Health inspection·December 14, 2023

F 0638 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interest and can interfere with daily routine), bradycardia ( a slow heart rate), and age related physical debility (a state of general weakness or feebleness that may be a result or an outcome of one or more medical conditions that produce symptoms such as pain, fatigue, cachexia and physical disability, or deficits in attention, concentration, memory, development and/or learning). Review of Resident #63'Quarterly MDS dated [DATE] was the last full MDS completed and transmitted by the facility. Review of Resident #63's Quarterly MDS dated [DATE] reflected in the electronic medical record the MDS was in progress. In section Z of the MDS, Z0500, Signature of RN Assessment Coordinator Verifying Assessment Completion, was not signed or dated. The Quarterly MDS was required to be completed, signed and transmitted by the due date of 11/23/2023. Review of Resident #63's last Comprehensive Care Plan was completed on 10/11/2023 and there was not an MDS completed to reflect what was documented on the care plan dated on 10/11/2023. In an interview on 12/14/2023 at 8:40 AM the MDS Coordinator stated the due date for Resident #63's Quarterly MDS was 11/23/2023. She stated she had not transmitted the MDS with the ARD date of 11/9/2023 she stated the assessment was complete, but she had 90 days to do it. She stated the same for Resident #2 with her due date being 12/1/2023 she stated she did not speak well and was maybe not telling the surveyor the right thing so she would speak to her DON and get the DON to explain and bring the facility policy and procedure. In an interview on 12/14/23 at 9:39 AM the DON she stated her expectation was that assessments be completed and transmitted on time. She stated she tracks the completion of the MDS's, and the report did not show any late assessments. She stated after looking in the EMR that Resident #2 and Resident #63 MDSs were still in process and had not been transmitted. She stated it appeared to be an education issue with the MDS Coordinator and she would provide her more training. She further stated she would get with IT to see why her report was not showing the MDS's had not been transmitted to CMS. Review of the facility policy Transmission of the MDS dated 09/2010 reflected All MDS assessments (e.g., admission, annual, significant change, quarterly review, etc.) and discharge and reentry records will be completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data . 6.The MDS Coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data and that feedback and validation reports from each transmission are maintained for historical purposes and for tracking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 2 of 11 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 12/14/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure a PASRR screening was completed for residents with mental disorder or an intellectual disability for one of three residents (Resident # 11) reviewed for PASRR Level I screenings. The facility failed to ensure an accurate PASRR Level I screening (a preliminary assessment completed for all individuals prior to admission to a Medicaid - certified nursing facility to determine whether they might have a mental illness or intellectual disability) was completed for Resident #11. Resident #11 was readmitted after hospitalization on 2/08/22 with the diagnosis of Bipolar disorder. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services accordance with individually assessed needs. Findings include: Review of the Face Sheet for Resident #11 reflected she was a [AGE] year old female admitted on [DATE] with diagnosis of: Chronic Atrial fib , Weakness, Bipolar Disorder(02/08/22), Osteoporosis , unspecified Dementia (2/08/22). Resident #11 was readmitted on [DATE] after hospitalization for change in mental status. Review of the quarterly MDS assessment for Resident #11 dated 8/23/23 reflected a BIMS score of 11 indicating moderately impaired cognitive abilities. Her functional assessment reflected she needed extensive assistance for all ADLs except eating. She was assessed as incontinent of bowel and bladder. Review of the Care Plan dated 11/08/23 for Resident #11 reflected interventions were in place for: Behavioral symptoms- making accusations about roommate, refuses to allow brief changes, Insomnia, Osteoporosis, History of Falls, Resists care-bathing, bipolar disorder with extreme mood swings, Dementia, DNR order in place. Resident #11's care plan listed behavioral symptoms including impaired judgement, dangerous/extreme mood swings and refusal to complete tasks. Review of Records for Resident #11 reflected her PASRR evaluation dated 11/13/2020 was negative and no diagnosis of mental illness was checked. Resident #11 facility records reflected she had a diagnosis of bipolar disorder dated 2/08/22. Review of History and Physical Records for Resident #11 dated 12/16/22 reflected the resident had a diagnosis of Dementia, Bipolar Disorder, a history of falls and high blood pressure. Observation of Resident #11 on 12/12/23 at 10:02 am revealed her room contained a strong urine odor smell. In an interview Resident #11 stated her roommate was responsible for the odor and refused care from staff. Observation of Resident #11 on 12/12/23 at 3:05 pm revealed the urine smell was gone from the room. Resident #11 stated she had received a shower that day, but her roommate had refused to shower. In an interview on 12/13/23 at 9:25 am LVN P stated Resident #11 had a behavior of