Health inspection·April 24, 2025

F 0641 signs of acute distress. She was not complaining of pain or discomfort. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Post Fall Review, dated 02/03/2025 at 03:05 a.m., signed by LPN A, reflected Resident #1 had a fall on 02/03/2025 at 01:40 a.m. Resident #1 was noted as having stated that she fell off the toilet. Resident #1 was documented as having no apparent injury. Potential interventions noted included toileting schedule, evaluate timing of medications, and daily nap. Residents Affected - Few During an observation and interview with Resident #1 on 04/24/2025 at 11:06 a.m., Resident #1 was sitting in a wheelchair in her bathroom. She appeared clean and groomed. She reported she had had multiple falls at the facility, but not a fall with injury in over a year. She stated her current need for the wheelchair was not due to a fall. She stated she felt safe at the facility and that the staff responded to her falls appropriately. She stated she continued to go to therapy and was trying to follow the fall interventions the nursing staff and therapy staff recommended to her. 2. Record review of Resident #2's admission Record, dated 04/23/2025, reflected a [AGE] year-old female. She was admitted on [DATE]. Record review of Resident #2's Medical Diagnosis Report, undated and accessed 04/23/2025, reflected a principal diagnosis of multi-system degeneration of the autonomic nervous system (a disorder that impacts the systems of the body that control how a person moves, resulting in a loss of coordination and balance, and involuntary functions such as blood pressure or digestion), a secondary diagnosis of Parkinsonism (a disorder of the nervous system that affects movement, often including tremors), and a secondary diagnosis of repeated falls. Record review of Resident #2's MDS tab on the EMR, accessed 04/23/2025, reflected Resident #2 had two MDS assessments, a Quarterly MDS and a State Optional MDS, dated [DATE]. Resident 2 had two MDS assessments, a Quarterly MDS and a State Optional MDS, dated [DATE]. A MDS assessment was noted to have not been completed between 11/26/2024 and 02/26/2025. Record review of Resident #2's Quarterly MDS, dated [DATE] and signed as completed on 03/09/2025 by Nurse Assessment Coordinator B, reflected assessment observation end date of 02/26/2025. Resident #2 had a BIMS score of 15 indicating she was cognitively intact. She required partial/moderate assistance for transferring from lying to sitting on the side of the bed or sitting to standing. She was documented as having no falls since admission/entry or reentry or prior assessment. An injury (except major) was defined as including skin tears, abrasions, or any fall-related injury that causes the resident to complain of pain. Record review of Resident #2's Neuro Checks, dated 02/09/2025 at 06:20 p.m., reflected Resident #2 had an unwitnessed fall without evidence of a head injury. Her first noted neuro check was dated 02/09/2025 at 06:20 p.m. and she was noted to be stable at baseline. She was noted to have complaints of right shoulder and back pain but no obvious signs or symptoms of injury. She was noted to not be distressed. Record review of Resident #2's Nursing Progress Note, dated 02/09/2025 at 09:45 p.m. by LPN C, reflected Resident #2 was found lying on the floor of her room, in front of her wheelchair. Resident #2 had complaints of shoulder and back pain but with history of chronic back pain and joint pain. She had no signs or symptoms of injuries. Record review of Resident #2's Neuro Checks, dated 02/14/2025 at 03:15 a.m., signed by LPN D, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 2 of 9 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 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reflected Resident #2 had an unwitnessed fall without evidence of a head injury. Her first noted neuro check was dated 02/14/2025 at 03:15 a.m. and she was noted to be alert, with pupils equal and reactive to light, and at a zero-pain level. Record review of Resident #2's Nursing Progress Note, dated 02/14/2025 at 09:53 a.m. by LPN E, reflected Resident #2 was sitting up in her wheelchair and denied any pain or discomfort from a fall. Record review of Resident #2's Post Fall Review, dated 02/25/2025 at 06:00 p.m., signed by LPN F, reflected Resident #2 had an unwitnessed fall on 02/25/2025 at 06:00 p.m. Resident #2 was noted to be anxious or irritated and had an abrasion (scrape or cut) to her left elbow and right hand. Record review of Resident #2's Neuro Checks, dated 02/25/2025 at 06:00 p.m., signed by LPN F, reflected Resident #2 had an unwitnessed fall without evidence of a head injury. Her first noted neuro check was dated 02/25/2025 at 06:00 p.m. and she was noted to be alert, with pupils equal and reactive to light, and at a zero-pain level. Record review of Resident #2's Nursing Progress Note, dated 02/25/2025 at 06:29 p.m. by LPN F, reflected Resident #2 was found sitting on her bottom in her room, between her bed and her wheelchair. Resident #2 was noted to state, I was trying to get in my chair to go to the bathroom. Resident #2 was noted to report that her elbow was hurting, and an abrasion was noted to her left elbow and right hand in-between her thumb and pointer