Inspection·February 4, 2026

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete For the safety of staff and other patients I ordered him to be sent to the ER. He was reportedly fine with no behaviors at the ER and was sent back. No interventions or medications were required. Upon return I spoke with nursing to monitor carefully. I received a call thathe was continued to be agitated [sic] but was a bit more directable. He was given dose of clonazepam and depakote. I called the ER to let them know that we might need to send him back if he continued to be a danger to our staff and other patients. Early this morning I received a call from nursing that he had attempted to smother his roommate with a pillow. I then ordered that he be sent back to the hospital. We are unable to accept him back until he has undergone thorough psychiatric evaluation and has been stable for a couple of days. He has represented aclear risk to the safety of our staff and other residents. In an interview on 2/04/2026 at 3:30 PM, the DON stated Resident #1's behavior was a significant safety risk to himself, other residents, and the facility staff. She said Resident #1 required a level of care that could not be provided by the facility, and the status of his cognition and behaviors was not accurately conveyed to the facility prior to admission. She said the facility was attempting to find alternative placement for Resident #1, and his family member was aware, but he had not yet been accepted for transfer. Due to the nature of the behaviors of 1/10/2026, she said she instructed facility staff to transfer Resident #1 to the local emergency department and to provide the explicit information to the receiving hospital that Resident #1 could not return to the facility for safety reasons. She said Resident #1 had likely not been given a written notice of discharge after the unplanned discharge as the LSW was out of town and it was an unusual circumstance. She said the failure to provide this written notice could a violation of a resident's rights. In an interview with the LSW on 2/04/2026 at 3:38 PM, she said Resident #1 had not been given a written notice of discharge after the unplanned discharge on [DATE] as she was out of town during Resident #1's entire admission. She said all residents receive written notice of discharge and room changes as required by law, but she was unaware Resident #1 had been admitted and discharged in her absence. Record review of the facility policy titled Transfer and Discharge (Involuntary; initiated by the facility, not the resident) undated, received 2/04/2026; reflected the following:The notice must be provided at least 30 days prior to the transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because:Health and/or safety of individuals would be endangered due to the clinical or behavioral status of the resident .In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate and the LTC Ombudsman as soon as practicable before the transfer or discharge. Event ID: Facility ID: 676114 If continuation sheet Page 2 of 5 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 676114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Hills Health and Rehabilitation Center 2091 Bandera Hwy Kerrville, TX 78028 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #1) reviewed for resident assessments. The facility failed to ensure Resident #1's discharge MDS accurately reflected the frequency of the resident's physically aggressive and wandering behaviors at the time of discharge. This failure could lead to improper oversight and care of residents. Findings included: Record review of Resident #1's admission Record dated 2/04/2026 reflected an [AGE] year-old male admitted to the facility on [DATE] and discharged on 1/10/2026 to an acute care hospital. Relevant diagnoses included unspecified dementia (a cognitive disorder that impacts memory) and anxiety (a mental health disorder characterized by excessive worrying). Record review of Resident #1's Discharge- Return Not Anticipated MDS submitted 1/10/2026 reflected a BIMS score was not assessed. Section E of the MDS reflected the following:E0200 Behavioral Symptom- Presence and FrequencyA. Physical behavioral symptoms directed toward others (1) Behavior of this type occurred 1 to 3 daysB. Verbal behavioral symptoms directed toward others (0) Behavior not exhibitedE0600 not included in assessmentE0800 Rejection of care- Presence and FrequencyDid the resident reject evaluation or care that is necessary to achieve the resident's goals for health and well-being? (1) Behavior of this type occurred 1 to 3 daysE0900 Wandering Presence and FrequencyHas the resident wandered? (2) Behavior of this type occurred 4 to 6 days, but less than daily Record review of Resident #1's Progress Notes dated 2/04/2026 reflected the following entries:Effective date 1/10/2026 7:01 PM: Verbal aggression Initiated, Resident's room, Nursing Description: 100 Hall Nurse witnessed: @1:47 RESIDENT BECAME AGITATED STAFF ATTEMPTING TO REDIRECT AND REASSURE WIFE WOULD BE COMING TO VISITWHEN HE WAKES UP IN THE MORNING TO NO AVAIL. RESIDENT CONTINUES TO BECOME MORE AGITATED PUNCHED CAREGIVER IN FACE. PROVIDER AND DON AWARE AND BOTH RECOMMEND RESIDENT GO BACK TO THE HOSPITAL FOR HIGHERLEVEL OF CARE FOR EVAL FOR GERI PSYCH RELATED TO BEHAVIORS. RESIDENT MEDICATED WITH CLONAZEPAM ANDDEPAKOTE IN ICE CREAM WITH NO AFFECT. RESIDENT FOUND IN BED WITH ROOMMATE WITH PILLLOW AND LYING ON TOPOFROOMMATE. RESIDENT REMOVED FROM HIS ROOM TO COMMON AREA WHERE RESIDENT FLIPPED OVER COFFEE TABLE,ATTEMPTED TO THROW LAMP THROUGH WINDOW AND BEGAN BANGING ON WINDOW AS WELL RESIDENT SENT TO [Local Hospital Emergency Department} VIA AMBULANCE AND POLICE. PROVIDER CALLED REPORT TO THE ER AS WELL AS NURSE.Effective date 1/10/2026 5:26 PM Physician Progress NoteI was called last evening because [sic] [Resident #1} was severely agitated. He was refusing his medications. He was trying to leave facility. He was aggressive with hitting, biting and kicking staff. He tried to head-butt staff as well. He reportedly attempted to throw his wheelchair. For the safety of staff and other patients I ordered him to be sent to the ER. He was reportedly fine with no behaviors at the ER and was sent back. No interventions or medications were required. Upon return I spoke with nursing to monitor carefully. I received a call that he was continued to be agitated [sic] but was a bit more directable. He was given dose of clonazepam and depakote. I called the ER to let them know