refusing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 3 of 11 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 12/14/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few incontinence care. She stated she tried to stay on top of Resident #11's care and offered to bath her frequently. The LVN stated a Resident #11 had a history of mental illness. In an interview on 12/14/23 at 10:20am the DON stated Resident #11 most recent PASRR uploaded reflected she was negative for mental illness. She consulted with other staff and stated her diagnosis of bipolar disorder was not new and the resident had her needs met and her condition was stable. She stated therefore the PASRR evaluation would be negative for further services. The DON stated the regional coordinator was in the building and a new PASRR evaluation would be completed today. The document the DON showed the surveyor had mental illness diagnosis was checked and bipolar disorder was written in . In a further interview at 10:38 am the DON stated the facility was wrong and the PASRR should have been redone when Resident #11's Bipolar diagnosis was verified. She confirmed the bipolar disorder diagnosis was added on 2/08/22 after Resident #11 returned from an acute care hospital for treatment of Pneumonia. She stated the facility was in the process of redoing the PASRR assessment immediately. In an interview on 12/14/23 at 11:25 am the Administrator stated staff should have been following guidance and reassessing Resident #11's needs when the Bipolar diagnosis was added. Review of the Facility Policy on PASRR assessments supplied to surveyor on 12/14/23 reflected a new PL1 (PASRR level 1) assessment should be completed when a resident returns from hospital. The policy reflects any person diagnosed with a major mental disorder as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) should be noted as positive in a PL1 assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 4 of 11 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 12/14/2023 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the staff failed to provide daily hygiene and dressing assistance to one of two residents (Resident #30) reviewed for ADL care. Staff failed to provide Resident #30 with a change of clothes for threee days. Residents Affected - Few The facility failed to assist Resident #30, who required staff assistance, to change her clothes for 3 days on 12/12/23, 12/13/23 and 12/14/23. This failure could place residents at risk of not receiving care and services to meet their needs and a decreased quality of life. Findings include: Review of the Face sheet for Resident #30 reflected she was admitted on [DATE] with diagnosis of: Dementia, Pneumonia, Bronchitis, Heart Failure, Senile Degeneration of brain, Alzheimer's disease, Obstructive Uropathy , Generalized Anxiety disorder. Her chart reflected she had a Do Not Resuscitate (DNR )order and was receiving Palliative care . Review of the MDS for Resident #30 dated 10/04/23 reflected a BIMS score of 5 indicating severe cognitive impairment. Her assessment had no behaviors marked. Her functional assessment reflected she required one person assistance for most ADLs and two person assist for mobilizing. Resident #30 was asessed as requiring moderate or more than half the work for dressing herself. She was assessed as always continent of bowel and bladder. Review of the Care Plan for Resident #30 reflected interventions were in place for: Hard of Hearing with hearing aides, Cognitive loss/Dementia, Osteoporosis , Occasionally incontinent of bowel and bladder, needs extra time for ADLs, Fall risk. The plan listed interventions for one to one activities to be offered in her room. The Care Plan did not mention refusal behaviors except to allow the Resident extra time and to honor her choices for clothing, food and her physical limitations. No other interventions for dressing assistance were listed, only provide time for care and ensure and allow appropriate clothing choices. Review of Progress Notes dated from 9/01/23 to 12/14/23 reflected infrequent notations of Resident #30 refusing to bath. On 12/14/23 a progress note mentioned three aides had reported Resident #30 had refused to change her pink nightgown. The name of the aides was not listed. Review of the Skin Assessment for Resident #30 dated 12/01/23 reflected no impairment of the skin was found. Observation on 12/12/23 at 10:02 am revealed a strong urine smell was present in the room housing Resident #30 and #11 . Resident #30 was seated in her wheelchair, wearing a pink nightgown with her name written on the back. She stated she was fine and had no complaints about her care. Observation on 12/13/23 at 8:55 am of Resident #30 revealed she was wearing the same pink nightgown as the previous day. The strong urine smell in the room was gone. In an interview on 12/13/23 at 9:00 am CNA H she stated she was not aware Resident #30 wore the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 5 of 11 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 12/14/2023 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 0677 Level of Harm - Minimal harm or potential for actual harm same clothing as the previous day, she stated she did not regularly work on Hall 4. She stated Resident #30 was due for a shower today . In an interview on 12/13/23 at 9:25 am LVN P stated Resident #30 was due for a shower today and had a behavior of wanting to not change her clothing each day. Residents Affected - Few In an interview on 12/14/23 at 8:15 am LVN P stated Resident #30 should have received a