview with the CNA-F said she should have cleaned the resident's genital by one time pass with one wipe to prevent possible urinary tract infection. Interview on 10/18/2024 at 2:30 p.m. with the DON said CNA-F should have cleaned Resident #23's genital by one time pass with one wipe to prevent possible urinary tract infection, DON was responsible for overseeing it, and the potential harm was the resident might have infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 4 of 13 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 10/18/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy, titled Perineal care, dated 2001, revealed . Use new wipe with each stroke. Cleanse the penis shaft with wipe from the top of the shaft toward the rectum, including the scrotum and using a new wipe with each stroke clean from the upper part if the elf to the hip. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 5 of 13 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 10/18/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 3 (Resident #7) reviewed for respiratory care. Residents Affected - Few Resident #7's oxygen tubing and nasal cannular connected to the oxygen concentrator was not covered in a plastic bag on 10/15/2024 when it was not used. This failure could affect residents administered oxygen and could lead to infections if the tubing and humidifier bottle are not cleaned/ or replaced as ordered by the physician. The findings included: Record review of Resident #7's face sheet, dated 10/18/2024, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] with the diagnosis of cerebral infarction (blood flow to the brain is blocked), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), muscle wasting and atrophy (loss of muscle tissue and strength), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hypertension (high blood pressure), and urinary tract infection (bacteria infection to bladder, urethra, and kidney). Record review of Resident #7's admission MDS, dated [DATE], reflected her BIMS score was 14 of 15 reflecting she had cognitively intact. Further record review of Resident #7's admission MDS, dated [DATE], indicated the resident required dependent (helper does all of the effort) to shower, dressing, and toilet hygiene. Record review of Resident #7's care plan, start dated 08/24/2024, revealed the resident hospice care due to terminal condition related to cerebral infarction, to maintain optimal quality of lift, administer medications and treatment as ordered. Monitor side effects, effectiveness. Administer oxygen therapy as ordered observing oxygen precautions. Record review of Resident #7's hospice physician order, dated 07/26/2024, revealed the resident had the order of medical oxygen 2 to 5 liter as needed for dyspnea (difficulty breathing) via nasal cannula. Observation on 10/15/2024 at 10:59 a.m. revealed Resident #7 was observed sleeping on the bed, and the oxygen tubing and nasal cannula connected an oxygen concentrator was hung over the side rail of Resident#7's bed, and it was not covered in a plastic bag. Resident #7 did not use it. Interview on 10/15/2024 at 11:08 a.m. with LVN-D acknowledged Resident #7 did not use oxygen, and the tubing and nasal cannula connected an oxygen concentrator was hung over the side rail of the resident's bed, and it was not covered in a plastic bag. Further interview with the LVN-D said it should have been covered with a plastic bag when it was not used. The potential harm was the resident might have infection. Interview on 10/18/2024 at 2:30 p.m. with DON said Resident #7's oxygen tubing and nasal cannula should have been covered with a plastic bag when it was not used to prevent possible respiratory infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 6 of 13 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 10/18/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy, titled Oxygen Administration, revised 10/2010, revealed The purpose of this procedure is to provide guidelines for safe oxygen administration. 15. Discard used supplies into designated containers. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 7 of 13 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 10/18/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 7 residents (Resident #4, #42, and #38) and 1 of 1 medication room reviewed for pharmacy services. 1. Resident #4 received milk of magnesia for gastro-esophageal reflux disease (stomach contents leak back into the esophagus) on 10/17/2024 at 8:14 a.m., but the resident's physician order said Geri-Lanta (alum-mag hydroxide-simeth) for gastro-esophageal reflux disease. 2. There was Resident #42's insulin flex pen (Aspart) for diabetes with open dated 09/17/2024 found inside the A and B hall nursing cart on 10/16/2024. It should have been discarded 28 days (10/15/2024) after opening. 3. There was Resident #38's insulin flex pen (Lantus) for diabetes with open dated 09/08/2024 found inside the A and B hall nursing cart on 10/16/2024. It should have been discarded 28 days (10/06/2024) after opening. 4. There was one medication (Cherry Flavor Sore Throat Spray for sore throat) expired on 07/2024 found inside the medication room on 10/16/2024. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: 1. Record review of Resident #4's face sheet, dated 10/18/2024, revealed Resident #4 was [AGE] years old male and admitted to the facility 11/24/2003 and re-admitted to the facility 04/25/2017 with diagnoses of cerebral infarction (blood flow to the brain is blocked), gastro-esophageal reflux disease (stomach contents leak back into the esophagus), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), muscle wasting and atrophy (loss of muscle tissue and strength), constipation (infrequent bowel movement), and ataxia (lack of coordination in muscle movement). Record review of Resident #4's Quarterly MDS assessment, dated 09/17/2024, revealed the resident's BIMS score was 12, which indicated moderately cognitive impairment. The Quarterly MDS assessment further revealed Resident #4 required setup or clean-up assistance (helper sets up or cleans up) to eating, chair/bed-to-chair transfer, and toilet transfer, and partial/moderate assistance (helper does less than half the efforts) to shower and personal hygiene. Record review of Resident #4's physician order, dated 06/10/2024, revealed the resident had the order of Geri-Lanta (alum-mag hydroxide-simeth) over the counter suspension 200-200-20 mg per 5 ml give 300 ml by mouth once a day at 8:00 AM for gastro-esophageal reflux disease (stomach contents leak back into the esophagus). Observation on 10/17/2024 at 8:14 a.m. revealed MA-C administered 30 ml of milk of magnesia to Resident #4, and the resident took it by mouth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 8 of 13 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 10/18/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 10/17/2024 at 1:10 p.m. with MA-C acknowledged she administered 30 ml of milk of magnesia to Resident #4, but the resident's physician order said, Geri-Lanta (alum-mag hydroxide-simeth) over the counter suspension 200-200-20 mg per 5 ml give 300 ml by mouth once a day at 8:00 AM for gastro-esophageal reflux disease (stomach contents leak back into the esophagus). Further interview with the MA-C stated she thought milk of magnesia and Geri-Lanta (alum-mag hydroxide-simeth) was the same medication for gastro-esophageal reflux disease (stomach contents leak back into the esophagus). That was why MA-C administered milk of magnesia to Resident #4, instead of Geri-Lanta (alum-mag hydroxide-simeth). Interview on 10/17/2024 at 1:07 p.m. with the DON said milk of magnesia and Geri-Lanta (alum-mag hydroxide-simeth) was not the same medication. A milk of magnesia was used for constipation, and it was laxative. However, Geri-Lanta was used for gastro-esophageal reflux disease or heartburn, and it was acid reducer. If MA-C was confused if the two medications were the same or not, MA-C should have asked the charge nurse before giving the medication to Resident #4. DON was responsible for overseeing for medication administrations. The potential harm was the resident might have allergy to milk of magnesia and not have therapeutic effect. Record review of the facility policy, titled Administering Medications, revised 12/2012, revealed . 3. Medications must be administered in accordance with the orders, including any required time frame. 5. If a dosage is believed to be inappropriate or excessive for a resident or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's attending physician or the facility's medical director to discuss the concerns. 2. Record review of Resident #42's face sheet, dated 10/18/2024, reflected the resident was [AGE] years old male and initially admitted to the facility on [DATE] with diagnoses included: cerebral infarction (blood flow to the brain is blocked), dysphagia (difficulty finding words and speaking slowly), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), heart failure (heart cannot pump enough blood and oxygen), dementia (decline in cognitive abilities), and hypertension (high blood pressure). Record review of Resident #42's admission MDS, dated [DATE], reflected his BIMS score was 7 of 15 reflecting he had severe cognitive impairment. Further record review of Resident #42's admission MDS, dated [DATE], indicated the resident required set up or clean-up assistance (helper sets up or cleans up) to eating, chair/bed-to-chair transfer, and toilet transfer. Record review of Resident #42's physician order, dated 07/03/2024, revealed the resident had the order of Insulin aspart pen 100 unit/ml per sliding scale; if blood sugar is less than 70 call medical doctor; if blood sugar is 150 to 200 give 3 units; if blood sugar is 201 to 250 give 6 units; if blood sugar is 251 to 300 give 9 units; if blood sugar is 301 to 350 give 12 units; if blood sugar is 351 to 400 give 15 units; if blood sugar is 401 to 800 give 18 units; if blood sugar is greater than 800 give 18 units and call medical doctor. Observation on 10/16/2024 at 3:37 p.m. revealed inside the A and B hall nursing cart, there was Resident #42's insulin flex pen (Aspart) for diabetes with open dated 09/17/2024. Interview on 10/16/2024 at 3:44 p.m. with ADON stated the ADON saw there was Resident #42's insulin flex pen (Aspart) for diabetes with open dated 09/17/2024 inside the A and B hall nursing cart. The ADON said nurses should have discarded Resident #42's insulin flex pen (Aspart) on 10/15/2024, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 9 of 13 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 10/18/2024 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 0755 which was 28 day because nurses opened it on 09/17/2024. Level of Harm - Minimal harm or potential for actual harm Record review of Medline Plus for National Library for Medicine (https://medlineplus.gov/druginfo/meds/a605013.html#:~:text=Unrefrigerated%20unopened%20vials%20of%20insulin,time dated 10/16/2024, revealed Insulin aspart can be used within 28 days once it was opened; after that time it must be discarded. Residents Affected - Some 3. Record review of Resident #38's face sheet, dated 10/18/2024, reflected the resident was [AGE] years old female and initially admitted to the facility on [DATE] with diagnoses included: lack of coordination (difficulty walking and maintain balance), type 2 diabetes mellitus (body does not insulin properly, resulting in high blood sugar