Inspection·December 10, 2025

F 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few including wandering or attempted elopements. Record review of Resident #1's IDT: Care Plan Conference & Advanced Care Planning Review., dated 06/24/2025, revealed 4. Psychiatric/Psychological Status and or Behaviors selected for under C. Advanced Care Plan: Care Choices Elected; however, additional comments not provided and secure unit placement not noted as an intervention. Record review of Resident #1's Order Recap Report, dated 09/25/2025 for order dates: 06/01/2025 - 09/30/2025, reflected no orders for secure unit placement. Record review of Resident #1's care plan, undated and accessed 09/22/2025 at 03:48 p.m., did not reveal mention of secure unit placement, risk for elopement, or wandering interventions. Record review of Resident #1's progress notes, dated 06/22/2025 (day of admission) to 06/24/2025 (day of transfer to secure unit), indicated no documentation about why a room change to the secure unit was made. No progress notes were found mentioning Resident #1 had tried to elope, ask where the exit was, or had wandering behaviors. Resident #1 was unavailable for observation or interview. During an interview on 09/26/2025 at 03:06 p.m., Resident #1's family member and emergency contact #1 stated the facility notified her of Resident #1's move to the secure unit and stated the move was due to Resident #1 having been exit seeking. She revealed she did not consent to Resident #1's move and stated she did not feel the facility attempted alternate interventions such as redirecting and providing activities to Resident #1 while he settled in at the nursing home. She revealed, upon moving Resident #1 to the secure unit, the facility staff removed some of Resident #1's personal property from his initial room. She stated the family were then notified he could not have specific items, those items removed, while he resided in the secure unit due to safety. She did not reveal if Resident #1 had a decline resulting from his secure unit placement, only mentioned Resident #1 was unable to perform some self-care tasks he typically did, such as cutting his own nails, while in the secure unit. She revealed Resident #1 was discharged home from the nursing facility per family request. During an observation and interview on 09/26/2025 at 05:52 p.m., the DNS revealed the only reason for a resident to have been placed in the secure unit was if the resident had a tendency for elopement or attempted elopement. He stated the exit seeking behavior determined the resident's need for secure unit placement. He stated an assessment would be done on the resident for exit seeking and if the resident was appropriate for secure unit placement, a consent from the family with an order from the physician would be obtained. The DNS was observed to review Resident #1's assessments to identify the exit seeking assessment and stated the assessment should have been there but he could not find it. The DNS revealed he could not recall the reason behind Resident #1's transfer to the secure unit but did not believe Resident #1 had a decline or was negatively impacted due to the transfer. He revealed there should have still been an assessment in Resident #1's EMR and the consent for transfer was a part of the assessment documentation. During an interview on 09/26/2025 at 07:00 p.m., the ADMIN revealed he recalled Resident #1's transfer to the secure unit was due to Resident #1 attempting to leave the nursing facility and asking where the exit door was located. The ADMIN stated Resident #1 was moved to the secure unit due to his attempt to elope. The ADMIN stated he did not know if the attempts or behaviors were documented but was sure the family was notified of the transfer. The ADMIN stated he was unaware of the family expressing any concerns or requests for Resident #1 to not be placed in the secure unit. The ADMIN stated he did not believe Resident #1 was negatively impacted by his secure unit placement. During an interview on 09/29/2025 at 03:32 p.m., MD D returned call for attempted interview on 09/26/2025. MD D stated he was unaware if he was required to put in a physician order for a resident to be placed in the secure unit. Record review of policy titled, Criteria for Memory Support Unit, date revised January 2023, revealed Residing on the Memory Support Unit (MSU) should be the least restrictive course of action in that it allows the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete free movement in a safe environment. The following criteria will serve as a guide for admission to and discharge from the memory care support unit (MSU).Admission- The interdisciplinary team review should review each resident's condition, need and risks when considering admission to the memory support unit.The attending physician should be consulted as part of the IDT and should provide an order for admission to the MSU.- Must be self-mobile by foot or wheelchair or another device.- Family/RP accepts the admission, transfer, and discharge criteria of the community. Event ID: Facility ID: 676418 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 observation, interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for two of six residents (Resident #1 and Resident #3) reviewed for clinical records. 