Health inspection·September 5, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 8 residents (Resident #9) reviewed for care plans. The facility failed to revise Resident #9's comprehensive care plan to reflect the resident's ADL self-care performance for transfers. These deficient practices could place residents at risk of receiving improper care.The findings were: Record review of Resident #9's admission record, dated 09/04/2025, reflected resident was a [AGE] year-old male initially admitted [DATE] and re admitted [DATE], with diagnoses to include dementia (loss of cognitive functioning that interferes with daily life and activities), muscle weakness, acquired absence of left leg above knee (04/01/2023), and acquired absence of right leg below knee (12/31/2018). Record review of Resident #9's quarterly MDS assessment, dated 08/22/2025, reflected resident had a BIMS score of 06 out of 15, indicating severely impaired cognition. It reflected Resident #9 was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for Chair/bed-to-chair transfer. It revealed Resident #9 had no falls since admission or prior assessment, whichever was more recent. Record review of Resident #9's comprehensive care plan, last review completed on 04/25/25, reflected [Resident #9] has an ADL self-care performance deficit r/t poor cognitive deficit, bil BKA, and decreased function, revised 05/11/2029. Record review of incident and accident report for the past 6 months reflected Resident #9 did not have any falls due to transfers. Observation on 09/02/2025 at 12:13 PM revealed Resident #9 with a sling for a mechanical lift. Attempted to interview Resident #9 but he did not answer any questions. Interview on 09/05/25 at 02:30 PM, RN AE revealed she reviewed care plans for transfers. She revealed things change and that was why care plans were important to get updated for resident care and to keep up with resident changes. She revealed Resident #9 got transferred with a mechanical lift and it should be care planned because it was how they cared for this resident. She revealed he had only one fall within the last year because he was trying to transfer himself from wheelchair to bed without using the call light. She revealed Resident #9 was educated to use the call light and now used the call light for help. Interview on 09/05/25 at 02:49 PM, CNA S revealed he used the Kardex (guidance in the electronic medical record for CNAs) for resident care. He revealed Resident #9 was transferred out of bed via a mechanical lift. Interview on 09/05/25 at 04:37 PM, MDS RN revealed Resident #9 was dependent in transfers per his MDS assessment. She revealed Resident #9 fluctuated from extensive assistance to dependent assistance, but Resident #9 was now dependent for transfers. Interview on 09/05/25 at 5:05 PM, the Interim DON revealed Resident #9's care plan should be updated to reflect he needed to be transferred by a mechanical lift, but sometimes things will change shift to shift with resident care. She revealed it was important for care plans to be updated to reflect the resident's current status. Record review of facility's policy Comprehensive Care Plans, dated 2025, reflected 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Event ID: Facility ID: 676240 If continuation sheet Page 2 of 16 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure resident receives adequate supervision to prevent accidents for 1 of 2 residents (Resident #70) reviewed for accidents and hazards. The facility failed to ensure Resident #70 received adequate supervision when Resident #70 was missing on 8/28/2025 for approximately 45 minutes and found lying next to her wheelchair outdoors on an enclosed, outdoor patio. An IJ was identified on 9/3/2025. The IJ template was provided to the facility on 9/3/2025 at 12:10 PM. While the IJ was removed on 9/5/2025 at 10:09, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of the new procedures and training. This failure could place residents at risk of inadequate supervision and monitoring leading to an environment that is not free of accidents/hazards. Findings included:Record review of Resident #70's face sheet (dated 9/02/2025) reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's Disease (a progressive neurological disorder affecting reasoning, memory, and cognitive skills), repeated falls, and unspecified dementia (a progressive neurological disorder that causes memory and cognitive decline). Record review of Resident #70's quarterly MDS (submitted 7/08/2025) reflected a BIMS score of 06, indicating moderately impaired cognition. This MDS also reflected in section E Resident #70 exhibited wandering behavior 0 days of the 14-day assessment period. Record review of Resident #70's comprehensive care plan (dated 8/28/2025) reflected the following:The resident is an elopement risk/wanderer r/t impaired safety awareness, resident wanders aimlessly (date initiated 8/28/2025)Record review of Resident #70's progress included the following documentation:This nurse went looking for resident with CNA in order to give her a scheduled shower. When staff was unable to locate resident, Code Green/Missing Resident was activated and all staff searched for resident whereabouts. Resident then was located by PT on an outside patio, lying by her wheelchair. Resident was assessed by nursing staff, hoyered into her wheelchair and taken inside to cool off, rehydrate and for further assessment [sic]. (8/28/2025 7:16 PM by RN A)This nurse was alerted by other staff that resident had been located by PT on a side patio, lying in front of her wheelchair. Resident was assessed for injuries by nursing staff, hoyered back into her wheelchair and taken indoors to cool off, rehydrate and for further assessment. No injuries noted, all notified [sic] (8/28/2025 7:24 PM by RN A)Record review of the facility's incidents log dated 9/2/2025 reflected an elopement incident for Resident #70 on 8/28/2025 at 2:30 PM. Record review of the facility's investigation report related to the elopement incident reflected an undated, typed statement from the Dietician that read as follows: I arrived at [the facility] at approximately 2:10 PM