Inspection·May 26, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an observation on 5/23/2023 at 11:42 AM, Resident #44 was sitting upright in her bed requesting assistance from staff. Resident #44 presented with a shiny face and greasy, uncombed hair. In an interview on 5/24/2023 at 2:10 PM, Resident #44 stated she missed about 5 showers a month for most of the time she has lived here. Resident #44 stated this made her feel dirty and she did not want to participate in social engagements when this happened. Resident #44 stated there was no pattern that she could discern as to when she would most likely miss a shower. Resident #44 stated she had never been offered a shower on an unscheduled day after missing a scheduled shower. Resident #44 stated her scheduled shower days were Mondays, Wednesdays and Fridays. Resident #44 stated it was particularly frustrating if she missed a Friday shower, knowing she would not get another opportunity to shower until after the weekend. Resident #44 stated she felt that waiting 3 days between showers was too long for sanitary reasons. In an interview on 5/25/2023 at 9:40 AM, CNA A stated paper forms are given to the nurse at the end of the shift but also there was documentation in the electronic health record. CNA A stated either one would indicate if the resident refused or was not in the facility. CNA A stated she was not aware of any resident missing any showers. CNA A stated no resident had mentioned to her needing a shower on a different day because of a missed scheduled shower. In an interview on 5/25/2023 at 5:30 PM, the DON stated showers should be documented in the electronic health record. The DON stated the expectation was for the paper body sheets be submitted by the CNA to the nurse as a means of communicating any skin issues. The DON stated some of the agency staff may not have been aware to submit the paper form and document in the electronic health record, or that showers may have been intermittently missed and not communicated to staff for follow up. The DON stated she did not think that happened very often. The DON stated a skin condition or hygiene issue could have delayed assessment and treatment if showers were missed. Record review of the policy entitled Resident Showers, copyrighted 2022, revealed the facility's policy was to . Assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues . Under the section entitled Policy Explanation and Compliance Guidelines: 1.) . provided showers as per request, or as per facility schedule protocols, and based upon resident safety. 11.) Assist the resident was showering as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents were free of any significant medication errors for 3 (Resident #234, #233, and #75) of 6 residents reviewed for safe administration of midodrine [a medication intended to raise systolic blood pressure], in that: Residents Affected - Some 1. Resident #234 was administered midodrine on 4 instances outside of the parameters established by the Primary Care Physician (PCP) to hold if greater than 160 systolic blood pressure between 5/01/2023-5/25/2023; 2.Resident #233 was administered midodrine on 3 instances outside of the parameters established by the Primary Care Physician (PCP) to hold if greater than 160 systolic blood pressure between 5/01/2023-5/25/2023; 3.Resident #75 was administered midodrine on 4 instances outside of the parameters established by the Primary Care Physician (PCP) to hold if greater than 160 systolic blood pressure between 4/01/2023-5/25/2023; This failure could place residents at risk of not receiving the intended therapeutic benefit of drugs and biologics, worsening or exacerbation of chronic medical conditions, and place residents at risk for serious injuries up to and including strokes. The findings include: 1.Record review of the admission Record dated 5/25/2023 revealed Resident #234 was a [AGE] year-old female admitted [DATE]. Record review of the annual MDS assessment revealed Resident #234 primary medical condition for admission was disability, cardiorespiratory conditions related to respiratory failure with hypoxia. Other active diagnoses included atrial fibrillation or other dysrhythmias (e.g., bradycardia or tachycardias) heart failure, hypertension, cardiomegaly [enlarged heart]. Resident #234 required supplemental oxygen therapy. Record review of the Care Plan revealed Resident #234 had a focus area of Congestive Heart Failure initiated 5/21/2021 with the following interventions: give cardiac medications as ordered. Additional focus areas included risk for altered cardiovascular status, initiate 1/17/2023 with the following interventions: administer medications as ordered and directed. Record review of the Order Summary, active as of 5/25/2023, revealed Resident #234 had a physician's order for midodrine tablet 5 milligrams; give one tablet by mouth two times a day before breakfast and after dinner; hold for systolic blood pressure greater than 160, dated 3/19/2023. Record review of the medication administration record for the month of May 2023 revealed Resident #234 received midodrine outside of the established parameters on the following dates: *5/02/2023 at 7:30 AM when systolic blood pressure was 162 administered by MA B; *5/02/2023 at 4:00 PM when systolic blood pressure was 162 administered by MA B; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0760 *5/05/2023 at 7:30 AM when systolic blood pressure was 188 administered by MA B; and Level of Harm - Minimal harm or potential for actual harm *5/24/2023 at 4:00 PM when systolic blood pressure was 175 administered by LVN D. Residents Affected - Some In an observation and interview on 5/25/2023 between 8:20 and 8:34 AM, LVN E stated Resident #234 was not her normal self and could not consent to having her blood pressure taken [a prerequisite prior to administering midodrine]. Resident #234 was sitting in bed, with the head of bead elevated between 45-60 degrees, eyes were open and would track movement, but Resident #234 did not respond to verbal stimuli from LVN E. LVN E stated she was going to try again once Resident #234 was a little more awake. In an interview on 5/25/2023 at 12:50 PM via telephone, MA B stated she could not recall if she administered medications to Resident #234 without being able to view the chart. MA B stated if vital signs are out of the parameters set by the physician, she does not administer the medication, documents the reason code and immediately notifies the nurse of those details. MA B stated the nurse would make the decision to contact the doctor for instructions to administer the medications if the residents' vital signs were within a few points of the parameters. MA B stated she did not know what the parameters were for midodrine and would need to see the electronic health record or electronic medication administration record for clarity. MA B stated she did not know what harm could happen if medications were administered when vital signs were out of parameters. In an interview on 5/25/2023 at 2:00 PM, LVN C stated she does not typically administer midodrine, as the medication aides are responsible for that. LVN C stated an alert does pop-up on her screen when an MA holds a medication due to the residents' vital signs not being within the parameters designated. LVN C stated the expectation was for the MA to also report this information verbally to the nurse. LVN C stated that the nurse would then re-check the vital signs and assess the residents' condition and follow up with the physician. In an interview on 5/25/2023 at 5:20 PM, ADON A stated she had worked a double, but the morning shift had been on another hallway. ADON A stated she was now assigned the hallway where Resident #234 lived. ADON A stated she had not had the chance to see Resident #234 prior to her being sent out via ambulance to the local emergency room. ADON A Stated Resident #234 was sent to the emergency room around 11 in the morning [5/25/2023]. ADON A obtained a verbal report from the emergency room that Resident #234 was stable, but under continued monitoring and would most likely be admitted and transferred to the hospital. In an interview on 5/25/2023 at 6:00 PM, with agency nurse LVN D, she stated that midodrine was a medication that increases a resident's blood pressure. LVN D stated midodrine would have individualized parameters set by the physician to hold the medication if the residents blood pressure was at or above a particular number. LVN D stated midodrine was to be held typically if the systolic blood pressure was above 160. LVN D stated that raising the blood pressure above that point by administering midodrine could have an adverse effect on a resident. LVN D accessed the electronic medication administration record for Resident #234 and stated that she should not have administered the midodrine yesterday [5/24/2023] when the systolic blood pressure reading for Resident #234 was 175 on 5/24/2023. LVN D stated midodrine should have been held. LVN D stated that 5/24/2023 was her first day at the facility. LVN D stated she had been given a brief tour of the unit and a one-page written report on all the residents she would be responsible for prior to being given responsibility to administer medications. LVN D stated the sheet listed the residents' preferences such as must crush medications, or pudding versus applesauce only. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Attempted interview on 5/26/2023 at 10:55 AM with primary care physician, but not receive a response for the primary care physician. In an interview via telephone on 5/26/2023 at 11:32 AM, the Medical Director stated Resident #234 was not one of his assigned residents, and that it would be best to speak to the primary care physician of record [Attempted interview with primary care physician but did not receive call back]. The Medical Director stated, How would I be able to answer any questions on this patient. I would not be able to tell you anything that isn't already in the chart you have access to. The Medical Director ended the telephone call. 2. Record review of the admission Record revealed Resident #233 was a [AGE] year-old male admitted [DATE]. Diagnoses included hypotension (low blood pressure), presence of cardiac defibrillator, heart disease with angina pectoris [a condition marked by severe pain in the chest, often spreading to the shoulders, arms or neck, caused by an inadequate blood supply to the heart]. Record review of the Care Plan, initiated 5/16/2023, revealed Resident #233 did not include a focus area or interventions related to hypotension. Record review of the Order Summary, active as of 5/25/2023, revealed Resident #233 had a physician's order for midodrine tablet 5 milligram; give 2.5 tablet by mouth two times a day; hold for systolic blood pressure greater than 140, dated 5/19/2023. Record review of the medication administration record for the month of May 2023 revealed Resident #233 received midodrine outside of the established parameters on the following dates: *5/19/2023 at 6:00 PM when systolic blood pressure was 173 administered by an unidentified staff; *5/24/2023 at 6:00 PM when systolic blood pressure was 149 administered by MA B; and *5/25/2023 at 9:00 AM when systolic blood pressure was 166 administered by an unidentified staff. 