shower yesterday and she had no idea why she would be wearing the same pink nightgown for three days. Observation on12/14/23 at 8:02 am of Resident #30 seated in wheelchair in room [ROOM NUMBER] revealed she was clothed in the same pink nightgown as on previous days. In an interview on 12/14/23 at 8:33 am the DON stated she was not aware Resident #30 was wearing the same pink nightgown for three (3) days. She reviewed computer records and stated Resident #30 was due for a shower on 12/13/23 and she would check if she received one. She noted Resident #30 had a history of behaviors of refusing care, showers and clothing changes. In a further interview on 12/14/23 at 10:00 am the DON stated Residents on 400 hall were bathed twice a week and if a resident refused a shower or bath, they could go up to seven days without a bath. The charge nurse was responsible for supervising Resident care. In an interview on 12/14/23 at 10:30 am CNA G stated she had worked with Resident #30 many times and she just flatly refused to shower or change her clothes at times. She stated her family member visited daily and she would ask her to convince her mom to shower and change. When asked what the facility did when Resident #30 refused care, CNA G responded they called her family member. Observation on 12/14/23 at 10:35 am revealed Resident #30 was seated in her wheelchair and wearing the same pink nightgown with her name on the back. In an interview on 12/14/23 at 11:25 am the Administrator stated her expectation was ADL care would be completed daily by aides. She stated the charge nurse and DON were responsible for overseeing care. The facility stated no policy was available for assisting residents with ADL care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 6 of 11 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 12/14/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure residents who was fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #69) of two reviewed for enteral feeding. LVN A failed to inject air into Resident #69's gastrostomy tube and listen with a stethoscope for air movement. This failure could place residents with gastrostomy tubes at risk of medical complications, and a decline in health due to inappropriate care. Findings included: Review of Review of Resident #69's Face Sheet, dated, 12/12/2023 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body function), feeding difficulties (delays and/ or disorders in the development of eating), and malaise (feeling tired, not hungry, no energy, and body aches). Review of Resident #69's Quarterly MDS, dated , 08/16/2023 reflected Resident #69 was assessed to have a BIMS score of six indicating severe cognitive impairment. Resident #69 was assessed to require assist with eating, personal hygiene, and bathing. Resident #69 had a feeding tube. Review of Resident #69's Comprehensive Care Plan dated 11/29/2023 reflected Resident #69 required a peg tube for adequate nutritional intake and for medications. Interventions: Check for residual before initiating Resident #69's feeding. Monitor for changes that may indicate worsening of Resident#69's condition and notify the physician. Observation of Gastrostomy bolus feeding for Resident #69 on 12/13/23 at 12:10pm revealed care by LVN A was unsafe in two ways. The LVN was observed injecting air into the feeding tube/Gastrostomy with a large syringe and listening with a stethoscope for air movement. This process is known as auscultation and is not recommended due to the risk of introducing infectious agents into the abdomen and the added risk a displaced tube would inject air into the abdomen and lead to other problems. The LVN was observed flushing the feeding tube with water before checking if any residual volume was present, normally performed by gently pulling outward on the feeding syringe. Resident #69 received 250 ml of Nutien 2.0 feeding tube formula and his feeding tube was flushed again with water after the feeding. Resident #69 stated he was comfortable and displayed no signs of gastric distress after the feeding. In an interview on 12/13/23 at 12:35pm LVN A stated she was not aware the use of injecting air for auscultation was no longer recommended. She stated she had been trained in nursing school to use auscultation and had continued to do so. The LVN stated she was aware she did not check or residual volume and stated she may have felt nervous about being observed. In an interview on 12/14/23 at 10:23 am the DON stated she was not aware the auscultation of air was no longer recommended for checking Gastrostomy/feeding tube placement. She consulted the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 7 of 11 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 12/14/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few policy which reflected tube placement must be verified' but did not reflect how the placement was to be verified. The surveyor referred her to CMS regulation F693. In an interview on 12/14/23 at 11:25 am the Administrator stated her expectation was nursing staff would follow recommended clinical practices. She stated she was not a nurse and depended on licensed staff for safe clinical practices. Review of the Enteral Tube Feeding Policy dated November 2018 the policy reflected the nurse should verify the placement of the tube without describing a method for verifying. Monitor the resident for signs of aspiration or feeding intolerance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 8 of 11 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 12/14/2023 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 - Many 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 food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary Aide B, Dietary Aide C, and Dietary [NAME] D properly sanitized her hands between tasks. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: 1. Observation on 12/12/2023 beginning at 7:40 AM revealed Dietary Aide B was not wearing gloves. She touched her shirt, picked up her personal cell phone, and touched disinfectant wet cloth to wipe the food prep table. Dietary Aide B touched all the fourchettes (a narrow strip that joins the front and back sections of the fingers of a glove) on both gloves when obtained the gloves from the container. Dietary Aide B did not wash her hands when she placed the pair of gloves on her hands. Dietary Aide B also touched her shirt and touched the disinfectant rag after placing gloves on her hands. She began to open raisin bread package and touched the bread to with all her fingers on her right hand. Dietary Aide B placed the raisin bread in the toaster oven for the resident's breakfast. In an interview on 12/12/2023 at 2:05 PM (interpreter was the Dietary Manager) Dietary Aide B stated she was in a hurry completing her tasks prior to breakfast. She stated she did touch her personal phone, touch her shirt, and may have touched the disinfectant rag to wipe off the food prep table. She stated she did not wash her hands prior to placing gloves on her hands and she did touch the outside of the gloves prior to placing the gloves on her hands. Dietary Aide B stated she touched the raisin bread bag when opening the bag to get the raisin bread and put the bread in the toaster oven. She also stated the germs from her cell phone, her clothes, the disinfectant rag, and the bread bag was considered contaminated. Dietary Aide B stated she was expected to wash her hands when she touched any item considered contaminated. She also stated when she placed gloves on her hands, she was not to touch the outside of the gloves where her fingers go inside the gloves. She stated she did contaminate the gloves. Dietary Aide B stated when she touched the bread and placed the bread in the toaster, she had a potential to contaminate the bread. She stated there was a possibility the bread may have germs on it from her gloves. She also stated if the bread was contaminated and a resident ate the bread, they resident may develop stomach issues such as diarrhea or vomiting from the bacteria. Dietary Aide B stated she had been in serviced within the past two months on hand hygiene and wearing gloves in the kitchen. 2. Observation on 12/12/2023 beginning at 11:50 AM Dietary Aide C was not wearing gloves. She touched her clothes, cleaned the food prep area, the sink with a disinfectant rag, and touched a portion of her hair (underneath the hair covering on the right side of her head). Dietary Aide C moved a tray of small bowls with sliced apple pies in the small bowls from one food prep table to another food prep table. When Dietary Aide C placed the tray of apple pies on the second food prep table some of the cellophane covering the bowls came off and she touched three of the sliced apple pies in bowls with her middle finger, forefinger, and ring finger on both hands. She had a paper towel and discarded the paper towel into the garbage can and touched the lid of the garbage can. Dietary Aide C moved (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 9 of 11 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 12/14/2023 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 - Many another tray of slice apple pies in the small bowls from one food prep table to another food prep table and she touched two of the apple sliced pies when she re-covered the pies with cellophane. Dietary Aide C walked from the food prep area of the kitchen toward the dishwashing area of the kitchen. She obtained two gloves and placed the gloves in her shirt pocket. Dietary Aide C washed her hands and continued to enter the dishwashing area of kitchen. After she washed her hands, she touched her shirt, her face, and another person shirt with the forefinger, middle finger, and ring finger of her right hand. Dietary Aide C removed the gloves from her shirt pocket with all her fingers on her right hand and touched all the fourchettes (a narrow strip that joins the front and back sections of the fingers of a glove). Dietary Aide C exited the dishwasher room and returned to the kitchen area. She picked up 4 clean plates to be used for the lunch meal with her right gloved hand and all her fingers touched the plates. In an interview on 12/12/2023 at 2:20 PM (interpreter was the Dietary Manager) Dietary Aide C stated she was not wearing gloves and had not washed her hands when she was cleaning the food prep table with disinfectant rag. She stated the entire time she was completing different tasks with moving the bowls of sliced apple pies on a tray she did not wash hands or wear gloves. She stated she moved the apple pies after she had touched the disinfectant rag and after she touched the garbage can lid. Dietary Aide C stated she was trying to get the pies ready for the lunch meal. Dietary Aide C also stated she did touch the applies with her fingers and her fingers were not clean. She stated there was a possibility germs from her hands may contaminate the apple pies. Dietary Aide C stated the only time she washed her hands was when she was going into the dishwasher room. She stated she did place gloves in her shirt pocket. Dietary Aide C stated the pocket of her shirt was considered dirty with germs. She stated her hands and the gloves were contaminated. She stated she did pick up clean dishes in the kitchen area after she exited the dishwasher room. Dietary Aide C stated there was a possibility the dishes had germs on them from her dirty gloves. She stated if a resident ate the apple pie or ate from the plates she touched, the resident had a potential of having gastro problems with their stomach such as: vomiting and diarrhea. She also stated there was a possibility a resident may need to be hospitalized due to becoming very sick with stomach issues. 