and checked in with the DON. I was in the DON's office for approximately 5-10 minutes. After checking in, I went to the private dining room and set down my belongings, then I went into the kitchen and checked in with the Dietary Manager. I was in the kitchen for approximately 5-10 minutes, and then I returned to the private dining room. There was an alarm going off at the door that connects the private dining room to the outdoor area. I looked through the glass door and did not see any person outside or anything that appeared out of the ordinary, then I disabled the alarm. This occurred prior to 2:28 PM when I sent an email to another Dietician who works for [company]. At approximately 3:30 PM, I became aware that staff was trying to locate a resident. I looked out the windows of the private dining room, and this time I observed a wheelchair outside. I informed a staff member that I saw a wheelchair outside of the private dining room, and that I thought (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 3 of 16 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few there might be a resident outside in the wheelchair [sic]. In an observation on 9/2/2025 at 2:33 PM, the private dining area was observed to be closed to the main dining area and the hallway with unlocked doors. The exit alarm that is activated upon pushing the door handle was functioning, and the survey team initiated the alarm by pushing on the door handle for approximately 15 seconds, at which time the door lock released and the door opened. A continuous alarm then sounded. A secondary alarm was observed to be attached to the exit door but was not alarming. The survey team remained in the closed private dining area, and no staff responded to the alarm. At 2:38 PM, a surveyor exited the private dining area and observed the alarm was difficult to hear in the hallway through the closed doors of the private dining area due to environmental noise. At 2:41 PM, the survey team opened the doors to the private dining area, at which time the AD responded to the alarm. Resident #70 was interviewed on 9/2/2025 at 11:19 AM, but she was unable to recall the incident or participate in the interview in a meaningful way due to cognitive decline. In an interview with RN A on 9/2/2025 at 2:15 PM, she stated Resident #70 was discovered to be missing when the CNA attempted to give the resident her scheduled shower. She had not witnessed wandering or exit seeking behavior from Resident #70 prior to that day. She stated she did not hear a door alarm on the day Resident #70 was missing. She stated she activated the missing resident protocol and the resident was located by a physical therapist shortly after. She then assessed Resident #70 and found her to have a mild sunburn on her face and she provided the resident with a cool shower to decrease her body temperature. She then notified the physician, and the Admin. had notified Resident #70's family. She stated Resident #70 required no additional treatment. In an interview on 9/2/2025 at 2:43 PM, the DOR stated he was verbally notified by a staff member in the therapy gym that Resident #70 was missing. He located Resident #70 after being notified by an unknown staff member that a wheelchair was observed on the patio next to the private dining area. He stated the door alarm was not alerting when he entered the key code and exited the building. He stated Resident #70 was lying next to her wheelchair and using a sling for the mechanical lift to cover her face from the sun. She was awake and alert, and she told the DOR that her hands, head, and back felt hot. In an interview on 9/2/2025 at 3:00 PM, the Admin. stated Resident #70 left the facility unsupervised through the exit door in the private dining room, and the alarm had sounded but had been disabled by a visiting Dietician. She stated the outdoor patio area was not routinely used, and Resident #70 had not exhibited wandering behavior prior to the incident. She stated Resident #70 told staff she was attempting to get outside to view the horses in the stables located across the street from the facility and fell from her wheelchair but was uninjured. She stated Resident #70 was outside for approximately 30 minutes and after being located was put on observation every fifteen minutes by staff for 72 hours and then downgraded to observation every shift. She stated the facility had also added the secondary alarms to the doors on 9/2/2025 as she felt the existing alarms were too quiet, but she was unsure why the Maint. Dir. had not turned the alarms on. CNA B did not respond to an attempted interview via telephone call/voicemail on 9/3/2025 at 8:57 AM. An IJ was identified on 9/3/2025. The Administrator was notified of the IJ on 9/3/2025 at 12:31 PM and was given a copy of the IJ template and a POR was requested. The facility's POR for the IJ was accepted on 9/04/2025 at 8:06 AM and reflected the following:1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address and prevent any additional residents from adverse outcomes. Started on 8/28/25 Completion Date: 9/3/25 Residents directly involved in this deficient practice had their care plan reviewed and updated by the DON or designee and updated to reflect current wandering and elopement risk, dehydration risk completed on all residents. The MDS Coordinator reviewed section E of the MDS and associated CAA for all residents. Care plans (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 4 of 16 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few were reviewed and updated to ensure they reflect audit findings. Concerns were not identified. The DON, designee(s) and/or MDS Coordinator(s) re-evaluated residents at risk for wandering/elopement and dehydration using an elopement risk assessment tool and dehydration risk tool. Dietary Staff will ensure that there are hydration stations at the courtyard exits and rear patio exit to ensure any resident who wants to sit outside has access to hydration that is easily accessible. Any resident that requires supervision will be offered fluid during their supervised visitation outside as needed. All staff in-serviced on all shifts by in person or over