1. The facility failed to ensure Resident #1's medical record included an initial physician visit note when reviewed greater than 90 days (09/22/2025) after admission [DATE]). 2. The facility failed to ensure Resident #3's medical record included an initial physician visit note when reviewed greater than 90 days (09/22/2025) after admission [DATE]). 3. The facility failed to document wound care was provided to Resident #3 on three (3) occasions (Friday, 08/22/2025, Sunday, 08/24/2025, and Sunday, 08/31/2025) on Resident #3's August Treatment Administration Record (TAR). These failures could place residents at risk of not receiving the care and services needed due to inaccurate or in-complete clinical records. The findings included:1. Record review of Resident #1's admission Record, dated 09/22/2025, revealed a [AGE] year-old male admitted on [DATE]. Resident #1 was not listed as his own responsible party with his [family member] listed as Emergency Contact #1. Resident #1 discharged on 09/01/2025. Record review of Resident #1's Medical Diagnoses, undated and accessed 09/22/2025 at 03:37 p.m., revealed diagnoses including Alzheimer's Disease (a progressive disease that affects memory and other important mental functions), muscle wasting and atrophy (shrinking of muscle or nerve tissue), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), and hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body). Record review of Resident #1's admission MDS, dated [DATE] and signed 07/03/2025 as completed, reflected a BIMS score of 09, indicating moderate cognitive impairment. Resident #1 was documented as having not exhibited any behavioral symptoms, including wandering. Resident #1's functional abilities were documented as requiring partial/moderate assistance to set up or clean-up assistance. Record review of Resident #1's discharge MDS, dated [DATE] and signed 09/06/2025 as completed, reflected Resident #1 wandered 1 to 3 days. Resident #1's functional abilities were documented as requiring supervision or touching assistance to being independent. Record review of Resident #1's progress notes dated 06/01/2025- 09/01/2025 did not reveal a progress note written by a physician or MD. A MD, NP Progress Notes, dated 07/26/2025 and signed by NP F was the only note noted in the progress notes written by the NP. Record review of Resident #1's MD, NP Progress Notes, dated 07/26/2025 and signed by NP F reflected Resident #1 was seen by NP F on 07/26/2025. Record review of Resident #1's EMR Misc tab on 09/25/2025 did not reveal documentation of a physician or MD note apart from referral documentation. Resident #1 was unavailable for observation or interview.During an interview on 09/26/2025 at 03:06 p.m., Resident #1's family member and emergency contact #1 stated she was unaware of and didn't know if Resident #1 had seen a physician while at the nursing facility. 2. Record review of Resident #3's admission Record, dated 09/22/2025, revealed an [AGE] year-old male admitted on [DATE]. Resident #3 was noted as on hospice. Resident #3 was not listed as his own responsible party with his [family member] listed as Emergency Contact #1. Record review of Resident #3's Medical Diagnoses, undated and accessed 09/22/2025 at 06:08 p.m., revealed diagnoses including chronic obstructive pulmonary disease (a type of progressive lung disease), dementia (a general term for impaired ability to remember, think, or make decisions), and adult failure to thrive (a condition where an older adult loses appetite, weight, and interest in activities). Record review of Resident #3's quarterly MDS, dated [DATE] and signed 06/22/2025 as completed, reflected Resident #3 had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 BIMS score of 03, indicating severe cognitive impairment. Resident #3 was noted as dependent for all self-care and mobility needs, except substantial/maximal assistance with rolling left or right on the bed. He was at risk for developing pressure ulcers/injuries but documented as not having a current skin condition, including a pressure ulcer/injury. He was noted to have a pressure reducing device for his chair and for his bed.Record review of Resident #3's progress notes dated 03/08/2025- 04/21/2025 did not reveal a progress note written by a physician or MD. Record review of Resident #3's EMR Misc tab on 09/25/2025 did not reveal documentation of a physician or MD note apart from initial referral, hospice, and physician orders documentation. During an observation of Resident #3 on 09/22/2025 at 04:35 p.m., he was noted to be asleep in bed. Attempted interview with Resident #3 revealed he was not interviewable. During an observation on 09/24/2025 at 12:07 p.m., Resident #3 was noted to not be present in his room. His bed was noted to have a pressure reducing mattress with scoop sides. Attempted interview with Resident #3's [family member] and emergency contact #1 on 09/26/2025 at 03:29 p.m. but they did not return the call. During an interview on 09/26/2025 at 05:52 p.m., the DNS revealed the physicians were notified immediately when a resident was admitted . He stated the physicians had a nurse practitioner in the facility multiple times a week and the physicians would come weekly to do rounds, sometimes in the morning, and sometimes on the weekend. He stated