Health inspection·October 13, 2022

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent Urinary Tract Infection (UTI's) and to restore continence to the extent possible for one of three residents (Resident #87) reviewed for bladder incontinence. The facility failed to ensure Resident #87's urinary drainage tubing and bag were kept from touching and resting on the floor. This deficient practice could place residents at risk of developing or increased UTI's. The findings include: Record review of Resident #87's face sheet, dated 10/11/22, documented a [AGE] year-old female with an admission date of 06/23/22 with diagnoses which included multiple sclerosis (disease in which the immune system eats away at the protective covering of nerves), tachycardia (fast heart rate), bipolar disorder, weakness, dementia, neuromuscular dysfunction of the bladder, history of urinary tract infections, and muscle spasms. Record review of Resident #87's physician order summary, dated 10/11/22, documented an order started on 03/28/22 for 18 French Foley catheter 30 cc balloon. Record review of Resident #87's physician order summary, dated 10/11/22, documented an order started on 03/28/22 for privacy bag in place on wheelchair/ bed at all times, every shift, day, evening, and night. Record review of Resident # 87's Minimum Data Set (MDS), dated [DATE], revealed: - BIMS of 14, which indicated the resident was cognitively intact -required extensive one-person physical assistance with bed mobility, dressing, toilet use, and personal hygiene. -had an indwelling catheter and is always incontinent. Record review of Resident #87's care plan, dated 09/22/22, documented: start date of 08/15/22 - Category: Indwelling Catheter- Resident with Suprapubic catheter. Goal: Efforts will be made for Suprapubic catheter will remain in place without complications over the next 90 days. Approach: Monitor for signs and symptoms of infection, bladder stones, septicemia (life threatening complications of an infection), skin break down, urine leakage around the catheter, urinary tract infection. Provide Cath care as directed, secure tubing and position tubing and urine collection bag below level of bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 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 675943 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Hope Manor 1623 W New Hope Dr Cedar Park, TX 78613 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation of Resident # 87 on 10/11/22 at 10:59 AM revealed she was laying in a low bed with her Foley catheter bag and tubing laying on the floor. During an interview with Resident # 87 on 10/11/22 at 11:03 AM revealed she was unsure when her foley catheter bag fell or why it was placed on the floor. She stated she was unable to move her foley bag or adjust it because she could not turn all the way to pick the foley catheter bag up from the floor. She was able to press the call light for assistance. She revealed she had not had a urinary tract infection lately and could not recall the date of the last infection. During an interview with CNA D on 10/11/22 at 11:19 AM revealed the residents Foley catheter bag and tubing should not be touching the floor and should hang on the side of the bed. She stated she had not worked with Resident #87 and did not know why the foley catheter bag was resting on the floor. She revealed CNA's had been educated and in-serviced by the facility on ensuring the residents catheter did not touch the floor for infection control purposes. She stated when a catheter touched the floor there could be an increased risk of infection for Resident #87. During an interview with LVN A on 10/11/22 at 11:21 AM revealed the Foley catheter should not be on the floor. She stated, the catheter bag should be below the bladder hanging on the bed and not touching the floor. She revealed having the catheter bag and tubing on the floor could cause contamination and bacterial infections. LVN A revealed it's the nurses and CNA's jobs to check the foley catheter every 2 hours and as needed to make sure its secured, not full of urine, and not touching the floor. She revealed it was ultimately the charge nurses jobs to monitor the staff to make sure they were hanging the catheters safely and securely. She was unable to identify who placed the catheter on the floor or if it fell on its own. During an interview with the DON on 10/12/22 at 4:31 PM revealed the Foley catheter and bag should not be on the floor. She revealed it should be hanging on the bed at or below the height of the bladder. The DON stated it's important to not let the Foley catheter touch the floor because of infection control, bacteria could travel up to the bladder and cause infections. She revealed its everyone's jobs to make sure it's not touching the floor, anyone could at least identify it and let a nursing staff know, so they could help fix it or adjust it. She revealed all CNAs had a competency check off for Foley catheter care in June 2022, and staff had been educated on care of a Foley catheter. Record review of the facility's Catheter Care, Urinary Policy, dated September 2014, documented the purpose of this procedure was to prevent catheter-associated urinary tract infections. 2. b. Be sure the catheter tubing and drainage bag are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 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 675943 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Hope Manor 1623 W New Hope Dr Cedar Park, TX 78613 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 in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 1 nutrition room reviewed for sanitation. The facility failed to ensure the steam table holding temperatures were accurate. The facility failed to ensure the thermometer calibration for the steam table holding temperatures was done. The facility failed to maintain the monthly temperature logs for the nutrition refrigerator, and the logs were either missing information, scantily recorded, or completely missing, and one was falsified. The facility failed to ensure the thermometer inside the nutrition refrigerator was operable. These failures could place residents at serious risk for complications from food contamination, and/or foodborne illness. The findings were: An interview and observation on 10/11/22 at 09:30 AM during the initial tour of the kitchen with DMA revealed dietary was responsible for stocking, monitoring, and cleaning the nutrition refrigerator. Observation and interview with COOKA on 10/11/22 at 11:55 AM revealed she did not calibrate