the phone education on wandering, elopement, and resident safety, Accidents and Hazards and Hydration from the Administrator/ DON or designee(s). Any staff on leave will receive education on their next scheduled work day. On 8/29/25 facility purchased Stop Alarms for exit door to improve audible tone of dining room exit door. Alarms on exit doors at 8am on 9/2/25 and staff education was conducted on 9/2/25. Hydration carts have been implemented on 9/3/25 at 5:30pm.2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 9/3/25) Elopement and wandering residents' policy and Accidents and Supervision and Hydration Policies were reviewed/revised by [NAME], RN. Administrator or Maintenance Director will conduct weekly alarm response drill to ensure timely response for 6 weeks. The DON or designee will audit new admissions for elopement risk and dehydration risk to ensure appropriate interventions are in place for 6 weeks. The DON or designee will audit completed MDS's to ensure the care plan reflects needs/concerns identified in the CAAs for At risk residents for elopement or dehydration. New hires and agency staff will receive education on wandering, elopement, and resident safety as well as Freedom from Accidents and Hazard and hydration by the Administrator or designee(s). Agency staff will be given access to point click care to view residents identified as requiring additional supervision as well the look at me now binder containing high risk residents. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained.Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 9/3/25Action Plan to Ensure Relevant Recommendations Are Followed:Action/TaskPerson(s) AssignedDate CompletedReview/modify current policies as applicable to ensure appropriate procedures are in place to prevent harm/potential harm.[COO]9/3/25New policies written/implemented when applicable to ensure additional serious harm will be prevented.[COO]9/3/25Checklists and monitoring tools used to verify compliance.[Admin}9/3/25Educate necessary staff on facility procedures with return demonstration, where applicable.[COO, Admin, ADON]9/3/25Document PIP implementation, PIP progress, and QAA Committee Meeting Minutes where PIP is discussed.[Admin, COO]9/3/25 Verification of the facility's POR was as follows: Record review of a document dated 9/3/2025, reflected a signed statement from MDS RN and MDS LVN indicating care plans were updated for residents identified at risk following dehydration and elopement risk assessments.Record review of Resident #70's comprehensive care plan, dated 8/28/2025, reflected the following:The resident is an elopement risk/wanderer r/t impaired safety awareness, resident wanders aimlessly (dated 8/28/2025)Interventions: assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: (blank); document wandering behavior and attempted diversional interventions in behavior log, identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate.Record review of a facility documented titled Dehydration Risk Evaluation report dated 9/3/2025 reflected risk for dehydration assessments were documented for 79 residents on 9/3/2025, and 56 of the assessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 5 of 16 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents had scores indicating a risk for dehydration.Record review of a facility document titled Elopement Evaluation report dated 9/3/2025 reflected elopement/wandering risk assessments were documented for 79 residents on 9/3/2025, and 4 of the assessed residents had scores indicating a risk for elopement or wandering, including Resident #70. Record review of staff development/in-service attendance sheet dated 8/28/2025 reflected in-service topics of exit alarm response; check on residents every 30 minutes when outside; and review of policies: hydration, accidents/hazards, and elopement. Record review of an invoice dated 9/2/2025 reflected an online order for 7 secondary door alarms placed on 8/29/2025. Record review of the facility policies Hydration (undated, copyright 2023), Accidents and Supervision (undated, copyright 2024), and Elopement and Wandering Residents (undated, copyright 2025) reflected the policies were present at the facility. Record review of the facility document titled Action Plan dated 8/28/2025 signed by the Admin. and MD reflected the areas identified as requiring attention were: wandering/elopement, resident care plan review, MDS review of care plans and new admission risk assessment, hydration stations implementation, in-services, and stop alarms. Record review of document titled Action Plan Monitoring for Week 1 of 6 dated 8/29/2025 through 8/31/2025 reflected the following:The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place 5 days per week for 6 week with no issue identifiedThe DON or designee will audit completed MDS' to ensure the care plan reflects needs/concerns identified in the CAAs 5 days per week for 6 weeks with no issue identifiedRecord review of document titled Action Plan Monitoring for Week 2 of 6 dated 9/1/2025 through 9/7/2025 reflected the following: 9/3/2025 Active IJ change to plan of correctionRecord review of document titled Action Plan Monitoring for Week 1 of 6 dated 9/4/2025 through 9/7/2025 The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place 5 days per week for 6 weeks. 9/4/2025 no new admissionsNew hires will receive education on wandering, elopement, and resident safety and Accidents and Hazards by the DON, Director of Social Services, or designees on hire. 9/4/2025 new hire completedThe Admin. or Maint. Dir. will conduct weekly alarm response drills to ensure timely response for 6 weeks.Record review of the facility documented titled New Team Member Orientation Guide dated 1/5/2021 included education regarding the facility's Look at Me program to educate about residents with known elopement/wandering behaviors, as well as education regarding challenging behaviors, types of dementia, and fall prevention. In an observation on 9/4/2025 at 8:39 AM, ice water dispensers and disposable cups were observed in the central courtyard, the two indoor entrances to the courtyard, and the exit doors leading to the patio. In an observation on 9/5/2025 at 9:22 AM, the survey team activated the door alarm in the private dining area. Upon opening, the primary and secondary door alarms activated. 