Health inspection·December 29, 2023

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few effects from this situation. LVN A stated she conducted the in-service with employees regarding misappropriation of property on 09/29/23. Resident #1 was interviewed on 12/27/23 at 3:18 pm. Resident #1 stated he had been in the facility about 5 years. Regarding the incident, Resident #1 said he had his wallet on his overbed table with his bank card in it. He had to go to the ER, so the wallet was left on his table. Resident #1 stated he was surprised about learning of the theft and said he was very pleased with the facility's response. Resident #1 stated they reimbursed him right away. Resident #1 stated he was pressing charges and was waiting to hear from the police department about the case. Resident #1 stated that if he must leave the facility, he would either take his wallet with him or lock it up in the ADM office. Resident #1 stated he was very satisfied with care and plans to stay at the facility permanently. A review of CNA B's personnel file contained the Criminal History check that was conducted on 05/01/23. CNA B was hired on 04/28/23. The Criminal History revealed 6 arrests for theft including a robbery charge on 10/22/12 in which she was convicted of a 2nd degree felony . During an interview with ADM on 12/28/23 at 9:47, the ADM stated she was employed at the facility on 08/28/23. ADM stated We run criminal history checks prior to hire and if something comes up then the ADM looks at it. If I would have seen this prior to hire, then I would not have hired her. ADM stated, The HR Person who ran the check at the time is no longer here and I was not employed here at the time. ADM stated the aide had been fired and the resident was pressing charges. ADM stated the facility immediately reimbursed the resident for the stolen funds rather than wait for the bank to do it. Record review of a copy of the check from the facility to Resident #1 in the amount of $920.99 dated 10/02/23 verified the facility reimbursed the resident for the lost funds in a timely manner. The facility reported this incident to HHSC and an Abuse and Neglect and Misappropriation Inservice was conducted on 9/29/23 by LVN A who was the ADON at the time. A phone interview was conducted on 12/28/23 at 11:00 am with the Detective in the Police Department assigned to this case. Det C stated they were still trying to tie the Cash App charges to CNA B. The Cash App company said they did not have anyone with the name given on the app. The other payment was a car payment that was also under a different name. Det C stated, This is an active investigation. Det C stated she contacted CNA B and at first, she said she would come in to talk with the PD but then changed her mind and now does not answer calls. CNA B said she was working elsewhere but it was unknown where she was working. In an interview on 12/28/23 at 11:30 am with RN D, she stated she had worked for this company for 2 years. RN D stated HR runs the criminal history checks. If any type of infraction is indicated on the check, the results are given to the ADM so the ADM can make a decision about hiring. The HR person or ADM may go to the President of the company if further investigation is needed on whether a person is employable. RN D stated, I am unable to look at criminal histories since only HR and ADM have approved access. During an interview on 12/28/23 at 1:34 with the HR/Payroll Manager, she explained she is authorized to run criminal history checks. The HR/Payroll Manager stated, If anything comes back with any type of infraction, I have to let the ADM review it. We sometimes give the applicant the opportunity to explain. I don't have the final say in bars to employment. After years of theft, I would not have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 2 of 8 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 12/29/2023 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hired her. We have strong processes and if anything is flagged, it is escalated to the ADM. I did my training with the Corporate HR but she is no longer there . A phone interview was conducted with the previous ADM on 12/29/23 at 12:23 pm. ADM 2 stated she did remember the identified CNA but did not remember if she checked her background. She said the facility had gone through several HR people during the year, so she did not know who had run the background check. She said if an issue was flagged the HR person either gave it to her or to the company's President who offices in the facility. ADM 2 said if she was the one who checked it, she would have initialed and dated the first page of the form to indicate she had reviewed it. There were no initials on the background check provided so it could not be determined if anyone had checked it prior to the employee being hired. ADM 2 stated she was not aware that the employee had an arrest that would be a bar to employment. Record review of Staff Development/Inservice Attendance sheet dated 09/29/23 revealed staff were inserviced on the Abuse Prevention policy which included Misappropriation of Funds. A review of an undated facility policy titled Background Investigations, revealed the following guidelines: 1. The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied . 2. For all applicants applying for a position as a certified nurse aide, the human resources department will contact the nurse aide registry of the state in which the individual is certified and/or previously employed to verify that the applicant's certification is in good standing. 5. The facility will not employ individuals who: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. b. Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 3 of 8 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 12/29/2023 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 failed to follow its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of property . Residents Affected - Few The facility failed to follow its hiring policy and hired a nurse aide who had an extensive criminal history of theft and had a bar to employment of robbery on her record which resulted in the misappropriation of property of Resident #1. The non compliance was identified as past noncompliance. The noncompliance began on 09/29/23 and ended on 09/29/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of abuse, neglect, and exploitation due to staff not properly screened for employability. The findings included: Record review of Resident #1's electronic face sheet, dated 12/29/2023, indicated Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included mechanical complication of nephrostomy catheter (small tube draining urine from kidney), infection and inflammatory reaction due to indwelling urethral catheter (tube that drains urine), diabetes mellitus (too much sugar in the blood) due to underlying condition with severe nonproliferative diabetic retinopathy (weakened blood vessels in retina) with macular edema (blood vessels leaking into part of the retina called the macula), bilateral, and chronic kidney disease, Stage 3. Record review of the MDS, dated [DATE], indicated Resident #1 had a BIMS of 15, which indicated the resident was cognitively intact. During an interview on 12/27/23 at 2:30 LVN A stated Resident #1 had lost his phone so asked to use her phone to call his bank. Resident #1 had it on speaker and when he heard his balance, he wanted to know the last 5 withdrawals since the balance did not seem correct to him. LVN A overheard the last 5 withdrawals which included 2 Cash Apps to CNA B and another withdrawal to a company with whom Resident #1 was not familiar. LVN A stated she immediately went to get the ADM and they called the bank again to verify the amounts. LVN A was asked how CNA B could have accessed Resident #1's account. LVN A stated, Resident #1 had just returned from hospital and he had left his bank card on the bedside table. LVN A stated she had conducted the inservice with employees on the abuse policy prohibiting misappropriation of resident funds. A record review of CNA B's personnel file contained the Criminal History check that was conducted on 05/01/23. CNA B was hired on 04/28/23. The Criminal History revealed 6 arrests for theft including a robbery charge on 10/22/12 in which she was convicted of a 2nd degree felony. A record review of the Texas Health and Human Services Employability Status Check Search Results dated 04/27/23 revealed that the CNA B had an active NAR Status and was not considered to be unemployable. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 4 of 8 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 12/29/2023 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with ADM on 12/28/23 at 9:47, ADM stated she was employed at the facility on 08/28/23. ADM stated We run Criminal History checks prior to hire and if something comes up then the ADM looks at it. If I would have seen this prior to hire, then I would not have hired her. ADM further stated, The HR Person who ran the check at the time is no longer here and I was not employed here at the time. ADM stated the aide had been fired and the resident was pressing charges. ADM stated the facility immediately reimbursed the resident for the stolen funds rather than wait for the bank to do it. During an interview on 12/28/23 at 1:34 with the HR/Payroll Manager, she explained she is authorized to run Criminal History checks. The HR stated, If anything comes back with any type of infraction I have to let the ADM review it. We sometimes give the applicant the opportunity to explain. I don't have the final say in Bars to Employment. After years of theft, I would not have hired her. We have strong processes and if anything is flagged, it is escalated to the ADM. I did my training with the Corp HR but she is no longer there. A phone interview was conducted with the previous ADM on 12/29/23 at 12:23 pm. ADM 2 was asked about the hiring practices during her administration in regard to checking the criminal histories of potential employees. She stated she did remember the identified CNA but did not remember if she checked her background check. She said the facility had gone through several HR people during the year so she did not know who had actually run the background check. She said if an issue was flagged the HR person either gave it to her or to the company's President who offices in the facility. ADM 2 said if she was the one who checked it, she would have initialed and dated the first page of the form to indicate she had reviewed it. There were no initials on the background check provided so it could not be determined if anyone had checked it prior to the employee being hired. ADM 2 stated she was not aware that the employee had an arrest that would be a bar to employment. Record review of Staff Development/Inserv ice Attendance sheet dated 09/29/23 revealed that staff were inserviced on abuse, neglect and misappropriation of funds. A review of an undated facility policy titled Background Investigations, revealed the following guidelines: 1. The Human Resource department will conduct all applicable background investigation(s) on each individual making application for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied . 2. For all applicants applying for a position as a certified nurse aide, the human resources department will contact the nurse aide registry of the state in which the individual is certified and/or previously employed to verify that the applicant's certification is in good standing. 