Health inspection·January 25, 2024

F 0697 What is most important to the [Resident #1] today? Family requests comfort Level of Harm - Immediate jeopardy to resident health or safety . [Resident #1] appears pre-active and is using morphing PRN for pain and shortness of breath. He is also using a nebulizer. Staff nursing administer medications, and nebulizers. Residents Affected - Few [Resident #1] is [AGE] year-old male veteran with a primary hospice diagnosis of prostate cancer with mets (metastasize) to pelvis and lymph nodes. [Resident #1] was diagnosed in 2016 s/p orchiectomy (a surgery to remove one or both testicles) and then did not follow up . was getting treatment for prostate cancer until late 11/2023 . Today [Resident #1] was diagnosed with hypernatremia (electrolyte problem characterized by increased sodium concentration in the blood), increased BUN and Creatinine and aspiration pneumonia via x-ray. He was on IV fluids and IM Rocephin and will stay on Rocephin till 12/27/23. Family wants to give him a chance have antibiotics help him and IVF but knows this likely will not work. . Pain: pain left hip managed with new pain regimen of morphine 5 mg po every 1-hour PRN Review of Resident #1's progress notes in his EMR, dated 12/22/23 at 11:58 AM and documented by the ADON, reflected the following: Palliative care form signed. Review of Resident #1's physician order, dated 12/21/23, reflected the following: Morphine concentrate - schedule II solution; 100 mg/5 mL (20 mg/ML); Amount to administer: 0.25ML; oral every hour PRN for pain and dyspnea (shortness of breath) Review of Resident #1's TAR, December of 2023, reflected he was administered morphine by LVN B on 12/22/23 at 2:30 AM, on 12/23/23 at 7:24 AM for pain and agitation. It was documented as being effective (unknown time). He was also administered morphine on 12/23/23 after it was administered by the Hospice Nurse at 4:00 PM and 8:00 PM; on 12/24/23 at 12:00 AM, 4:00 AM, 8:00 AM, and 12:00 PM. Review of Resident #1's Hospice Visit Clinical Note, dated 12/23/23 at 10:22 AM and documented by HN E, reflected the following: [Resident #1] lying in his bed on his back upon RN arrival. [Resident #1] writhing in pain with mouth gaping open and gasping for breath. RN immediately spoke to his nurse [LVN B] who stated he did not receive any morphine overnight and she has given him 0.25 mils a few hours ago. RN called (hospice doctor) immediately and received an order to give one ML morphine Q 15 minutes as needed times three doses to get pain under control. This RN was nurse to administer morphine, [FM A] and [FM F]/MPA were at the beside and continued to stay they only want [Resident #1] to be comfortable. It did require three doses of morphine to get [Resident #1] comfortable as he continued to be in severe pain and shortness of breath until third dose took effect. [Resident #1] continually pulling off nasal cannula from oxygen with his current pain and agitation. For this reason, oxygen level was in the mid 80s when RN able to obtain via pulse oximeter when [Resident #1] finally calm and comfortable. Several medication orders were changed by (hospice doctor) and written to the facility. This includes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 2 of 12 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 01/25/2024 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few scheduled morphine and lorazepam every four hours with continued availability of PRN. Morphine every hour for breakthrough pain. (Hospice doctor) sent changes to (pharmacy) as well per their request. RN counted number of medications with RN on staff and assured that [Resident #1] gas enough quantity of both morphine and lorazepam. [Resident #1] has had no intake of food or water in past 24 hours and is currently only oral care at this time. RN worked with staff CNA to get [Resident #1] into a comfortable position. [Resident #1] was resting calmly upon closure of RN visit. RN reminded staff to call hospice company at any time with any change in condition or for any needs, questions, or concerns. [FM A] and [FM F] to come back later to visit and grateful for hospice assistance. [Resident #1] is actively dying and expected to pass within the next 24 to 48 hours. Review of Resident #1's progress notes in his EMR, dated 12/23/23 at 1:15 PM and documented by LVN B, reflected the following: (Late Entry) Restless and agitated. Opens mouth but makes no verbal noise. Hospice nurse present and administered 3 does of 0.5ml Morphine 15 minutes apart per Hospice physician orders. New order for Ativan every 4 hours. Continues to remove oxygen. Morphine effective. Resting in bed in fetal position. During a telephone interview on 01/24/24 at 12:33 PM, HN D stated she admitted Resident #1 for hospice services on 12/21/23. She stated on that day he was not in any obvious pain but ensured facility staff knew he had an order for Morphine PRN for pain, shortness of breath, or agitation. She stated the family was adamant