6 staff members responded to the alarm within 1 minute and commenced a search of the exterior area. Staff inside of the facility were observed performing a headcount of all residents. All residents were accounted for after comparing to census. In an observation on 9/4/2025 at 9:43 AM, a hydration cart was observed at the north nurse's station. In an observation on 9/4/2025 at 10:00 AM, a hydration cart was observed at the south nurse's station. In an interview on 9/4/2025 at 10:14 AM, the DM stated she put the hydration carts and stations in place on 9/3/2025 at 5:30 PM. In an observation on 9/4/2025 at 11:35 AM, Look at me Now binders were observed at both nurse's station and at the reception area. In an interview with RN F on 9/4/2025 at 11:35 AM, she stated the Look at Me Now binders were found at every nurse's station and contained information about residents who were identified as wandering/elopement risks. In an interview on 9/4/2025 at 2:54 PM, the MDS RN and MDS LVN stated they reviewed Section E of all residents' MDS to determine if any wandering behavior had been documented on residents, and they did not identify any concerns. They also stated they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 6 of 16 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 09/05/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete updated all care plans based on the risk assessments completed by the other nursing staff, to include ensuring access to water, monitoring for signs/symptoms of dehydration, redirection and distraction, and other personalized interventions. In an interview on 9/4/2025 at 3:12 PM, the DON stated all residents at the facility received dehydration and wandering/elopement risk assessments, and Resident #70 had an update to her care plan after the incident on 8/28/2025 to include interventions for the behaviors, as well as the other residents identified as risks for wandering. She stated quite a few residents were identified as at risk for dehydration, and all had their care plans updated to reflect interventions for the risk of dehydration. She reported sending a mass message to all staff employed by the facility summarizing the required in-services for the POR, and she notified them that they will receive the in-service before their next working shift. She stated she had staff at the time clocks performing in-services as staff members were clocking in for their shifts. She stated she had reviewed the relevant policies, and no edits or adjustments were needed. She stated she also will be reviewing the dehydration and elopement risk assessments for every new admission to ensure accuracy and completeness. In an interview on 9/4/2025 at 3:53 PM, the Admin. stated she would be performing a weekly drill on the door alarms and reporting the findings to the facility quality committee. She stated she would confirm verbally with the Maint. Dir. that he had performed the drill on the weeks in which he was assigned the task. She stated all new hires would receive training on wandering/elopement behaviors and resident safety as part of the new hire orientation. She stated the Weekly Audit checklist had been created by the facility to audit their compliance with their action plan and for review internally. 37 total staff members from all departments and shifts were interviewed on 9/4/2025 to ensure required trainings were received (responding to exit alarms, hydration of residents, wandering/elopement behaviors):Activity DirectorMA (morning shift: 1)CNA/Hospitality Aides/Aides in Training (morning shift: 4, evening shift: 4, overnight shift: 1, PRN: 1)Dietary staff (morning shift: 2, evening shift: 1, overnight shift: 1)Housekeeping (morning shift: 2)MDS RN/LVN (2)RN/LVN (morning shift: 3, evening shift: 3, extended shift: 2, overnight shift: 1)Therapy (full time staff: 3, PRN staff: 4)WC Nurse (1)While the IJ was removed on 9/5/2025 at 10:19 AM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because the facility needed to evaluate the effectiveness of the POR and complete required staff training. Event ID: Facility ID: 676240 If continuation sheet Page 7 of 16 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 09/05/2025 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 - Some 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 for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to maintain the temperature of walk-in refrigerator at or below 41 degrees F for the last 3 months2. The facility failed to take temperatures for the cold foods (to include milk for 09/05/25 breakfast and fresh fruit cups for 09/05/25 lunch). 3. The facility failed to ensure food products were labeled with discard dates. These failures could place residents at risk for food borne illness.The findings included:Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated June 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)2: morning 423: evening 434: morning 43 and evening 435: morning 437: morning 428: morning 429: evening 4211: morning 4312: morning 4214: morning 43 and evening 4315: evening 4316: morning 4317: morning 4318: morning 4219: morning 4222: morning 4224: morning 4325: morning 4226: morning 43 and evening 4228: morning 4329: morning 43 Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated July 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)1: evening 432: morning 423: morning 444: morning 426: morning 438: morning 429: morning 4311: morning 4212: morning 4313: morning 4314: morning 42 15: morning 4317: evening 4318: morning 43 and evening 4319: morning 43 and evening 4222: evening 4624: morning 4327: morning 43 and evening 4328: morning 42 and evening 4229: morning 43 and evening 4330: morning 43 and evening 4331 evening 43 Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated August 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)2: evening 444: morning 428: morning 439: morning 4210: morning 4311: evening 4213: morning 43 and evening 4214: morning 43 16: evening 4317: morning 4218: morning 42 and evening 4719: morning 43 20: evening 4324: morning 4325: morning 4227: morning 43 Record review of the Resource: Refrigerator/Freezer Temperature Log from June to July 2025 reflected no action was taken after the temperature was above 41 degrees Fahrenheit. Record review of temperature logs for 08/25-08/31 and 09/01 to 09/07, untitled and copyright 2023, reflected the temperature of milk for breakfast was not taken 08/25-08/31 to 09/01-09/03. Record review of the facility's infection surveillance for the last 3 months reflected there were no cases of foodborne illness in the facility. Observation on 09/01/25 at 10:01 AM reflected there were prepared foods that did not have discard dates on them, to include sliced cheese that was dated 08/25, chocolate pudding that was dated 09/02, [Peanut Butter and Jelly] sandwich dated 09/01/25. It was observed that the microwave had brownish stains and brownish particles to the right-hand side of the inside of the microwave. Interview on 09/02/2025 at 10:15 AM, DA AF and Dietary Manager (DM) revealed they sometimes put discard dates on food labels. DA AF revealed he knew to throw prepared food items after 3 days. He revealed if foods were not discarded on the correct date, then food can get spoiled. They revealed the walk-in refrigerator temperature had been fluctuating and they thought it was because the freezer door would not close all the way. They revealed the refrigerator walk-n refrigerator should not be above 41 degrees Fahrenheit. The Dietary Manager revealed she oversaw ensuring the temperatures in the kitchen were at an appropriate temperature. The DM revealed the only corrective action that was taken was the Maintenance Director coming to fix the freezer but was not doing anything else the meantime. DA AF and DM revealed the microwave they used has always been stained and looked dirty, but they insisted it was not dirty. They revealed if it was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 8 of 16 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 09/05/2025 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 - Some dirty, this could cause cross contamination. Combined interview on 09/03/25 at 10:04 AM, [NAME] G revealed he took the morning temperatures of the refrigerator at 06:30 AM. The DM revealed this was to capture the overnight temperature. The DM revealed the temperatures had not been consistent and she would notice some vegetables in the walk-in refrigerator would get frozen and then inedible so she would not cook with these when she was a cook and ensured these food products were thrown out. The DM had become a manager for about a month already. She revealed she did not know the temperatures nor took the temperatures because she worked in the evening. Interview on 09/03/25 at 10:26 AM, the Maintenance Director revealed he did not know about temperatures not being within their proper temperature range until yesterday. He revealed it was the kitchen's responsibility to let him know when kitchen equipment needed repair. He revealed he reviewed the temperature logs yesterday and all the temperatures were within the appropriate range that they needed to be (32 to 45 degrees Fahrenheit). He revealed this was the range for state regulations. Combined interview and observation on 09/03/25 at 11:18 AM, the DM revealed it was important for foods to be in the recommended temperature range to prevent foodborne illness. Observation reflected sour cream was on the line for lunch service and in a pan, on ice. [NAME] G took the temperature of this sour cream, and it was 42 degrees Fahrenheit and had to be put in the reach-in refrigerator to cool down to temperature (below 41 degrees Fahrenheit). [NAME] G revealed he had taken the sour cream out of the walk-in refrigerator about 10 minutes ago. The DM revealed she was in charge of educating the kitchen staff about policies and procedures and she oversaw these were being done, taking corrective action as needed. Interview and observation on 09/03/25 at 11:38 AM, the DM took the temperature of a tomato from the walk-in refrigerator. The walk-in refrigerator was observed to read 41 degrees Fahrenheit. The DM checked the temperature of a tomato, and it was 41 degrees Fahrenheit. The DM checked the temperature of Italian dressing, and it was at 42.6 degrees Fahrenheit, which the DM revealed could have been because they were preparing for lunch service and were going in and out of the walk-in refrigerator. The DM revealed when they served milk for meals, the temperature for the milk was not checked because they took it out of the refrigerator right before service so it would be within the range it needed to be. She revealed there was not corrective action taken for temperature above 41 degrees Fahrenheit because the walk-in refrigerator was not consistently over 41 degrees Fahrenheit, and it was never over 45 degrees. She revealed if either of these situations occurred, they would throw the food out. She revealed they also did not do corrective action when temperatures were above 41 degrees Fahrenheit because the walk-in refrigerator was in the process of getting fixed. The DM was not able to provide any proof of taking multiple temperatures to show the refrigerator was back within proper temperature range. Interview and observation on 09/03/2025 at 12 PM, the DM took the temperature of the sour cream being served for lunch because all the other kitchen staff were busy serving lunch. The temperature of the sour cream was 41.4 degrees. The DM took the temperature of the fruit cups that were being served for lunch service and they were 51 degrees Fahrenheit. She revealed they did not take the temperatures of the fruit cups prior to service because they did not have a sheet where they could document foods like desserts. Interview on 09/03/25 at 01:56 PM, the former Dietary Manager revealed the food temperatures were sometimes out of range. She revealed the maintenance director was told about this but could not remember a specific date and could not remember a specific date when the walk-in refrigerator was giving temperatures above 41 degrees