5. The facility will not employ individuals who: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 5 of 8 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 12/29/2023 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 0607 b. Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 6 of 8 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 12/29/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, interviews and record reviews, 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 two of two residents (Residents #2 and #3) out of 13 residents reviewed for medication administration., in that: The facility failed to ensure Resident #2 was discharged from the facility with only his prescribed medication. The facility failed to ensure Resident #3 was given his prescribed medication prior to his discharge. The non compliance was identified as past noncompliance. The noncompliance began on 10/05/23 and ended on 10/07/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. The findings included: Record review of Resident #2's admission Record dated 12/28/23 documented an 84- year- old male admitted to facility 09/20/23. His diagnoses included presence of cardiac pacemaker (device to control irregular heartbeats), paroxysmal atrial fibrillation (rapid, erratic heart rate that begins suddenly and then stops on its own), and difficulty in walking, not elsewhere specified. Record review of Resident #2's Discharge MDS assessment dated [DATE] revealed a BIMS score of 14 indicating he was cognitively intact. Record review of Nurses Notes revealed Resident #2 was discharged home on [DATE] with all his medications and personal belongings. On 10/07/23 he called the facility to report that last night he took one of the medications, Quetapine 400 mg , although his name was not on the card of medications. He had a fall and could not get himself up. A neighbor found him the next day. He refused to go to the ER and said he was fine. He called the facility to report what had happened. The nurse advised him to go to the ER, but he stated he did not need to do that. He stated his neighbor was giving him fluids and getting him something to eat. The nurse reported the call to the ADM and corporate nurse. Record review of Medication Administration Record dated 10/01/23 to 10/31/23 for Resident #3 revealed a [AGE] year old male admitted to facility 09/21/23 with diagnosis that included schizophrenia. The Administration Record showed a missed dose of Seroquel Oral Tablet 400 mg (Quetiapine Fumerate) on 10/06/23. Resident #3 discharged on 10/07/23. The MAR also indicated that monitoring for side effects or adverse effects of the antipsychotic medication did not show any evidence of adverse effects. During an interview with ADM on 12/27/23 at 10:27 am, the ADM stated she and the corporate nurse went to Resident #2's home after learning about his phone call to the facility. ADM stated they picked up the incorrect medication and made sure he was alright. Resident #2 told them he had no adverse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 7 of 8 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 12/29/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few effects from taking the incorrect medication. The ADM stated they did a Medication Error on Resident #3 since he missed the dose from the medication card that was given to Resident #2. Resident #3 had also discharged the day following Resident #2's discharge. The nurse who conducted the discharge was an agency nurse and was placed on a Do Not Return list . In an interview with LVN A on 12/27/23 at 11:06 am, LVN A stated the neighbor called and reported that Resident #2 had taken a pill from the card that had another person's name on it. LVN A stated she called Resident #2 and encouraged him to go to the ER but he refused. LVN A stated he did not want anyone to call his son since his son lived out of town. LVN A stated the facility did an in-service with the nurses to make sure medications were checked prior to discharge. They now have a system where two nurses will check medications prior to discharge. LVN A stated that Resident #3 had missed 2 doses of the medication that were accidentally given to Resident #2. He did not report any adverse effects from missing the doses. When Resident #3 discharged , LVN A stated she called his pharmacy to order his medication since he discharged prior to the ADM bringing the medication card back to the facility . On 12/28/23 at 9:50 am, an interview was conducted via phone with LVN E. LVN E stated she had worked at the facility several times but did not receive any training on discharge protocol. LVN E stated she did remember discharging Resident #2 but was not aware she sent the wrong medication with him. LVN E stated she always does her own discharges since the other nurse has her own residents to tend to. LVN E stated she got the medications from the Medication Aide. LVN E stated she usually checked the med list and the discharge list in the electronic record system. LVN E could not explain how the error happened. LVN E stated she was not aware she was on a Do Not Return list for this facility . During an interview on 12/28/23 at 10:20 am, LVN A stated there was a book of instructions for agency personnel. LVN A showed the manual to the state surveyor. The manual included instructions on how to discharge a resident. LVN A stated it was updated after this incident to include that 2 nurses would have to check the medications prior to discharge. Record review of undated Transfer and Discharge Policy stated: b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results. ii. A final summary of the resident's status. iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 8 of 8