that they wanted palliative/comfort care only for Resident #1. She stated when HN E made her routine visit on 12/23/23 she found Resident #1 in extreme pain and distress. She stated she would have expected facility staff to contact them immediately if they were unable to control his pain. During a telephone interview on 01/24/24 at 12:47 PM, Resident #1's NP stated she last saw him on 12/22/23 and at that time, he appeared comfortable. She stated since Resident #1's order for Morphine was such a low dose and it had a short half-life., She stated she would expect nurses to assess the resident at least every hour after administering to assess the effectiveness. During a telephone interview on 01/24/24 at 12:58 PM, FM A and FM F stated when they walked into Resident #1's room on 12/23/23 around 10:30 AM, HN E was already there. FM A stated he was writhing in agony, thrashing in his bed, and pointing to his back. FM F stated HN E looked completely disheveled with the state Resident #1 was in. FM F stated HN E turned to them and said, He is mouthing 'help me, help me, help me'! FM F stated HN E stated, Honestly, I am not supposed to say this, but this is not okay. FM F stated LVN B walked in to the room and was surprised to see the condition Resident #1 was in and stated, Oh my God, I do not know how this happened and continued to apologize profusely. FM A and FM F continuously repeated how heart-breaking it was to walk in on their loved one in so much distress and pain. They both stated they repeatedly told the facility they wanted comfort measures only and felt like they neglected Resident #1. FM F stated after HN E administered three doses of morphine, Resident #1 finally looked peaceful and comfortable. FM A stated without the hospice agency, they did not know if Resident #1 would have passed away without pain or his dignity. FM A stated they just wanted to ensure this does not happen to anyone else's loved one. During a telephone interview on 01/24/24 at 2:27 PM, HN E stated Resident #1 had an order for morphine every hour or as needed for shortness of breath or pain since 12/21/23. She stated she was not contacted by the facility on 12/23/23 but was making a routine visit. She stated when she walked into Resident #1's room he was absolutely not comfortable as he was showing a lot of symptoms of pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 3 of 12 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 01/25/2024 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few such as thrashing his arms, mouth agape, and was extremely anxious. She stated even lightly touching him made him more agitated. She stated although it was hard to discern, but it did look like he was mouthing help me. She stated she asked LVN B when she last saw Resident #1 and she told her she administered morphine a few hours ago. She stated it appeared LVN B seemed to think his current condition at that time was normal. She stated she was extremely surprised because normally when a resident on hospice resided at a facility with nurses on staff, they typically do not see that type of situation because nurses are trained and licensed to know what to look for when it comes to pain and agitation. She stated she would expect for a resident who was on hospice services and receiving morphine to be assessed at least every hour if not more frequently. She reiterated she was very shocked at the state he was in and was glad she arrived when she did. During an interview on 01/24/24 at 2:44 PM, the ADON stated she saw Resident #1 on 12/21/23 and 12/22/23 and he seemed comfortable. She stated she was not in the building on 12/23/23 and had not heard of anything unusual happening. She stated it depended on resident's condition as to how often a resident should be assessed after being administered pain medication. She stated LVN B had administered Resident #1 morphine a few hours before HN E arrived and a change in condition could have happened five minutes before she arrived. She stated it could happen quickly especially with Resident #1 continuously taking his oxygen off. She stated LVN B marked the morphine as being effective. She stated there was no actual pain assessments in their electronic charting system for the nurses to complete. During a telephone interview on 01/24/24 at 4:17 PM, LVN B stated she started her shift on 12/23/23 at 6:00 AM. She stated she checked on Resident #1 sometime between 6:30-7:00 AM. She stated at that time he was restless, looked like he was in pain, grimacing, moving around a lot, and did not want to keep his oxygen on. She stated she administered morphine at 7:24 AM. She stated she went back assess to see if the morphine had been effective sometime that morning. She stated, nothing seemed to help and did not believe the morphine was helping. She was asked why she marked the morphine as being effective and she stated that must have been a time where he had quieted down. She stated she thought she had contacted hospice. She stated once