Fahrenheit. She revealed she did not put in a maintenance request in for the refrigerator, but the Maintenance Director was aware. She revealed it was important for the walk-in refrigerator to be within an appropriate temperature so there was no spoiled food, rotten food, or cross contamination. She revealed the RD knew about this and could not remember (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 9 of 16 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 09/05/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete if they said anything about the temperatures of the walk-in refrigerator. She further revealed the walk-in refrigerator was fine as long as it was below 45 degrees Fahrenheit. Interview on 09/03/25 at 03:41 PM, the Maintenance Director revealed he was not told about the temperatures in the walk-in refrigerator fluctuating. He revealed he contacted someone to inspect the walk-in refrigerator yesterday. He revealed it was found that there was a valve that was stuck in the condensing unit outside. He revealed this valve was moved and now there should be colder air blowing in the walk-in refrigerator to make the walk-in refrigerator cooler than what it was at. Interview on 09/09/25 at 1:11pm the RD revealed discard dates did not need to be put on food labels because it was not a part of their policy. She revealed kitchen staff knew to throw food products out after 3 days. She revealed she only knew there were walk-in refrigerator temperatures above 41 degrees Fahrenheit in the month of August. She revealed the corrective action that was taken was the maintenance director fixing this issue. She revealed there were no other corrective action. She revealed having foods at higher than recommended temperatures could cause food borne illnesses and food spoilage. Record review of the FDA Food Code 2022, U.S. Department of H&HS, revealed 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (2) At 5 C (41 F) or less. Record review of the FDA Food Code 2022, U.S. Department of H&HS, reflected, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 Record review of the facility's policy Food Temperatures, dated 2013, reflected 2. All cold food items must be maintained and served at a temperature of 41 degrees Fahrenheit or below. Record review of the facility's policy General Food Preparation and Handling, dated 2013, reflected 1. The kitchen is kept neat and orderly. a. The kitchen and equipment are clean and sanitized as appropriate. The facility did not have any policy that reflected labeling food products with a discard date, as is reflected in the 2022 FDA Food Code. Event ID: Facility ID: 676240 If continuation sheet Page 10 of 16 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 09/05/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure the medical records. In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are Complete; Accurately documented; Readily accessible; and systematically organized for 3 _of 16 (#20, #38, #5) residents reviewed for clinical records in that:1.Resident #20 did not have a current care plan conference meeting documented in her file. 2. Resident #38 did not have a current care plan conference meeting documented in her file. 3. The facility failed to ensure accurate documentation of Resident #5's July MAR per doctor's orders. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.The findings included: Record review of Resident #5's admission record, dated 09/05/2025, reflected resident was a [AGE] year-old male initially admitted [DATE] and re admitted [DATE], with diagnoses to include hypertension (high blood pressure) and congestive heart failure (the heart is unable to pump blood effectively). Record review of Resident #5's admission MDS assessment, dated 06/22/2025, reflected resident had a BIMS score of 14 out of 15, indicating intact cognition. Record review of Resident #5's comprehensive care plan, last review completed on 09/04/25, reflected “The resident has Congestive Heart Failure”, initiated 06/05/2025, with an intervention “Give cardiac medications as ordered.” Record review of doctor’s orders reflected “Furosemide Oral Tablet 20 MG Give 1 tablet by mouth one time a day for diuretic” with start date 06/05/2025 and “Spironolactone Oral Tablet 25 MG Give 1 tablet by mouth one time a day for diuretic…” with start date 06/05/2025. Record review of Resident #5's July MAR reflected DIURETICS-MONITOR FOR THE FOLLOWING: DECREASED PO INTAKE, ACUTE CONFUSION, AGITATION, DELUSIONS, AGGRESSION, LETHARGY, DECREASED SWEATING, TACHYCARDIA, HYPOTENSION, ORTHOSTASIS, GENERALIZED WEAKNESS, AND/OR SUNKEN EYES. every shift Document N if none of the above observed. Y if any of the above observed, notify physician and note findings in progress note, start date 06/04/2025. It further reflected RN AE documented 0 instead of N on 07/04/25 (2p-10p and 10p-6a), 07/05/25 (2p-10p and 10p-6a), 07/06/25 (2p-10p), 07/09/25 (2p-10p), 07/10/25 (2p-10p and 10p-6a), 07/11/25 (2p-10p), 07/12/25 (2p-10p), and 07/13/25 (2p-10p). Interview on 09/05/25 at 02:30 PM, RN AE revealed for Resident #5’s doctor’s orders for diuretics she should have put an “N” instead of a 0 as the doctor’s orders state. She revealed 0 meant no, and she did not have a good reason as to why she did this, and she should have followed the doctor’s orders. She revealed it was important to follow doctor’s orders for resident care. Interview on 09/05/25 at 5:05 PM, the Interim DON revealed in Resident #5’s July MAR nursing staff put a “0” instead of an “N”. She revealed the staff should put an “N” because it was the doctor’s orders. Record review of facility's policy, copyright 2024, Documentation in Medical Record reflected 4. Principles of documentation include, but are not limited to: b. Documentation shall be accurate, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 11 of 16 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 09/05/2025 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 0842 relevant, and complete, containing sufficient details about the resident's care and/or responses to care . Level of Harm - Minimal harm or potential for actual harm 1.Record review of Resident #20s