that we might need to send him back if he continued to be a danger to our staff and other patients. Early this morning I received a call from nursing that he had attempted to smother his roommate with a pillow. I then ordered that he be sent back to the hospital. We are unable to accept him back until he has undergone thorough psychiatric evaluation and has been stable for a couple of days. He has represented a clear risk to the safety of our staff and other residents.Effective date 1/09/2026 7:00 PM Health Status NoteResident continues to attempt to elope facility, staff redirecting resident away from the doors and attempting to engage in alternative activities to distract resident. Wife just left facility as resident had previously been napping when she arrived. @ 1920 [7:20 PM] resident awake and attempting to ambulate without assistance, redirected to his Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676114 If continuation sheet Page 3 of 5 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 676114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Hills Health and Rehabilitation Center 2091 Bandera Hwy Kerrville, TX 78028 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair. Resident is aggressive hitting, kicking, headbutting staff; resident attempting to throw wheelchair at staff. Staff attempted to medicate for anxiety and resident threw medication across the room. At thistime resident also purposefully put himself on the floor by crawling out of his wheelchair on to the floor.Staff attempted to contact wife multiple times with no answer, on call management notified as well as [sic] provider regarding residents' behavior. Provider gave new order to send resident out for further eval and treatment of behaviors. During this time resident being aggressive to other residents grabbing their wheelchair. EMS contacted to transport patient to hospital, police and fire arrived as well. Resident calmed to some degree with presence of uniformed individuals. Resident sent to [Local Hospital Emergency Department] @ 1933 [7:33 PM] report called to ER, wife notified as well as on call management for facility.Effective date 1/09/2026 10:28 AM Behavior NoteResident continues to try and elope out of the door by nurse's station; unable to be redirected without behaviors such as verbal aggression and or trying to get out of wheelchair and crawl on floor. Received in report that resident was physically aggressive towards staff and sitter last evening during shift. Night nurse had to call spouse to come sit with resident throughout the night. Behaviors continued.Effective 1/08/2026 1:51 PM Health Status NoteResident continues with 1:1 oversight related to behaviors and previous elopement concern. Referral sent to Deer Oaks Services for physch [sic] consult. Pending initial visit. No currents signs of distress or wandering noted.Effective date 1/07/2026 8:52 AM Health Status NoteRESIDENT D 2/3 S/P FALL WITHOUT INJURY, REMAINS ON NEURO'S. RESIDENT CONTINUES TO BE CONFUSED, PLACED ON 1:1 DUE TO BEHAVIORS AND ATTEMPTS TO ELOPE FROM FACILITY. RESIDENT PLEASANT AT THIS TIME, IN COMMON AREA WITH SITTER, APPEARS IN NAD, DENIES PAIN AND OR DISCOMFORT, APPETITE REMAINS INADEQUATE AS WELL AS FLUID INTAKE, SPOUSE MADE AWARE OF CHANGES, WILL CONTINUE TO MONITOR.Effective date 1/06/2026 9:31 PM Health Status NotePatient awake alert and oriented to baseline, patient 1:1 with CNA for wandering and behaviors as per ordered. Patient medicated as per orders refusing vitals for neuro checks. Will Continue to assess for neuros as patient tolerates.Effective date 1/06/2026 1:12 PM Health Status NoteResident refusing to take PRN for anxiety, stating I am not taking anything from you all. Resident continues to be agitated, spouse just returning to facility. Will continue to monitor.Effective date 1/06/2026 11:30 AM Health Status Note Resident attempted to elope out of side door at end of 100 hall; set alarm off. Difficulty redirecting resident, verbally and physicallyaggressive while trying to redirect. In an interview on 2/04/2026 at 2:02 PM, the MDSC said she was responsible for the completion of the completion of Resident #1's admission and Discharge MDS assessments. She said she obtains the information for Section E of the MDS from the progress notes and behavioral notes documented by the nursing staff. After reviewing the discharge MDS together, the MDSC stated Section E did not accurately reflect the behaviors exhibited by Resident #1 in the time period assessed for the discharge MDS. She said an inaccurate MDS could affect proper care and provide an inaccurate reflection of the status of residents. In an interview on 2/04/2026 at 2:31 PM, LVN A said Resident #1 exhibited verbally and physically aggressive behaviors multiple times a day while he was a resident. She said he continuously attempted to elope from the facility on a daily basis, except for the few hours every afternoon when Resident #1's family member was visiting. She said Resident #1 was a danger to himself, other residents, and the staff, and his behaviors could not be properly cared for at the facility. In an interview on 2/04/2026 at 3:30 PM, the DON said Resident #1 exhibited daily behaviors that were physically and verbally aggressive. She said Resident #1 required a constant 1:1 observer due to his behaviors and continuous attempts to elope from the facility. She said Resident #1's discharge MDS should accurately reflect the continuous behaviors that required unplanned, emergent discharge of Resident #1, and the MDSC should have reviewed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676114 If continuation sheet Page 4 of 5 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 676114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/04/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Hills Health and Rehabilitation Center 2091 Bandera Hwy Kerrville, TX 78028 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 0641 Level of Harm - Minimal harm or potential for actual harm the progress notes when completing the assessment. Record review of the facility policy titled Comprehensive Assessments (dated 2001, revised March 2022), reflected the following: 8. A significant error is an error in as assessment where:a. the resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an appropriate plan of care; andb. the error has not been corrected via submission of a more recent assessment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676114 If continuation sheet Page 5 of 5