HN E arrived, she (HN E) administered three doses of morphine every 15 minutes and that settled Resident #1 and he seemed calm and relaxed. She stated HN E then ordered scheduled morphine to be administered every four hours and PRN. She stated she was grateful for HN E as the morphine she administered really seemed to help Resident #1 a lot. Review of the facility's Pain Assessment and Management Policy, revised March of 2020, reflected the following: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing for the potential for pain; b. Recognizing the presence of pain; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 4 of 12 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 01/25/2024 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 0697 c. Identifying the characteristics of pain; Level of Harm - Immediate jeopardy to resident health or safety d. Addressing the underlying causes of the pain; Residents Affected - Few f. Identifying and using specific strategies for different levels and sources of pain; e. Developing and implementing approaches to pain management; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. . 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after pain onset and reassessed as indicated until relief is obtained. Documentation 1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of intervention for pain) as necessary and in accordance with the pain management program. 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. Review of the facility's Hospice Program Policy, revised July of 2018, reflected the following: 10. c. Notifying the hospice about the following: (1) A significant change in the resident's physical, mental, social, or emotional status. (2) Clinical complications that suggest a need to alter the plan of care. d. Communicating with the hospice provider (and documenting such communication) to ensure the needs of the resident are addressed and met 24 hours per day. The ADM and ADON were notified on 01/24/24 at 5:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/25/24 at 12:35 PM: On 1/24/2024 an abbreviated survey was initiated at (facility). On 01/24/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constituteds an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: Resident #1 was supposed to be on comfort care measures and was found to be in an uncomfortable amount of pain after not being administered pain medication. The facility needs to take immediate action to ensure residents are receiving proper (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 5 of 12 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 01/25/2024 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 0697 treatment to alleviate pain. Level of Harm - Immediate jeopardy to resident health or safety The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Residents Affected - Few Regional Director of Operations re-educated Administrator on ensuring resident pain control needs are met per current policy by facility staff. Initiated 1/24/2024. Completed 1/24/2024 Regional Nurse Consultant re-educated Interim Director of Nursing and Assistant Director of Nursing on ensuring resident pain control needs are met per current policy by facility. Initiated 1/24/2024. Completed 1/24/2024 Evaluation of all current residents for pain performed by DON/ADON and/or designee with orders verified and any changes required noted and enacted immediately upon finding of IJ allegation. Initiated 1/24/2024. Completed 1/24/2024 DON/designee completed audit of all resident charts for current pain documentation to be performed every shift and as needed according to individualized needs with routine pain assessments added to four consolidated orders found lacking routine pain assessment. There were no relevant findings of unaddressed pain found upon resident assessments and interviews as noted below. Initiated 1/24/2024. Completed 1/25/2024 Re-education of all licensed staff members occurred per DON/ADON and designees in areas of pain control, medication, pain scales, documentation, and communication to adjunct personnel such as hospice and monitoring noting concern, if any, following verbal understanding and post test noted by licensed staff. Initiated 1/24/2024 Completed 1/25/2024 All residents currently receiving pain control or possible pain indications immediately checked by ADON, unit managers, and a designated licensed nursing team member for appropriate interventions if any noted with no relevant findings of unaddressed pain found from resident assessment/interviews. Initiated 1/24/2024 Completed 1/24/2024 Interventions and Monitoring Plan to Ensure Compliance Quickly: The facility will follow current policy and procedure for compliance and maintenance of pain control with understanding of pain control management and communication by nursing staff to be obtained on hire by DON/ADON and/or appointed designee for all full time and PRN staff and at least annually with re-education to be performed by DON/ADON