admission Record dated 9/5/2025 was documented she was admitted on [DATE], re-admitted on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Heart Failure, Diabetes II, aphasia and hypertension. Residents Affected - Some Record review of Resident #20's Quarterly MDS dated [DATE] was documented as cognition level was cognitively intact, she mobilized with a wheelchair, had upper/lower impairment on one side, she was set up assistance for eating, oral hygiene and dependent with toileting, upper/lower body dressing and footwear, she had aphasia, hemiplegia/hemiparesis, and cognitive communications deficit. Record review of Resident #20s care plan was dated 8/20/2020 was documented she was a risk for falls, dependent of staff for meeting emotional, intellectual, physical and social needs, she had ADL deficits related to history of occlusion and stenosis of right posterior cerebral artery, wasting atrophy, abnormal posture, unsteady, reduced mobility, and left sided hemiplegia, limited physical mobility, and refuses some showers due to not when she wants it. Record review of Resident #20s care plan conference was not documented on 11/5/2024. Record review of the Resident #20s Care Plan Conference meetings schedule provided by ADM/SW was documented, Resident #20s care plan conference meeting was 2/4/2025 and 5/6/2025. 2. Record review of Resident #38's admission Record dated 9/5/2025 was documented she was admitted on [DATE], re-admitted on [DATE] with diagnoses of osteoarthritis, chronic obstructive pulmonary disease, chronic kidney disease, mild cognitive impairment and unsteady on feet, Record review of Resident #38's Quarterly MDS dated [DATE] with cognition level was cognitively intact, she was able to mobilize with a walker, for ADLs she was independent with eating, oral hygiene, toileting hygiene, upper/lower body dressing, footwear and personal hygiene, she had mild cognitive impairment, and she was on pain management. Record review of Resident #38's Care Plan dated 6/4/2025 was documented she was a risk for infections, resident independent on staff for meeting emotional, intellectual, physical and social needs, her ADL self-care performance deficit related to fatigue, impaired balance, generalized weakness, she has a potential for communications problem related to mild hearing loss, and risk for falls. Record review of Resident #38s care plan conference was not documented on 5/23/2025. Record review of the Resident #20s Care Plan Conference meetings schedule provided by ADM/SW was documented, Resident #38s care plan conference meeting was 5/21/2025. Interview on 9/5/2020 at 12:02 PM with the ADM/SW stated there was a TEAM of managers that were involved in the resident care plan conference. ADM stated she was one of the staff responsible for resident care plan conferences and stated she did have a care plan conference for Resident #20 and #38 was not documented. The ADM/SW stated the importance was to identify captured all issues with resident and goals, and interventions for each resident. ADM/SW stated the care plane conferences to talk with families and educate with any concerns they have with resident care. ADM/SW stated the care plane conferences were for all staff to know everything about that resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 12 of 16 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 09/05/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #20’s admission Record dated 9/5/2025 was documented she was admitted on [DATE], re-admitted on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (neurological conditions that cause weakness or paralysis on one side of the body), Heart Failure (a condition where the heart muscle cannot pump blood effectively enough to meet the body's needs), Diabetes II ( a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels. ), aphasia language disorder that affects a person's ability to communicate.) and hypertension high blood pressure). Record review of Resident #20's Quarterly MDS dated [DATE] was documented as cognition level was cognitively intact, she mobilized with a wheelchair, had upper/lower impairment on one side, she was set up assistance for eating, oral hygiene and dependent with toileting, upper/lower body dressing and footwear, she had aphasia, hemiplegia/hemiparesis, and cognitive communications deficit. Record review of Resident #20’s care plan was dated 8/20/2020 was documented she was a risk for falls, dependent of staff for meeting emotional, intellectual, physical and social needs, she had ADL deficits related to history of occlusion and stenosis of right posterior cerebral artery, wasting atrophy, abnormal posture, unsteady, reduced mobility, and left sided hemiplegia, limited physical mobility, and refuses some showers due to not when she wants it. Record review of Resident #20s care plan conference was not documented on 11/5/2024. Record review of the Resident #20s Care Plan Conference meetings schedule provided by ADM/SW documented, Resident #20s care plan conference meeting was 2/4/2025 and 5/6/2025. 2. Record review of Resident #38's admission Record dated 9/5/2025 was documented she was admitted on [DATE], re-admitted on [DATE] with diagnoses of osteoarthritis (degenerative joint disease), chronic obstructive pulmonary disease (a group of lung diseases that cause breathing difficulties), chronic kidney disease (kidneys gradually lose their ability to filter waste products and excess fluid from the blood, leading to long-term damage), mild cognitive impairment and unsteady on feet. Record review of Resident #38's Quarterly MDS dated [DATE] with cognition level was cognitively intact, she was able to mobilize with a walker, for ADLs she was independent with eating, oral hygiene, toileting hygiene, upper/lower body dressing, footwear and personal hygiene, she had mild cognitive impairment, and she was on pain management. Record review of Resident #38's Care Plan dated 6/4/2025 was documented she was a risk for infections, resident independent on staff for meeting emotional, intellectual, physical and social needs, her ADL self-care performance deficit related to fatigue, impaired balance, generalized