the medical records staff member was responsible for monitoring and ensuring the physician documentation was present in the resident records. He stated they would audit the records for the physician's history and physicals. He stated the physician's history and physical documentation would either be found in the resident's progress notes or under the miscellaneous tab of the EMR. He stated he did not know why there was not initial physician documentation for Resident #1 and Resident #3. He stated Resident #3 was on hospice, so it was possible the physician documentation was in his hospice binder. He stated he did not believe the lack of physician documentation would have impacted the residents' care due to both residents having been frequently seen and followed by the nurse practitioner. During an interview on 09/26/2025 at 07:00 p.m., the ADMIN revealed it was the medical records department's responsibility to upload and monitor the physician's documentation. He stated the physician's documentation was usually saved under the miscellaneous tab of the resident's EMR. He stated the physicians might email their notes to medical records, and the medical records staff member would upload them. He stated this might be done months later in some cases. He stated the delay or lack of the physician notes did not really impact the resident's care because the nurse practitioners were in the facility multiple times a week to provide care. During an interview on 09/29/2025 at 03:32 p.m., MD D returned call for attempted interview on 09/26/2025. MD D stated he messed up and forgot to send his history and physical documentation to the nursing facility for both Resident #1 and Resident #3. MD D did not reveal the dates he had initially seen Resident #1 and Resident #3. Requested a policy for Physician Services from the ADMIN on 09/26/2025. He provided policy titled, Physician Services: Medical Director. Record review of policy titled, Physician Services: Medical Director, date revised January 2023, revealed .The medical director's responsibilities include but are not limited to:.participating in establishing policies, procedures, and guidelines designed to ensure the provision of adequate, comprehensive services; participating in the resident care management system; developing written rules and regulations for all attending physicians; .consulting in the development and maintenance of an adequate medical record system; .acting as the organization's medical representative in the community.3. Record review of Resident #3's care plan, dated 08/05/2025, revealed Resident #3 had actual or was at risk for skin impairment, with an actual impairment on his sacrum (the triangular bone at the base of the spine). The interventions included *Apply treatment as ordered and *Skin Risk: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 Keep clean & dry and apply skin barrier cream as indicated. The care plan focus was created and initiated on 05/05/2025 and revised on 09/17/2025. Record review of Resident #3's EMR revealed a Skin & Wound Evaluation., dated 06/23/2025 and signed 06/25/2025. Resident #3 was noted to have a shear (a wound resulting from downward pressure and friction) on his sacrum, present on 06/23/2025. The wound was noted as 5.6 cm, length by 3.1 cm, width and without depth. Record review of Resident #3's EMR revealed a Skin & Wound Evaluation., dated 08/29/2025 and signed 08/29/2025 by LPN A. Resident #3 was noted to have a stage 3 (full-thickness skin loss) pressure wound on his sacrum, present on 06/23/2025. The wound was noted as 1.8 cm, length by 1.2 cm, width and without depth. The wound was documented as stable.Record review of Resident #3's Order Summary Report, dated as Active Orders As Of: 09/22/2025, reflected the order: Wound Care: Cleanse sacrum with normal saline, pat dry, apply Cal alginate&silver [sic] cover with dry dressing. every [sic] day shift for wound care till healed. Order noted as Active with order date, 07/25/2025, and start date, 07/26/2025.Record review of Resident #3's Treatment Administration Record, printed on 09/22/2025 and revealing treatments from 08/01/2025- 08/31/2025, reflected the order: Wound Care: Cleanse sacrum with normal saline, pat dry, apply Cal alginate& [sic] silver cover with dry dressing. every [sic] day shift for wound care till healed, start 07/26/2025 0700 [07:00 a.m.]. The treatment for the order was scheduled at Day 0 and was found to be blank on the treatment administration record for Friday, 08/22/2025, Sunday, 08/24/2025, and Sunday, 08/31/2025. Other medications and treatments scheduled at Day 0 revealed the following staff provided Resident #3 care during the shift the wound care treatment was scheduled: LPN B on 08/22/2025, RN H on 08/24/2025, and LPN C on 08/31/2025. Record review of Resident #3's SBAR Communication Form, dated but unsigned 09/23/2025, reflected Resident #3 had a change in his Skin wound or ulcer, which started on 09/23/2025. Under skin evaluation, wound deteriorating was noted. Under appearance, Stage 3 pressure wound not healing, deteriorating. Hospice aware & changed Tx noted. Record review of Resident #3's progress notes and skin and wound evaluations, revealed no documentation as to why the treatment was not done on 08/22/2025, 08/24/2025, or 08/31/2025. No other