finger. During an observation and interview with Resident #2 on 04/24/2025 at 10:58 a.m., Resident #2 was lying in a low bed with her call light within reach. She appeared clean and groomed. She reported she had had multiple falls but had not had any injuries. She stated the reason for her falls was her trying to get from her wheelchair to her bed without calling for assistance with her call light. She stated that facility staff always checked her for injuries following her falls and encouraged her to use the call light to call for assistance. She stated she continues to go to therapy, has a wedge pillow that seems to help, and denied any of her falls were due to lack of staff assistance. During an interview on 04/24/2025 at 03:57 p.m., the Nurse Assessment Coordinator B stated the MDS assessment coordinators were responsible for ensuring the accuracy of the MDS assessments. She stated the facility also had a corporate supervisor who completed audits and double checked the facility assessment coordinator's work. She stated that she would also audit herself by double checking that she completed everything and then she would review the care plan to ensure everything was there for accuracy. She stated when completing the fall history on a MDS assessment, the procedure was for her to look at the fall UDAs for the previous quarter to identify if there was a fall. She stated the UDAs would capture if the resident had a change in condition, a fall, and a history of falls. She stated the UDAs would include post-fall reviews and details regarding IDT meetings. She stated for Resident #1, she just checked the UDA report, and Resident #1's fall on 02/03/2025 did show. She stated she must have just missed it; an oversight on her part. She stated for Resident #2, the UDA report showed the neuro checks for Resident #2 and she would consider the neuro checks to indicate a fall. She stated she probably should have caught those falls. She stated for Resident #2's fall on 02/25/2025, because of the date of the fall having been the day prior to the end date of the MDS assessment, she might have not known about it while completing the MDS look back. She stated the 02/25/2025 fall did show on the UDA report and might have had to go on Resident #2's next MDS assessment. She stated for Resident #1's fall and all of Resident #2's falls, because they were care planned appropriately, the lack of the falls having been documented on the MDS assessments would not have impacted the residents' care. She stated in these cases, the care plan would cover the residents' care needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 3 of 9 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 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/24/2025 at 05:35 p.m., the DON stated the MDS nurses would be responsible for ensuring the accuracy of the MDS assessments. She stated the facility procedure for falls was the staff had a meeting every morning where she would announce any outstanding and new falls. She stated the MDS nurses were a part of that meeting. She stated if a MDS assessment did not capture a resident's fall history accurately, it would not impact the resident's care if the care plan was updated appropriately. Residents Affected - Few During an interview on 04/24/2025 at 06:16 p.m., the ADMIN stated the MDS nurses would be responsible for ensuring the accuracy of the MDS assessments. He stated there would not be an impact on a resident's care if the MDS assessment was incorrect; however, he stated if the care plan was inaccurate, that would have impacted patient care. He stated the facility nurses and CNAs did not look at the MDS. He stated his understanding was that if the MDS was inaccurate, there might have been a financial impact for the facility. Record review of the facility's policy, Comprehensive Assessments, dated revised March 2023, reflected: Accuracy of Assessment Each resident receives an accurate team member assessment of relevant care areas that provide team members with knowledge of each resident's status, needs, strengths, and areas of decline. Assessment Process Coordination A registered nurse conducts or coordinates the assessment. The coordinator ensures that appropriate and qualified professionals contribute to the assessment. Regardless of whether the registered nurse conducts or coordinates, he or she is responsible for certifying that the assessment has been completed. Certification A registered nurse signs and certifies that the assessment is completed. Everyone who completes a portion of the assessment also signs and certifies the accuracy of that portion of the assessment. MDS information is the clinical basis for each resident's care planning and delivery. Each individual assessor is responsible for certifying the accuracy of responses on the forms relative to the resident's condition and discharge or reentry status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 4 of 9 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 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 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 resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 2 of 3 residents (Resident #1 and Resident #2) reviewed for clinical records. 