and/or appointed designee as noted per skills checklist. The facility does not employ the use of temporary or agency staff. Initiated: 1/24/2024 Completion: 1/25/2024 Audit of all existing and newly hired nursing staff to be performed weekly by DON and/or designee, to ensure completion of pain management understanding with emphasis on special circumstances, such as palliative care, to be ongoing following completion date per systems put in place. Initiated: 1/24/2023 Completion: 1/25/2024 and ongoing. Any nursing staff identified through ongoing education as noted above that require acute training on pain management will have education performed prior to presenting on shift until such time as knowledge and competencies in pain control and management are adequate. This will be ongoing following (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 6 of 12 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 01/25/2024 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 0697 completion date per systems put in place. Initiated: 1/24/2024 Completion: 1/25/2024 and ongoing Level of Harm - Immediate jeopardy to resident health or safety Return demonstration of understanding will be noted by post competency check for each person educated with a written post-test administered by Director of Nursing, Assistant Director of Nursing, and/or designee. For any nursing staff receiving re-education or training on pain control, including medication use, pain scales, documentation, communication, and management not found to be proficient through ongoing nursing proficiency checks following immediate education, on hire, annually, and as needed will receive one on one education with testing performed until such time as knowledge is of sound basis. Staff that are on leave from the facility, as well as newly hired staff in the future will be given the pain competency check off by the same individuals noted above before starting their next shift. This facility does not employ the use of agency personnel. This will be ongoing following the completion date per systems put in place. Initiated: 1/24/2024 Completion: 1/25/2024 and ongoing Residents Affected - Few The facility DON/ADON will act as monitoring liaison to coordinate completion of audits for competencies to include Administrator for continuum of care to be documented through signed attendance sheet in ongoing morning stand up. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing Audit sheets to ensure nursing staff competency in pain management, documentation, medication, assessment, and communication to be reviewed by DON/ADON for completion by random chart audits and resident assessment at least weekly with indication of last performed check off to be ongoing to ensure addition of any new or returning staff. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing All new admission or readmission orders to be checked within 24 hours for implementation of pain assessments as ordered and pain scales available for immediate use with discrepancies or omissions to be immediately resolved to ensure adequate pain management. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing The policy and procedure for maintenance and control of resident pain to be reviewed by Regional [NAME] President of Operations and Regional Nurse Consultant with current policy remaining in place. Any changes to policies that may be required to be implemented will have education provided by DON/ADON and/or appointed designee to affected staff members, including newly hired, full-time and PRN staff upon implementation. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing All licensed staff not on duty during pain management and control education, as well as all newly hired staff in the future, which will be ongoing, will be checked as noted above prior to returning to the floor for their next scheduled shift. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing Independent education to be performed in conjunction with facility DON and Regional Nurse Consultant, by hospice company educator designated by facility for all licensed nursing staff as adjunct to facility education on 1/25/24 and every week until all licensed staff has received external pain control and management education by outside, independent source. Any further education to be assessed and implemented from independent education findings. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing Pain control to include monitoring, medication, communication, and assessment will be reviewed by the QAPI committee to meet 1/25/24 and then q3months with changes to the plan to be made as needed with need for ongoing continuation of competency related to pain control as related to this IJ to be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 7 of 12 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 01/25/2024 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 0697 determined by findings during QAPI meetings. This will be ongoing following completion date per systems put in place. Initiated: 1/24/2024 Completed: 1/25/2024 and ongoing Level of Harm - Immediate jeopardy to resident health or safety The Medical Director was notified of Immediate Jeopardy and apprised of interventions and monitoring initiated with further updates to be given during QAPI meetings. Initiated: 1/24/2024 Completed: 1/24/2024 Residents Affected - Few The Surveyor monitored the POR on 01/25/24 as followed: During an interview on 01/25/24 at 12:43 PM, the ADON stated all staff were in-serviced on all of the topics listed in the POR before the start of their shift. She stated she in-serviced staff the evening prior at 10:00 PM before their 10:00 PM - 6:00 AM shift. She stated a pain assessment was conducted on all residents in the facility with no concerns. During interviews conducted on 01/25/24 between 1:18 PM and 2:27 PM, two RNs, two LVNs, and two CNAs all stated they had been in-serviced prior to working their shift. They were able to describe signs and symptoms of pain such as moaning, yelling, facial grimacing, agitation, and restlessness. The CNAs stated if a resident voiced pain or if they noted any residents showing any signs and symptoms of pain, they would notify their nurse immediately. The nurses stated they needed to document all signs and symptoms of pain, ensure they re-assessed a resident after administering pain medication within 30 minutes to an hour, and completing a pain assessment. The nurses stated if the pain medication did not appear to be effective, they were to document it, and contact the hospice nurse or resident's NP immediately. During observations and interviews on 01/25/24 between 1:28 PM and 1:56 PM, three communicative residents stated they were not in pain and their pain was always addressed when they notified a staff member. Two residents who were sleeping in their rooms were observed and they were showing no signs or symptoms of pain. Observation on 01/25/24 at 2:05 PM revealed nurses, medication aides, and CNAs in the dining room being in-serviced by a hospice agency on signs and symptoms of pain and the importance of addressing and assessing pain. Review of all residents' pain assessments (utilized PAINAD for nonverbal residents), dated 01/24/24, reflected no pain concerns. Review of an in-serviced entitled Reporting Pain Symptoms, dated 01/24/24 and 01/25/25 and conducted by the ADM and the ADON, reflected all nursing staff from all shifts were reeducated on the following: Any staff that notes signs and possible pain or a resident tells staff they are in pain should report this to their charge nurse. The Charge nurse must assess for pain, treat pain, and record effectiveness. Communication is the key to proper care of our residents. Signs and symptoms of pain include: moaning, grimacing, restlessness, voiced pain, and change in behavior. Review of an in-serviced entitled PRN Pain Medication, dated 01/24/24 and 01/25/25 and conducted by the ADM the ADON, reflected nurses for all shifts were reeducated on PRN pain medication and monitoring for effectiveness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 8 of 12 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 01/25/2024 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 0697 Level of Harm - Immediate jeopardy to resident health or safety Review of an in-serviced entitled Pain Assessments, dated 01/24/24 and 01/25/25 and conducted by the ADM the ADON, reflected all nurses from all shifts were reeducated on the following: Pain assessments must be done at least every shift, and if change in condition causing increased pain. Notify NP/MD/hospice if pain management is not appropriate or not alleviating pain. Document in progress notes details - who notified, what response was given, any new orders, notification of RP and doctor. Residents Affected - Few Review of the facility's Pain Assessment Post Test, dated 01/24/24 and 01/25/25, reflected all staff completed the test with the following questions: 1. Pain Assessments should be completed at least every shift for acute pain or significant changes in levels of chronic pain. (True/False) 2. If upon completion of pain assessment, it is determined that intervention is required, you may: 3. What are signs a resident can display of discomfort or pain? 4. What do you do if the pain medication is not effective? 