3. Observation on 12/12/2023 beginning at 12:10 PM the Dietary [NAME] was not wearing gloves. He placed his right hand in his pocket. He did not wash hands prior to placing gloves on his hands. There was one glove from the container that fell onto the floor. Dietary [NAME] picked up the glove from the floor. His forefinger, middle finger, and part of the palm area of his right hand touched the floor. The Dietary [NAME] placed his right hand inside the sandwich bags to open them. He picked up three sandwiches with his right hand and placed them in separate sandwich bags. The dietary manager explained to him the sandwiches needed to be discarded in the garbage. In an interview on 12/13/2023 at 2:35 PM Dietary cook stated he had been in-serviced on wearing gloves and washing hands in the kitchen. He stated he was expected to wash hands and change gloves in between tasks. Dietary [NAME] stated there was a possibility he may have contaminated the sandwiches and the sandwich bags by touching them with his right gloved hand. He stated he did not recall if his right hand or fingers on his right hand touched the floor, however, there was a possibility his hand did touch the floor when picking up the glove. He stated if a resident ate one of the sandwiched, he touched with his glove there was a possibility a resident may ingest bacteria and may become physically ill with a foodborne illness. Dietary [NAME] stated there was a possibility a resident may need to be transferred to hospital for further care from a physician. In an interview on 12/14/2023 at 8:35 AM the Dietary Manager stated all staff were expected to wash their hands when entering the kitchen, prior to placing gloves on their hands and anytime they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 10 of 11 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 12/14/2023 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 - Many remove gloves from their hands. He stated if staff was wearing gloves and the staff touched anything considered contaminated such as: disinfectant rag, clothes, inside pockets, floor, bread package, and/or cell phone, the staff was expected to remove gloves and discard the gloves, wash their hands before placing new gloves on their hands. He stated with the bread bag anyone could touched the bread bag prior to the bread being delivered to the kitchen. Dietary Manager stated no one knows who touched the bread bag outside of the facility. He also stated if anyone is touching a disinfectant rag and does not wash their hands, it was a possibility the disinfectant may transfer from the staff hands onto food and contaminate the food. He stated if a resident ate food with a possibility of having bacteria or disinfectant on the food the resident may become seriously ill and would need to be admitted to the hospital. He stated he did not know the extent of illness a resident may receive from bacteria or disinfectant; however, it may affect their immune (protected against a particular disease) system. In an interview on 12/14/2023 at 10:00 AM the Administrator stated all staff was expected to wash their hands prior to placing gloves on their hands. She also stated the staff was expected to remove gloves from their hands if the gloves were contaminated and between tasks. The Administrator stated any parts of clothing, the floor, garbage can lid, touching disinfectant rag would be considered contaminating staff hands and /or gloves. She stated staff was expected to wash their hands and change their gloves immediately. She also stated when the cook touched the sandwiches with contaminated gloves the sandwiches was expected to be thrown away immediately. The Administrator stated if a resident ingested bacteria from their food, plates, and/or silverware there was a potential a resident may become ill with a food borne illness such as vomiting and diarrhea. She also stated a resident may become dehydrated. She stated if the facility were not capable of caring for the resident's physical condition the resident would be transferred to the hospital for further evaluation. Review of the facility's policy on Hand Washing not dated reflected employees will wash hands as frequently as needed throughout the day using proper hand washing procedures. Hands and exposed portions of arms should be washed immediately before engaging in food preparation. When to wash hands: - after touching bare human body parts other than clean hands and wrists - during food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks. - before placing disposable gloves on for working with food and after gloves are removed. - after engaging in other activities that contaminate the hands. Review of the FDA Food Code 2022 Section 2-301.14 When to wash reflected Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapped single service and single use articles and: A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; E) After handling soiled equipment or utensils F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 11 of 11