levels), hyperglycemia (too much glucose in the blood), muscle wasting and atrophy (loss of muscle tissue and strength), and schizophrenia (mental condition affects how to think, feel and behave). Record review of Resident #38's annual MDS, dated [DATE], reflected her BIMS score was 12 of 15 reflecting she had moderate cognitive impairment. Further record review of Resident #38's annual MDS, dated [DATE], indicated the resident required set up or clean-up assistance (helper sets up or cleans up) to eating, chair/bed-to-chair transfer, and toilet transfer. Record review of Resident #38's physician order, dated 06/03/2024, revealed the resident had the order of Lantus Solostar insulin pen; 100 unit/ml give 5 units subcutaneous for diabetes. Observation on 10/16/2024 at 3:37 p.m. revealed inside the A and B hall nursing cart, there was Resident #38's insulin flex pen (Lantus) for diabetes with open dated 09/08/2024. Interview on 10/16/2024 at 3:44 p.m. with ADON stated the ADON saw there was Resident #38's insulin flex pen (Lantus) for diabetes with open dated 09/08/2024 inside the A and B hall nursing cart. The ADON said nurses should have discarded Resident #38's insulin flex pen (Lantus) on 10/06/2024, which was 28 day because nurses opened it on 09/08/2024. Interview on 10/16/2024 at 3:56 p.m. with DON said that nurses should have discarded Resident #42's insulin flex pen (Aspart) on 10/15/2024, which was 28 day because nurses opened it on 09/17/2024 and Resident #38's insulin flex pen (Lantus) on 10/06/2024, which was 28 day because nurses opened it on 09/08/2024. The facility did not have specific policy for that but following the standard of care. DON was responsible to oversee. The potential harm was the residents might not have therapeutic effects. Record review of Cleveland Clinic (https://my.clevelandclinic.org/health/drugs/19802-insulin-glargine-injection), dated 10/16/2024, revealed if stored at room temperature, the pen must be discarded after 28 days. 4. Observation on 10/16/2024 at 3:00 p.m. revealed one of Cherry Flavor Sore Throat Spray for sore throat was found inside the medication room, and it was expired 07/2024. Interview on 10/16/2024 at 3:13 p.m. with LVN-E acknowledged one of Cherry Flavor Sore Throat Spray for sore throat was found inside the medication room, and it was expired 07/2024. Further interview with the LVN-E said she did not know why the medication was in the medication room because nurses usually checked the medication room and should discard all expired medications from the medication room as the facility policy. Potential harm was nurses might use the expired medication, and the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 10 of 13 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 10/18/2024 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 0755 expired medication might not have therapeutic effects. Level of Harm - Minimal harm or potential for actual harm Record review of the facility policy, titled Medication Labeling and Storage, revised 02/2023, reflected 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 11 of 13 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 10/18/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. Residents Affected - Some There was an expired and open container of salsa in srored in the dry storage pantry. This failure could place residents at risk of food borne illnesses. Finding include: Observation of the Kitchen dry goods pantry on 10/15/24 at 08:10 AM revealed an open container of salsa bottle 1/3 full opened 7/2/24. Further observation revealed container labeled Refrigerate after opening. Container was room temperature. Interview and observation with the Dietary Manager on 10/15/24 at 08:10 AM revealed the Dietary manager threw away salsa bottle and stated, salsa should have been refrigerated. Record review of the facility policy named B Food receiving and Storage, Revised July 2014, revealed 8. Refrigerated foods must be stored below 41 degrees Fahrenheit unless otherwise specified by law. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 12 of 13 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 10/18/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 1 of 4 halls (A hall) reviewed, in that: Residents Affected - Some Facility observation of A Hall (male secured wing) on 10/15/24 at 9:30 AM revealed a strong/high urine odor on hallway. These failures could diminish the quality of life due to exposure to an environment that is unpleasant and unsanitary and cause infection. Findings included: A Hall observation 10/17/24 at 9:00 AM and various checks throughout the day revealed pervasive strong urine odor; A Hall observation on 10/18/24 at 9:00 AM and throughout the day continued to reveal a pervasive strong urine odor. Interview with the Administrator on 10/15/24 at 10:00 AM revealed he was aware of strong urine odor and stated, deep clean will be done today. Observation on 10/16/24 at 8:15 AM revealed improvement in urine odor however continued pungent smell in hallway. Observation of 13 male residents on Hall A revealed that the men did not present with a urine odor. Interview with Housekeeper-A on 10/17/24 at 1:46 PM revealed she cleans the shower room and rooms everyday and whenever asked. Record review of facility policy named Homelike Environment, Revised February 2021, revealed 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary, and orderly environment; and 3. The facility staff and management minimize, to the extent possible, the characteristics of the facility that reflect a depersonalized, institutional setting. These characteristics include b. institutional odors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675371 If continuation sheet Page 13 of 13