1. The facility failed to ensure Resident #1's [EMR] Skin & Wound- Total Body Skin Assessments were documented in her medical record for 5 (the weeks of: 01/03/2025, 01/17/2025, 01/31/2025, 02/14/2025, and 04/04/2025) of 16 weeks. 2. The facility failed to ensure Resident #2's [EMR] Skin & Wound- Total Body Skin Assessments were documented in her medical record for 3 (the weeks of 01/14/2025, 01/28/2025, and 02/11/2025) of 15 weeks. These failures could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records. Findings included: 1. Record review of Resident #1's admission Record, dated 04/23/2025, reflected a [AGE] year-old female. She was initially admitted on [DATE] and re-admitted on [DATE]. Record review of Resident #1's Medical Diagnosis Report, undated and accessed 04/23/2025, reflected a principal diagnosis of hemiplegia (paralysis of one side of the body) affecting left non-dominant side, a secondary diagnosis of non-ruptured cerebral aneurysm (a bulging blood vessel in the brain), and a secondary diagnosis of history of falling. Record review of Resident #1's Annual MDS assessment, dated 04/09/2025 and signed as completed on 04/21/2025 by Nurse Assessment Coordinator B, reflected assessment observation end date of 04/09/2025. Resident #1 had a BIMS score of 15 indicating she was cognitively intact. She required supervision or touching assistance to roll left and right on the bed and partial/moderate assistance for transferring from lying to sitting on the side of the bed or sitting to standing. She was documented as not at risk for developing pressure ulcers/injuries and not having unhealed pressure ulcers/injuries, venous and arterial ulcers, or other ulcers, wounds, and skin problems. Record review of Resident #1's Order Summary Report for Active Orders As Of: 04/23/2025, dated 04/23/2025, reflected the following order: Complete the [EMR] Skin & Wound- Total Body Skin Assessment every evening shift every Fri for Preventative, order status Active, order date 03/29/2024, start date 04/05/2024, no end date. Record review of Resident #1's EMR including the January 2025, February 2025, March 2025, and April 2025 Licensed Nurse Administration Records; and the [EMR] Skin & Wound- Total Body Skin Assessments, located under the EMR Assessment tab reflected the following, the order Complete the [EMR] Skin & Wound- Total Body Skin Assessment every evening shift every Fri for Preventative were documented in the Licensed Nurse Administration Records as complete; however, the [EMR] Skin & Wound- Total Body Skin Assessment were not recorded in the medical records as follows: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 5 of 9 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 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 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 - On 01/03/2025, LPN G documented the [EMR] Skin & Wound- Total Body Skin Assessment as Administered; however, the assessment was not recorded in the medical record. - On 01/17/2025, LPN G documented the [EMR] Skin & Wound- Total Body Skin Assessment as Administered; however, the assessment was not recorded in the medical record. Residents Affected - Some - On 01/31/2025, LPN F documented the [EMR] Skin & Wound- Total Body Skin Assessment as Administered; however, the assessment was not recorded in the medical record. - On 02/14/2025, LPN G documented the [EMR] Skin & Wound- Total Body Skin Assessment as Administered; however, the assessment was not recorded in the medical record. - On 04/04/2025, LPN G documented the [EMR] Skin & Wound- Total Body Skin Assessment as Administered; however, the assessment was not recorded in the medical record. Record review of Resident #1's Progress Notes from 01/03/2025 to 04/23/2025 did not reveal notes regarding alternative documentation of Resident #1's scheduled [EMR] Skin & Wound- Total Body Skin Assessments. During an observation and interview with Resident #1 on 04/24/2025 at 11:06 a.m., reflected Resident #1 was sitting in a wheelchair in her bathroom. She appeared clean and groomed. She had an observed scrape on her right knee that was closed, and the surrounding skin was not discolored and did not appear irritated. She reported she did not recall how or when she obtained the skin scrape. She stated she most likely scraped it against something and denied it resulted from a fall. She reported no other skin injuries, scrapes, or wounds. LPN G and LPN F were unavailable for interview on 04/23/2025 and 04/24/2025. During an interview and record review with LPN H on 04/24/2025 at 04:36 p.m., the March 2025 Licensed Nurse Administration Record reflected LPN H had documented Resident #1's [EMR] Skin & Wound- Total Body Skin Assessment as Administered on 03/28/2025 but the Assessment was dated and signed on 03/29/2025 by LPN C. LPN H stated she could not recall completing the assessment but that it was possible she entered it on 03/28/2025 and then signed or completed it the following day. She stated that the task for completing the skin assessment would populate for the charge nurses weekly and if they were unable to complete it, they may do it the next day or next morning. During an interview and record review with LPN C on 04/24/2025 at 04:57 p.m., the April 2025 Licensed Nurse Administration Record reflected LPN C had documented Resident #1's [EMR] Skin & Wound- Total Body Skin Assessment as Administered on 04/11/2025 but the Assessment was dated and signed on 04/07/2025 by LPN I. LPN C stated the order should have been adjusted to match the completed assessment. She stated the charge nurses had the ability to adjust the orders. She stated the documentation not matching the order did not impact the resident if the assessment was completed within the 7-day period. She stated the documentation and schedule was there to remind them (charge nurses) to ensure we documented that the skin assessment was done. She stated the resident's skin would have been assessed daily regardless by the charge nurses and CNAs. She stated skin assessments were scheduled on a weekly basis, and the charge nurse for the day, the assessment was assigned to, would have been responsible for making sure the assessment was done. She stated the weekly skin assessments were important to promote skin integrity and keep the resident's skin as healthy as possible. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 6 of 9 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 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 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 2. Record review of Resident #2's admission Record, dated 04/23/2025, reflected a [AGE] year-old female. She was admitted on [DATE]. Record review of Resident #2's Medical Diagnosis Report, undated and accessed 04/23/2025, reflected a principal diagnosis of multi-system degeneration of the autonomic nervous system (a disorder that impacts the systems of the body that control how a person moves, resulting in a loss of coordination and balance, and involuntary functions such as blood pressure or digestion), a secondary diagnosis of Parkinsonism (a disorder of the nervous system that affects movement, often including tremors), and a secondary diagnosis of repeated falls. Record review of Resident #2's Quarterly MDS, dated [DATE] and signed as completed on 03/09/2025 by Nurse Assessment Coordinator B, reflected assessment observation end date of 02/26/2025. Resident #2 had a BIMS score of 15 indicating she was cognitively intact. She required partial/moderate assistance for rolling left and right on the bed, transferring from lying to sitting on the side of the bed, or transferring from sitting to standing. She was documented as at risk for developing pressure ulcers/injuries but did not have an unhealed pressure ulcer/injury, venous and arterial ulcer, or other ulcers, wounds, and skin problems. Record review of Resident #2's Order Summary Report for Active Orders As Of: 04/23/2025, dated 04/23/2025, reflected the following order: Complete the [EMR] Skin & Wound- Total Body Skin Assessment every evening shift every Tue for Skin Integrity, order status Active, order date 03/29/2024, start date 04/02/2024, no end date. Record review of Resident #2's EMR including the January 2025, February 2025, March 2025, and April 2025 Licensed Nurse Administration Records; and the [EMR] Skin & Wound- Total Body Skin Assessments, located under the EMR Assessment tab reflected the following, the order Complete the [EMR] Skin & Wound- Total Body Skin Assessment every evening shift every Fri for Preventative were documented in the Licensed Nurse Administration Records as complete; however, the [EMR] Skin & Wound- Total Body Skin Assessment were not recorded in the medical records as follows: - On 01/14/2025, LPN G documented the [EMR] Skin & Wound- Total Body Skin Assessment as Administered; however, the assessment was not recorded in the medical record. - On 01/28/2025, LPN G documented the [EMR] Skin & Wound- Total Body Skin Assessment as Administered; however, the assessment was not recorded in the medical record. - On 02/11/2025, LPN G documented the [EMR] Skin & Wound- Total Body Skin Assessment as Administered; however, the assessment was not recorded in the medical record. Record review of Resident #2's Progress Notes from 01/14/2025 to 02/11/2025 did not reveal notes regarding alternative documentation of Resident #1's scheduled [EMR] Skin & Wound- Total Body Skin Assessments. During an observation and interview with Resident #2 on 04/24/2025 at 10:58 a.m., reflected Resident #2 was lying in a low bed with her call light within reach. She appeared clean and groomed. She did not have any observed injuries or skin conditions. She denied any skin injuries and stated the staff always checked her skin following her repeat falls. LPN G was unavailable for interview on 04/23/2025 and 04/24/2025. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 7 of 9 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 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 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 During an interview on 04/24/2025 at 02:04 p.m., ADON J stated facility skin assessments were typically scheduled weekly, or at least once a week and generally on the resident's day of admission. He stated the skin assessments were documented on the facility [EMR]- Skin Assessment document and the charge nurses were responsible for completing the documentation. He stated there were two notifications for the weekly skin assessment, a UDA notice would populate for 7 days, and an order would populate on the Licensed Nurse Administration Record. He stated that both the order and UDA might overlap. He stated the weekly skin assessments were important because they provided a quick summary on the resident regarding their wound status, skin color, and skin dryness. He stated the staff needed to maintain the schedule for assessments, but the impact of a missed assessment for a resident would be dependent on the scenario and a resident's skin was also assessed during the nurses' rounds. He stated the treatment nurse, LPN K was responsible for monitoring the skin assessment UDAs to ensure they were completed by the charge nurses throughout the week. He stated that if a nurse was unable to complete the scheduled skin assessment per the order, the best practice would be for the nurse to enter in an exception code in the Licensed Nurse Administration Record. They should also have communicated that during their shift report to the next shift. During an interview on 04/24/2025 at 03:08 p.m., LPN K stated she was the facility treatment nurse and sometimes worked as a charge nurse for staffing coverage. She stated the charge nurses were responsible for completing the weekly skin assessments. She stated there was a UDA report that she would try to review every week to make sure none of the skin assessments were missed. She stated if it was near the end of the week and an assessment was scheduled and still on the UDA report, she would go do the assessment herself. She stated she typically only audited the UDA, not the order. She stated the skin assessments should be done weekly and not have been missed. She stated if a resident's weekly skin assessment was missed, then the possible impact on the resident would be hard to determine. She stated the residents' skin would still be monitored by the CNAs, when they look at the residents and by the nurses, while they complete their daily assessments. She stated residents were seen weekly, but nurses did not always document it. During an interview on 04/24/2025 at 05:35 p.m., the DON stated the weekly skin assessments were noted in the orders that the nurses would click off on and on the UDA schedules. She stated the order was a reminder for the nurses to complete the weekly skin assessment, but the nurses could also look at their UDAs to discover what they needed to do that day. She stated that she, the unit manager, and the treatment nurse monitored the order and UDAs to ensure they were completed weekly, and the order would be red on the day after the order was due and would stay red until the order was done. She stated the unit manager would look at the orders and the treatment nurse would complete any skin assessments missed on the day of her rounds. She stated the resident would not be impacted by a missed weekly assessment because their skin would also be checked in other ways, during showers and when they are assisted with changing cloths. She stated the assessment's purpose was more for documentation, to be able to document that the skin was checked at least one time a week. She stated that if a nurse was not able to complete the assessment, it would be communicated in the shift-to-shift report between nurses and that the nurse would not need to put any type of indicator in the Licensed Nurse Administration Record because the order was just a reminder. She stated for the instances for Resident #1 and Resident #2 where the Licensed Nurse Administration Record was checked off but there was not an assessment, the nurse might have thought that by clicking the order, they were documenting that they did it. She stated that this might be an area for education for the staff. She stated the other possibility was that the nurse documented the skin assessment elsewhere. She stated that the facility staff documented by exception, so if they found a skin issue, it could have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 8 of 9 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 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Heights of Bulverde 384 Harmony Hills Spring Branch, TX 78070 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 documented under risk management or a change of condition. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/24/2025 at 06:16 p.m., the ADMIN stated it was the charge nurses' responsibility to complete the weekly skin assessments. He stated that if the skin assessment was completed weekly, it was fine regardless of the date of the ordered skin assessment; however, if it was missed, it could impact the resident. He stated the CNAs also monitored the residents' skin while changing them, and the CNAs would report any changes of condition. He stated LPN K, the treatment nurse, audited for missed or open skin assessments. Residents Affected - Some Record review of facility policy, Skin and Wound Prevention and Management, dated revised January 2023, reflected: Guideline: 1. Clinical team members should regularly inspect each resident's skin to identify new skin concerns. A licensed nurse should at least weekly conduct a routine skin assessment/evaluation in order to identify new pressure injuries or other types of skin concerns. The licensed nurse should document the results of weekly skin checks in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 9 of 9