3.Record review of the admission Record dated 5/25/2023 revealed Resident #75 was a [AGE] year-old male admitted [DATE]. Record review of the quarterly MDS assessment, dated 4/12/2023, revealed Resident #75 primary medical condition for admission was medically complex conditions related to acute kidney failure. Other active diagnosis included orthostatic hypotension. Record review of the Care Plan revealed Resident #75 had a focus area of hypertension, initiated 2/01/2023 with the following interventions: give medications as ordered; monitor any signs or symptoms of malignant hypertension (headache, confusion, disorientation, lethargy, difficulty breathing); obtain blood pressure readings. Additional focus area included coronary artery disease with the following interventions: give all cardiac meds as ordered; monitor blood pressure. Record review of the Order Summary, active as of 5/25/2023, revealed Resident #75 had a physician's order for midodrine tablet 10 milligrams; give one tablet by mouth three times a day; hold if blood pressure greater than 160/110, dated 2/07/2023. Record review of the medication administration record for the months of April and May 2023 revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0760 Resident #75 received midodrine outside of the established parameters on the following dates: Level of Harm - Minimal harm or potential for actual harm *4/05/2023 at 3:00 PM when blood pressure was 188/53 administered by an unidentified staff; *5/02/2023 at 3:00 PM when blood pressure was 168/96 administered by MA B; Residents Affected - Some *5/02/2023 at 9:00 PM when blood pressure was 168/96 administered by MA B; and *5/03/2023 at 9:00 AM when blood pressure was 168/96 administered by MA B. In an interview on 5/26/2023 at 11:41 AM, the Pharmacist stated midodrine regulates orthostatic hypotension [a drop in blood pressure when the person changes position from lying or seated to standing]. The Pharmacist stated the medication can raise systolic blood pressure around 15 points about an hour after taking it. The Pharmacist stated it was possible that one might experience more anxiousness and anxiety if their blood pressure was higher than their normal baseline. The Pharmacist stated that if a residents' systolic blood pressure was between 180 and 200, it would be possible a physician might order a one-time dose of Clonidine to lower the blood pressure. The pharmacist stated she would not normally be notified, but the expectation would be for the nurses to notify the physician if the systolic blood pressure was above the residence baseline or if the medication was given despite an already elevated blood pressure. The Pharmacist stated she would expect that follow up orders from the physician would include monitoring for probably 8 hours following the administration of the medication in the presence of an elevated systolic blood pressure. Record review of the facility's Medication Administration, copyrighted 2022, revealed policy statement of medications were to be administered .as ordered by the physician and in accordance with professional standards of practice. In step 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside of the physician's prescribed parameters. In step 17. For those medications requiring vital signs, record the vital signs onto the medication administration record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to assure that residents receive a therapeutic diet as prescribed by the physician for 1 of 1 resident (#52) reviewed for diets in that: Resident #52 was prescribed a renal diet (A renal diet is one that was low in sodium, phosphorous, and protein. A renal diet also emphasizes the importance of consuming high-quality protein and usually limiting fluids. Some patients may also need to limit potassium and calcium) and was provided a regular diet which did not meet his special dietary needs. This failure could affect residents who are prescribed renal diets and could result in potassium building up in the blood stream and could result in a heart attack. The findings were: Review of Resident #52's electronic face sheet dated 05/26/2023 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: WEDGE COMPRESSION FRACTURE OF THIRD LUMBAR VERTEBRA, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING (spinal fracture) , CHRONIC KIDNEY DISEASE, STAGE 4 (SEVERE) (a shutdown of the kidneys.) Record review of Resident #52's physician's orders reflected LCS, Renal Diet that was dated 3/5/22 with additional directions of Fluid restriction 1500mL Q24hrs. Nursing to provide: 420mL (6a-2p=180mL 2p-10p=180mL 10p-6=60mL. Dietary to provide 1080mL (Bkft=360mL Lunch=360mL Dinner=360mL) LOW POTASSIUM, LOW CALCIUM (NO MILK, NO CHEESE) Review of Resident #52's comprehensive person-centered care plan dated 