weakness, she has a potential for communications problem related to mild hearing loss, and risk for falls. Record review of Resident #38s care plan conference was not documented on 5/23/2025. Record review of the Resident #20s Care Plan Conference meetings schedule provided by ADM/SW was documented, Resident #38s care plan conference meeting was 5/21/2025. Interview on 9/5/2020 at 12:02 PM the ADM/SW stated there was a TEAM of managers that were involved in the resident care plan conference. ADM stated she was one of the staff responsible for resident care plan conferences and stated she did have a care plan conference for Resident #20 and #38 that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 13 of 16 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 09/05/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm was not documented. The ADM/SW stated the importance was to identify captured all issues with resident and goals, and interventions for each resident. The ADM/SW stated the care plan conferences to talk with families and educate with any concerns they have with resident care. The ADM/SW stated the care plane conferences were for all staff to know everything about that resident. Residents Affected - Some 3. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 14 of 16 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 09/05/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 walk-in refrigerators reviewed for essential equipment. The facility failed to ensure the walk-in refrigerator in the kitchen was functioning properly. This failure could place residents at risk for foodborne illness.The findings included:Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated June 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)2: morning 423: evening 434: morning 43 and evening 435: morning 437: morning 428: morning 429: evening 4211: morning 4312: morning 4214: morning 43 and evening 4315: evening 4316: morning 4317: morning 4318: morning 4219: morning 4222: morning 4224: morning 4325: morning 4226: morning 43 and evening 4228: morning 4329: morning 43 Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated July 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)1: evening 432: morning 423: morning 444: morning 426: morning 438: morning 429: morning 4311: morning 4212: morning 4313: morning 4314: morning 42 15: morning 4317: evening 4318: morning 43 and evening 4319: morning 43 and evening 4222: evening 4624: morning 4327: morning 43 and evening 4328: morning 42 and evening 4229: morning 43 and evening 4330: morning 43 and evening 4331 evening 43 Record review of facility's Resource: Refrigerator/Freezer Temperature Log for the walk-in refrigerator, dated August 2025, reflected the following days had temperatures that were above 41 degrees Fahrenheit:(day: degrees Fahrenheit for morning and/or evening)2: evening 444: morning 428: morning 439: morning 4210: morning 4311: evening 4213: morning 43 and evening 4214: morning 43 16: evening 4317: morning 4218: morning 42 and evening 4719: morning 43 20: evening 4324: morning 4325: morning 4227: morning 43 Interview on 09/02/2025 at 10:15 AM, the Dietary Manager (DM) revealed the walk-in refrigerator temperature had been fluctuating and they thought it was because the freezer door would not close all the way. They revealed the refrigerator walk-n refrigerator should not be above 41 degrees Fahrenheit. The Dietary Manager revealed she oversaw ensuring the temperatures in the kitchen were at an appropriate temperature. The DM revealed the only corrective action that was taken was the Maintenance Director coming to fix the freezer but was not doing anything else the meantime. Interview on 09/03/25 at 10:26 AM, the Maintenance Director revealed he did not know about temperatures not being within their proper temperature range until yesterday. He revealed it was the kitchen's duty to let him know if any kitchen equipment needed to be fixed. He revealed he reviewed the temperature logs yesterday and all the temperatures were within the appropriate range that they needed to be (32 to 45 degrees Fahrenheit). He revealed this was the range for state regulations. Interview on 09/03/25 at 01:56 PM, the former Dietary Manager revealed the food temperatures were sometimes out of range. She revealed the maintenance director was told about this but could not remember a specific date and could not remember a specific date when the walk-in refrigerator was giving temperatures above 41 degrees Fahrenheit. She revealed she did not put in a maintenance request in for the refrigerator, but the Maintenance Director was aware. She revealed it was important for the walk-in refrigerator to be within an appropriate temperature so there was no spoiled food, rotten food, or cross contamination. She revealed the RD knew about this and could not remember if they said anything about the temperatures of the walk-in refrigerator. She further revealed the walk-in refrigerator was fine as long as it was below 45 degrees Fahrenheit. Interview on 09/03/25 at 03:41 PM, the Maintenance Director revealed he was not told about the temperatures in the walk-in refrigerator fluctuating. He revealed he contacted someone to inspect the walk-in refrigerator. He revealed it was found that there was a Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676240 If continuation sheet Page 15 of 16 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 09/05/2025 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete valve that was stuck in the condensing unit outside. He revealed this valve was moved and now there should be colder air blowing in the walk-in refrigerator to make the walk-in refrigerator cooler than what it was at. Record review of the FDA Food Code 2022, U.S. Department of H&HS, revealed 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (2) At 5 C (41 F) or less.Record review of facility's policy, Personal Food Storage, dated 2013, reflected 4. Units must maintain safe internal temperatures in accordance with state and federal standards for safe food storage temperatures. Event ID: Facility ID: 676240 If continuation sheet Page 16 of 16