documentation was presented.During an interview on 09/26/2025 at 04:48 p.m., Resident #3's hospice RN revealed she observed initial problems, in June 2025, with the nursing facility staff regarding Resident #3's dressing, but the concerns were investigated and had been addressed. She revealed she felt the facility wound care had improved since the initial concerns. She revealed Resident #3's wound had been difficult to treat due to his complex medical conditions. She was unable to provide specific dates or state if wound care treatments had been missed. During an interview on 09/26/2025 at 12:32 p.m., LPN A stated the blanks in Resident #3's treatment records indicated the treatment was not checked off, indicating the treatment might have been completed but the nurse forgot to document the treatment completion. LPN A stated she believed she was out on planned leave on 07/22/2025 and 08/22/2025 and did not work on the weekends (08/31/2025 was a Sunday). She stated the nurses on the floor would cover wound care treatments when she was not at the facility. She stated the nurses had access to the treatment records and the treatments would have stayed open until someone clicked them off, indicating the treatments would have shown as due until a nurse noted they were completed. She stated she could not state what occurred on those dates, but she would have known if the treatment was not provided because the patches on the residents would have been dated and she would have noted a missed day. She stated she could not recall the dates in question. She stated she did not believe the residents were impacted by the nurses having not clicked off on the treatment record that they provided care because the care would have still been done. Attempted interview with MD E, Wound Care Specialist, on 09/26/2025 at 03:31 p.m., no return call received.Attempted interview with LPN B on 09/26/2025 at 05:05 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete p.m., no return call received.Attempted interview with LPN C on 09/26/2025 at 05:45 p.m., no return call received.Requested a policy for Wound Care from the ADMIN on 09/26/2025. He provided policy titled, Skin and Wound Prevention and Management. Record review of policy titled, Skin and Wound Prevention and Management, date revised January 2023, revealed .Each resident will receive the care and services necessary to retain or regain optimal skin integrity.Guideline: . 5.The licensed nurse should then document the notifications [sic] and any orders provided within the electronic health record. 6. The licensed nurse should communicate and collaborate with the IDT regarding the associated risks, identified wounds, skin concerns, and implement appropriate interventions. Event ID: Facility ID: 676418 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/10/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 laundry room reviewed for infection control. The facility failed to properly store clean resident clothing and mechanical lift slings in the facility clean laundry room.These failures could place the residents at risk of cross-contamination and development of infection.The findings included:During an observation of the clean side, noted on door of laundry room, of the nursing facility laundry room on 09/22/2025 at 04:52- 04:53 p.m., observed a bag of clean resident clothing, stored in a large clear bag with a hole in the bottom of the bag resulting in clothing spilled out and touching the laundry room floor. Observed approximately 5 mechanical lift slings hanging off the side of a trash can with straps of the slings touching the floor. During an interview on 09/26/2025 at 11:07 a.m., the LAM revealed he had been working as the manager for the facility's laundry for two weeks. He revealed the facility had been having issues with the laundry prior to his start and that he was still working to ensure all the resident clothing was cleaned and returned. He did not mention proper clothing or equipment storage for sanitation. During an interview on 09/26/2025 at 05:52 p.m., the DNS revealed the laundry services had been improving but he wouldn't say they were perfect yet. He revealed the department head for laundry was new. He did not mention proper clothing or equipment storage for sanitation. During an interview on 09/26/2025 at 07:00 p.m., the ADMIN revealed the facility had lost the prior laundry manager and had to let go of around 4-5 people in the laundry department recently due to not performing their job duties correctly. He revealed due to those changes the contracted laundry company had to send other people in to help with laundry and a new manager, the LAM, just started around 2 weeks ago. He did not mention proper clothing or equipment storage for sanitation. Requested policies for Laundry and Infection Control from the ADMIN on 09/22/2025. He provided policies titled, Routine Resident Care.Record review of policy titled, Routine Resident Care, date revised January 2023, revealed Residents should receive the necessary assistance to maintain good grooming and personal/oral hygiene.Care is taken to maintain resident safety at all times.f. Multi-patient use equipment should be cleaned/disinfected after patient use. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676418 If continuation sheet Page 8 of 8