Inspection·September 15, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of the care plan for Resident #12 revealed that she has a DX of osteoarthritis and should be assessed for pain every shift. Record review of the care plan for Resident #12 revealed that she is at risk for pain indicators D/T DX pain in right shoulder, neuropathy, rheumatoid arithritis and spondylosis. Resident #12 stated that she had not fallen due to not reaching the call light. Record review of the care plan for Resident #12 revealed that she is at high risk for falls D/T gait/balance problems and dizzy spells with an intervention to assure call light is within reach and encourage resident to call for assistance as needed. Record review of Resident #12's Medication Administration Record revealed that she received pain medication around 3 p.m. Observation on 9/13/23 at 3:25 p.m., Resident #12's call light was at the end of the bed, close to resident's feet, under the blankets. Record review of the care plan for Resident #12 revealed that she should be monitored for signs and symptoms of drug-related cognitive impairment. Record review of the facility's policy, titled Call Lights: Accessibility and Timely Response, undated, revealed The purpose of this policy is to assure the facility adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to call light. 5. Staff will ensure the call light is within reach of resident and secured, as needed. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the residents' room. During an interview and observation on 9/13/2023 at 3:25 p.m., Resident #12 stated she was not able to reach her call light and didn't know where her call light was. Resident #12 was observed to be moving her blankets around and couldn't see the call light. Resident #12 stated that this happened at least twice a week. Resident #12 stated that she was in pain at this time and needed to use the call light to call the nurse. During an observation and Interview on 9/13/23 at 4 p.m., RN D was observed picking up the blanket and looking for the call light to find that it was underneath the blanket. RN D grabbed the call light and gave it to the resident. RN D revealed the call light got lost and hidden under the blankets sometimes and resident #12 was confused and did not know where the call light was. During an interview on 9/14/23 at 9:30 a.m. with Occupational Therapist F, The Occupational Therapist revealed Resident #12 should have the call light within reach, on her chest. Observation on 9/14/23 at 10:34 a.m. in Resident #12's room revealed the call light was on the floor at the end of bed where the call lights are connected into the wall. Resident #12 was asleep and fully covered with blanket. Observation on 9/14/23 at 10:38 a.m. revealed Nurse E came to Resident #12's room to see the call light on the floor. Nurse E reported that both call lights were on the floor. One call light is to be used by resident. Nurse E picked up the call light and handed it to Resident #12 and confirmed with Resident #12 that she could reach the call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 2 of 4 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 675678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Choice of Boerne 200 E Ryan St 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 9/14/23 at 10:38 a.m. with Nurse E, she stated that call light should be care planned and the staff should know what Resident #12 needed the call light within reach. Interview on 9/15/23 at 9:58 a.m. with The DON revealed that all residents should have call lights within reach but especially Resident #12 because she was fragile. The DON stated that when she came into work she made it a priority to check in on Resident #12 but had not done so today. Interview on 9/15/23 at 1140 a.m. with Housekeeping and Laundry Supervisor revealed that housekeeping was in charge of sanitizing various places, including call lights. They placed the call lights on the table, clip to the curtain, or placed on the bed. If resident was in the room, call light were given to the residents. Housekeeping and Laundry Supervisor revealed that the call light had been on the floor at times, but they tried to keep the call light within reach Observation on 9/15/23 at 10:11 a.m. The DON picked up resident #12's blanket and showed that call light should be clipped to Resident #12 because she would move the blankets and the call light could fall on the floor. DON confirmed that Resident #12 doesn't kick blankets as much anymore and that she stayed covered with her blankets. The DON revealed that nurses were re- trained about the call lights being within reach after any incident that involved a fall. The DON stated that nurses were aware of the care plan for each resident. DON made notes for the nurses to make sure what things to specifically look out for, for each resident. Further interview revealed the DON stated that she made sure that nurses were aware that the call lights should be within reach of residents. When asked what the housekeepers did with the call lights, The DON reported that she did not ensure that housekeepers were continually educated on keeping call lights within reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 3 of 4 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 675678 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Care Choice of Boerne 200 E Ryan St 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 food service safety for 1 of 1 kitchen, in that: Residents Affected - Some Dishwasher A was observed in the dish room with no hairnet. Dishwasher B observed to not have a hairnet while preparing lunch. This could place residents at risk for food contamination. The Findings included: Observation on 9/13/23 at 12:24 p.m. revealed Dishwasher B had no hairnet while preparing lunch and his hair appeared to have gel in it. Dishwasher B was in the alley between the oven and preparation table. Observation on 9/13/23 at 2:28 p.m. Dishwasher A was not wearing a hairnet while in the dish room. During an interview on 9/13/23 at 2:35 p.m. The Dietary manager, while looking at Dishwasher A, stated that dishwasher A should be wearing a hairnet. Dietary manager then proceeded to give a hairnet to dishwasher A to wear. During an interview on 9/14/23 at 10:42 a.m. The Dietary manager stated that dishwasher A was taught to put ahair net on and wash hands as soon as they came into the kitchen. The DM would typically catch people with no hairnet and let the staff know if they needed to handwash and wear a hairnet. Hair nets were located by one of two doors that had access to the kitchen. The hairnets were located by the door where carts left to have food trays passed to resident. This door was where facility staff had been observed to interact with kitchen staff. DM reported that she kept hairnets only at this door and kitchen staff walked through this door when they started their shift. During an interview on 9/15/23 at 12:48 p.m., Dishwasher A revealed she was trained and aware that she needed to put a hairnet on and wash hands as soon as she came into the kitchen. When she wasn't wearing a hairnet, she had been in the kitchen for 5 minutes and forgot to put her hairnet on. Record review of Facility's policy, dated October 2017, titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices revealed Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils , and linens. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675678 If continuation sheet Page 4 of 4