05/26/2023 reflected under Focus . Provide, serve diet as ordered. Monitor intake and record q meal. Review of Resident #52's tray ticket dated 5/24/23 reflected Diet . Renal Review of the facility Week 5 Day 32, Fall/Winter 2023 diet spreadsheet revealed Lunch .Renal .chicken breast, turnip green beans. Observation on 05/24/2023 at 12:30 PM of lunch service revealed a meal tray intended for Resident #52 contained sausage, the standard diet for the day. The tray was observed to be inspected by the DON within the dining room, carted to hall 600, and provided to Resident #52. Observation and interview on 05/24/2023 at 12:35 PM of Resident #52 revealed the tray was to be handed to Resident #52. Resident #52 stated I just eat what they give me, but sometimes my stomach hurts after I eat. Interview on 05/24/23 at 12:40 PM, the DON stated Resident #52 received a regular diet instead of a renal diet and that Resident #52 received a renal diet meal once she was notified. The DON stated that the staff have a copy of the diet extension and that was where the therapeutic diet was listed. The DON stated the diet went unnoticed on the meal slip, because the term renal was not in bold like (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the other diets on the meal slips. The DON stated that Resident #52's renal failure could be affected by the wrong diet. Interview on 05/24/23 at 3:02 PM, the Dietary Manager stated the meal slips place the diet texture in bold but the renal diet slips are in the title line and can potentially be missed if the dietary aide does not notice it and the nurses also happen to miss it. The Dietary Manager stated the dietary aide who missed the renal diet normally worked on the other side of the food service line and got confused during observation by the surveyor. The Dietary Manager stated the risk associated with providing the wrong diet to a resident needing a renal diet could hurt their quality of care. Review of the facility's policy and procedure titled Therapeutic Diet Orders, undated, reflected: dietary and nursing are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 reviewed for kitchen sanitation in that: 1. The facility failed to maintain the cleanliness of the ice maker found within the kitchen. 2. The facility failed to prevent residents from receiving food that had made contact with an un-sanitized work surface. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation on 5/24/23 at 10:51 AM revealed black substance build-up within the ice maker in the kitchen. Interview on 5/24/2022 at 11:11 AM, the DM stated the kitchen staff was responsible for emptying and cleaning out the ice maker every 3 months by draining and emptying the ice maker and cleaning it from the inside. He stated once every 6 months the MS will come and do a deep clean of the ice maker if it was required to do a deeper clean. The DM stated he did not notice the black substance build-up and could not identify what it was. The DM stated the ice maker should be cleaned and will contact his MS to have it partially disassembled to remove the black substance build up as the substance can cause foodborne illness in residents who consume ice from the ice maker. Observation and interview on 5/24/23 at 11:56 AM, DA A picked up a cut sausage patty that had fallen on the kitchen counter and place it on a resident's tray. DA A stated she did not notice any loose sausage patty and did not place anything on the resident's tray. Interview on 5/24/23 at 3:02 PM, the DM stated he was not in the kitchen when DA A was observed to have placed the sausage on the resident's tray. The DM stated DA A was nervous and likely instinctually placed it back on the tray as the cook was sliding trays across the serving line to be time efficient. He stated the risk associated with serving food that contacted un-sanitized surfaces was that it may cause foodborne illness. Record review of the facility nutritional policy titled Foodhandling, dated revised July 2014, reflected All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. and This facility recognizes that the critical factors implicated in foodborne illness are: . c. Contaminated equipment. Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . And 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure the Arbitration Agreement contained all the required elements for 1 of 1 facility. Residents Affected - Many The facility failed to ensure the arbitration agreement contained the required elements: 1. The non-compulsory condition of admission in signing the arbitration agreement. 2. The acknowledgment of understanding the arbitration agreement. 3. The right to rescind the agreement within 30 calendar days of signing. 4. The retained ability to contact advocates and government representatives. This failure could place the residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services provided by the nursing facility. The findings included: During the entrance conference on 5/23/2023 at 9:03 AM with the ADM, a blank copy of the facility's admission packet and the binding Arbitration Agreement were requested, and these were received by the survey team on 5/23/2023 by 5:00 PM. The ADM stated during the entrance conference that the facility did not utilize arbitration agreements in admission. Record review of the facility's admission agreement, undated, reflected an Arbitration Agreement located on page 11 through 13 of 15 of the admission and Financial Agreement. The Arbitration Agreement did not state nor reference: *The ability for a prospective resident or representative to not sign the agreement or that the agreement was required as a condition of admission; *The affirmation of understanding the agreement by the prospective resident or representative; *The right to rescind the binding Arbitration Agreement within 30 calendar days of signing the agreement, and; *The retained ability to contact advocates and government representatives. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0847 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Interview on 5/25/2023 at 9:34 AM, the Admissions Director stated she has been operating as the Admissions Director since October of 2022 and has used the same Admissions Agreement and Arbitration Agreement since at least October of 2022. The AD stated she was unaware of the Arbitration Agreement being in the Admissions Agreement whatsoever and during the admissions process would read the agreement verbatim to the prospective residents or their representatives and any questions that they had would be directed to her BOM. Interview on 05/26/2023 at 9:54 AM, the AD stated she could not find the missing elements identified in within the agreement and was not certain whether the agreement included the missing elements and would consult with her BOM as to how the agreement can be changed to meet compliance. Telephone interview on 05/26/2023 at 10:06 AM, the BOM stated she has supported the admissions packets since 2020. The BOM stated when she began supporting the admissions packet in 2020 the agreement had been the same then as it was during the interview. The BOM stated she did not identify the Arbitration Agreement to contain the missing elements identified in record review and questioned whether the facility required Arbitration Agreements at all. The BOM stated no residents had attempted to utilize the Binding Arbitration process since 2020. The BOM stated the risk associated with the Arbitration Agreements to not include these elements would be that prospective residents or their representatives would be unaware of their rights. The facility did not provide a policy on admission agreements or specifically Arbitration Agreements prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 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 676240 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/26/2023 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)

F 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure the Arbitration Agreement contained all the required elements for 1 of 1 facility. Residents Affected - Few The facility failed to ensure the arbitration agreement contained the selection of a neutral venue that is convenient for both parties. This failure could place the residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services provided by the nursing facility. The findings included: During the entrance conference on 5/23/2023 at 9:03 AM with the ADM, a blank copy of the facility's admission packet and the binding Arbitration Agreement were requested, and these were received by the survey team on 5/23/2023 by 5:00 PM. The ADM stated during the entrance conference that the facility did not utilize arbitration agreements in admission. Record review of the facility's admission agreement, undated, reflected an Arbitration Agreement located on page 11 through 13 of 15 of the admission and Financial Agreement. The Arbitration Agreement did not state nor reference the selection of a neutral venue that is convenient for both parties. Interview on 5/25/2023 at 9:34 AM, the Admissions Director stated she has been operating as the Admissions Director since October of 2022 and has used the same Admissions Agreement and Arbitration Agreement since at least October of 2022. The AD stated she was unaware of the Arbitration Agreement being in the Admissions Agreement whatsoever and during the admissions process would read the agreement verbatim to the prospective residents or their representatives and any questions that they had would be directed to her BOM. Interview on 05/26/2023 at 9:54 AM, the AD stated she could not find the missing element identified in within the agreement and was not certain whether the agreement included the missing element and would consult with her BOM as to how the agreement can be changed to meet compliance. Telephone interview on 05/26/2023 at 10:06 AM, the BOM stated she has supported the admissions packets since 2020. The BOM stated when she began supporting the admissions packet in 2020 the agreement had been the same then as it was during the interview. The BOM stated she did not identify the Arbitration Agreement to contain the missing element identified in record review and questioned whether the facility required Arbitration Agreements at all. The BOM stated no residents had attempted to utilize the Binding Arbitration process since 2020. The BOM stated the risk associated with the Arbitration Agreements to not include this element would be that prospective residents or their representatives would be unaware of their rights. The facility did not provide a policy on admission agreements or specifically Arbitration Agreements prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 13 of 13