Inspection·April 11, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 1 resident (Resident #1) reviewed for advanced directives, in that: The facility failed to ensure Resident #1, a competent adult, signed his own OOH-DNR and allowed the resident's Medical Power of Attorney (MPOA) to complete the document. This failure could place residents at-risk of having their end of life wishes dishonored. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed the resident was admitted on [DATE] with diagnoses that included: olecranon bursitis (inflammation of the bursa or fluid filled sacs that reduce friction between moving parts in the body's joints) of left elbow, Parkinson's Disease (progressive nervous system disorder that affects movement), benign neoplasm (abnormal but noncancerous collection of cells) of lower jawbone and neurocognitive disorder with Lewy Bodies (abnormal aggregations of protein that develop inside nerve cells). Further review of Resident #1's face sheet, dated [DATE], revealed under the section ADVANCE DIRECTIVE: DNR Record review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's Care Plan, print date [DATE], revealed a focus area, Resident does not want CPR performed. Fully executed OOH DNR in place. Date initiated [DATE] Record review of Resident #1's electronic medical record Order Summary Report, Active Orders as of [DATE], revealed an order dated [DATE] for DNR. Further review revealed an OOH-DNR signed by Resident #1's family member in section C, Declaration by a qualified relative of the adult person who is incompetent or otherwise incapable of communication. The OOH-DNR was signed by the physician and two witnesses, witness #2 was the facility SW. Record review of the INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER, revised [DATE], by the Texas Department of State Health Services, revealed If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. If the adult person in incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cibolo Creek 1440 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)