the thermometer before taking the temperatures of the food on the steamer table. Her readings were: pureed pork = 154 degrees F, pureed rice = 136 degrees F, and mechanically chopped pork = 141 degrees F. She said the thermometer did not always work and it was the only one they had in the kitchen. She said she had never calibrated a thermometer, and she did not know how. She said she puts the number the thermometer showed on the log. She said she did not know if the temperatures were accurate. She said the residents could get sick if the temperatures were not good. She shrugged her shoulders and shook her head from side to side, indicating a no answer when asked if it was ok to make up temperature readings and log them. Food holding on a steamer table should have a temperature of 141 degrees F or above. An interview with the DMA on 10/11/22 at 12:00 PM revealed he would go get more thermometers. When asked who was responsible for monitoring the temperature logs for the steam table, he said he was just filling in for the regular DM (DMB), who was out sick for a couple of days. He said he did not know what kind of teaching nor who teaches or gives in-services to the dietary staff. Observation of the nutrition refrigerator in the dining room on 10/11/22 at 12:05 PM revealed a photo and instructions on how to read a thermometer taped to the outside of the door. The thermometer inside the refrigerator was not the same design as shown on the door and did not work. The temperature logs were blank for 2022 except July 1st; 40 degrees F, 2nd; 40 degrees F, 3rd; 39 degrees F, 4th; 41 degrees F, 5th; 40 degrees F, 6th; 42 degrees F, and June 10th; 36 degrees F, 13th-30th; 38-41 degrees F. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 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 675943 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Hope Manor 1623 W New Hope Dr Cedar Park, TX 78613 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 An interview with the AAD (assistant activity director) on 10/11/22 at 12:10 PM revealed the photo on the nutrition refrigerator door did not represent the one inside the refrigerator. She also stated the thermometer inside the refrigerator was the only thermometer in the refrigerator or freezer and it was not working. She also stated the temperature logs had not been filled out. Observation of the October nutrition refrigerator log on 10/12/22 at 4:14 PM revealed temperatures written in for the 8, 9, 10, 11, and 12. Except for the 12th, the temperatures recorded were all above the required 41 degrees F. An interview with the DMA on 10/12/22 at 4:20 PM (referring to the broken thermometer in the nutrition refrigerator and the refrigerator logs) revealed he was not sure how long it had been going on, but probably more than 3 years because that was how long he had been (employed) there. He said he should have been more diligent with the monitoring of the nutrition refridgerator logs and thermometer. An interview with the DMA and DMB on 10/13/22 at 02:05 PM revealed: The DMB said the cooks took the temperatures of the food on the steamer table 15 minutes before service, and the temperatures were written in the log. He also explained the temperatures were important so we do not make people sick because of how bacteria would grow if it was not at the correct temperature, especially ground beef. He said the dietary staff were trained to take the temperatures of the food before it went on the steamer table. He said he trained the entire dietary staff. He said he provided in-services like infection control, life safety, cleaning procedures, hairnets, cross-contamination, dishwasher temperatures, and temperatures of food. He said there was no excuse for not calibrating the thermometer. The DMA said he was supposed to do that (the in-services), but DMB did a much better job. He said, we haven't had any incidents. The DMB said in-services were done once a month and as needed. He said he went through the in-service and showed them, then they returned his demonstration. He said if they messed up, he showed them until they got it right. The DMA said he did not know where the numbers came from (on the 8, 9, 10, 11, and 12) on October's log when they were not there before. He said they had no idea how long the thermometer was not working. He said the morning dietary aids were responsible for monitoring the logs. He said he did not know who filled in the October log, then said it was HSK who filled them in. He said he was told by her that another page (for October) had been found and HSK said that's where she got the information, but she had thrown it (the other page) away. DMB said DMA was responsible for monitoring the logs and thermometers. DMA said, he just didn't do it, and to be honest, I didn't think about that refrigerator because the staff cleans that one. DMB said orientation was verbal and a walk-through. He said training consisted of questions being answered, demonstrations, return demonstrations, such as how to use the equipment, and in-services when he could get to them. He said he was unaware the cook did not know how to properly temp the food being served to the residents. He did not provide an answer as to the gaps in the in-services. HSK was unavailable for an interview on 10/13/22 at 2:30 PM. An interview with the ADM on 10/13/22 at 4:30 PM revealed it was time for changes in the leadership in the kitchen to be made. She said DMB recently completed a dietary manager's program dated 05/23/22. She said DMA only had a food manager certificate dated 03/18 20. She said she was unaware of the problems with temperatures-those from both the refrigerator and the steamer table. She said she would make sure she monitored the kitchen more closely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 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 675943 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Hope Manor 1623 W New Hope Dr Cedar Park, TX 78613 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 Record review of dietary in-service training reports dated 4/25/22; accident prevention, 05/06/22; minimum notice for requested days off, 07/06/22; handwashing, 08/15/22; dish machine temperatures, 08/28/22; food temperatures, 09/20/22; mandatory hair coverings. There were no in-service records for the months of January, February, March, June, or October. A record review of the facility's un-dated dietary manager's training tool kit on page 14 titled, how to calibrate a food thermometer included three step-by-step instructions with pictures. Event ID: Facility ID: 675943 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 675943 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Hope Manor 1623 W New Hope Dr Cedar Park, TX 78613 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of twenty residents (Resident #65) reviewed for accommodation of needs. Residents Affected - Few The facility failed to ensure Resident #65's room was equipped with a functioning call light or alternate methods to call for assistance. This failure could place residents at risk for not having his needs met. Findings include: Record review of Resident #65's face sheet, dated 10/12/22, documented an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Fractured left femur, unsteadiness of feet, anxiety, dementia, muscle weakness, overactive bladder, and Rheumatoid arthritis. Record review of Resident #65's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #65: -had a BIMS Score of an 8, which indicated the resident had moderate cognitive impairment. -was independent with bed mobility and eating with set up only. -was independent with transfers, locomotion on unit and off unit. -required supervision with set up help only for toilet use and dressing. -was always continent of bowel and bladder. Record review of Resident #65's fall care plan, dated 08/16/22, documented the resident was at risk for falls (resident had a fall on 10/03/21 self-transfer from bed). Goal: Effort will be made to prevent falls/falls with injury. Approach: Call light within reach. Remind resident how to use as needed. Anticipate needs. During an observation of Resident #65 on 10/11/22 at 9:30 AM revealed she was in her bed resting. No call light was noted in the room. Further observation of the call light system outlet on the wall revealed, a severed call light cord. Resident #65 did not have a hand bell or alternate means of calling for aid provided to her. During a interview with Resident #65 on 10/11/22 at 9:35 AM revealed she was unable to voice where the call light was in her room. She stated, I don't have a call light. Resident #65 stated she gets up and asks for help when she needs to contacts staff for help,. She also stated, she did not need help since she could do everything for herself. She was noted with some confusion during the interview she believed she was alone in a home and cooked, cleaned, and provided for herself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 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 675943 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/13/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE New Hope Manor 1623 W New Hope Dr Cedar Park, TX 78613 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 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with LVN B on 10/12/22 at 3:32 PM revealed when a resident needed assistance in their room, they should push the call light to alarm the nurses station of which room needed assistance. He stated all call lights should be within reach of the residents at all times. During an observation with LVN B at 10/12/22 at 3:33 PM revealed Resident #65's room did not have a call light. He stated he had no idea how long the resident had been without a call light or why Resident #65's room did not have a calling system. He revealed he never noticed if there was a call light in that room. He revealed the resident was confused but could use a call light and should have had one. He revealed it was everyone's responsibility to ensure the resident's call lights were within reach for safety reasons. He revealed it's important to have a call light to allow residents to call for help to prevent falls and to allow a better standard of care. During an interview and observation of Resident #65's room with MS on 10/12/22 at 3:40 PM revealed Resident #65 did not have a call light or bell in her room. He stated, she did not have a call light system because of her confusion. He revealed he was unsure why she did not have a call light, but he stated she had a bell at her bedside she could ring if she needed anything but while searching Resident #65's room he was unable to locate the bell. He asked Resident #65 where her bell was, and Resident #65 stated I don't have a bell. He revealed he was not sure how long the resident had a been without a bell, or since when the resident received the bell, and he was not sure why Resident #65 did not have a call light. During an interview with CNA C on 10/12/22 at 3:41 PM revealed on Sunday (10/09/22) when she worked, Resident #65 had a call light. She was unsure what happened to the call light or the bell Resident #65 had. She revealed she had been in-serviced on ensuring call lights were within reach of all residents. She revealed it was important that the residents had a call light within reach because if they needed something they could push it to reach a staff member and let them know they needed something. During an interview with the DON on 10/13/22 at 8:41 AM revealed she was unsure why Resident #65 did not have a call light in her room. The DON stated she tried to find documentation from when Resident #65 was on suicidal watch when admitted to the facility about 2 years ago. She revealed when a resident was on suicidal watch, the resident's call light ropes were removed to prevent choking or strangulation and were given another type of bell with no attachments that could be safe. The DON stated, Resident #65 was not on suicide watch and could not give a date of when suicide watch was completed for Resident #65. DON revealed she was unsure why the resident did not get a call light after suicide watch was over. She revealed it was important for all residents to have a call light or call system such as a bell, so they could ring to call for assistance. She revealed staff had been verbally in serviced on placing call lights within reach of residents to prevent falls. She revealed there was no competency check offs or written education for these teachings. The DON revealed she ensured proper placement of call lights by making rounds around the facility when she could. She revealed CNA's and charge nurses made rounds every 2 hours and as needed. Record review of the facility's Answering the Call Light policy, dated October 2010, documented the purpose of this procedure was to respond to the resident's requests and needs.General Guidelines: 1. Explain the call light to the new resident .4. be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .7. Report all defective call lights to the nurse supervisor promptly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 8 of 8