5. If a hospice resident is experiencing a change in their pain intensity, the licensed nurse should notify the hospice agency immediately. (True/False) 6. What should be included in your progress note documentation regarding the pain event? While the IJ was removed on 01/25/24 at 2:45 PM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 9 of 12 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to follow a changed physician medication order resulting in Resident #1 receiving four times the intended dose of Erleada (a prescription drug used to treat prostate cancer) for approximately five days. This failure was determined to be PNC due to the facility correcting the deficient practice prior (11/17/23) to the investigation. This deficient practice could place residents at risk overdose, could result in worsening or exacerbation of chronic medical conditions, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including vascular dementia, prostate cancer, and COPD. Review of Resident #1's quarterly MDS assessment, dated 11/03/23, reflected a BIMS was not performed. Review of Resident #1's quarterly care plan, dated 12/21/23, reflected he had prostate cancer with an intervention of administering medication as ordered. Review of Resident #1's physician order, dated 06/02/23, reflected the following: Erleada tablet; 60 mg Directions: Four tabs (240MG); oral; Once a day Review of Resident #1's physician order, dated 11/17/23, reflected the following: Erleada tablet; 240 mg Directions: ONE; oral; Once a day Review of Resident #1's NP assessment, dated 11/17/23, reflected the following: Chief Complaint/Reason for this Visit: Drug overdose/Medication error . [FM A] notified me about the mediation error. [Resident #1] was getting Erleada 60mg tabs x 4 previously but during the last refill the medication was changed to 240mg tabs. [Resident #1] was given Erleada 240mg x 4 tabs instead of Erleada 240mg x 1 tab. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 10 of 12 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 01/25/2024 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 0755 Review of Resident #1's NP assessment, dated 11/21/23, reflected the following: Level of Harm - Minimal harm or potential for actual harm Chief Complaint/Reason for this Visit: Follow-up on Erleada Overdose . Residents Affected - Some CBC, CMP reviewed and is stable . DON has notified the Urologist about the drug overdose/medication error. Erleada is on hold since 11/17/23. During a telephone interview on 01/24/24 at 12:47 PM, Resident #1's NP stated he was administered the wrong dose of Erleada for 5-6 days before 11/17/23. She stated she was not notified until Resident #1's FM A informed her. She stated the staff did not review the new order when it came in. She stated it would be her expectation that physician orders be followed as it was part of the Five Rights of medication administration (Right patient, Right drug, Right dose, Right route, Right time). She stated labs were ordered and he was monitored for any signs and symptoms of toxicity and did not believe he was negatively affected by the medication error. During a telephone interview on 01/24/24 at 12:57 PM, FM A stated she was called by a staff member from the facility on 11/17/23 and was notified Resident #1 was almost out of his Erleada. She stated that was impossible because it had just gotten filled at the beginning of November (of 2023). She stated she was aware Resident #1 would at times refuse his medications, so it made sense that he had not run out sooner. She stated she was furious and called the Urologist to find out if it could negatively affect Resident #1. During a telephone interview on 01/24/24 at 1:51 PM, the UPT stated Resident #1 had been on 60 mg tablets of Erleada for a while and then the drug manufacturer came out with a 240 mg tablet in September of 2023 and FM A agreed to switch him to one tablet since he often refused his medications. She stated on 10/02/23 and 11/01/23, the pharmacy refilled his Erleada - 30 240 mg tablets. She stated both refills had a note on them alerting to the dosage change. She stated FM A called the pharmacy in mid-November (could not remember the exact date) and asked for another refill. She stated she told her it was too soon for a refill. She stated once FM A told them (pharmacy) what had happened, they were not sure what toxicity would look like so she reached out to the drug manufacture to find out what too much of the medication would cause but did not receive a conclusive answer. During an interview on 01/24/24 at 2:44 PM, the ADON stated Resident #1 had been receiving four tablets of Erleada since he was admitted in June (of 2023). She stated apparently in November, his Urologist changed the dosage but it got missed by his nurse, LVN B. She stated LVN B and whoever else administered his medication during that timeframe should a have verified the dosage. She stated when LVN B went to administer it after five or six days and noticed he was almost out of the medication, she called FM A who realized he had run out too early. She stated she contacted his Urologist to notify him and was instructed to run labs and monitor him for three days for toxicity concerns. She stated the labs came back normal and he had not had a change in condition from the medication error. During a telephone interview on 01/24/24 at 4:17 PM, LVN B stated apparently the doctor changed the dose and frequency of Resident #1's Erleada medication but did not send a new order, so she followed the original order in (electronic medical charting system). She stated she knew it was a mistake to not verify the order on the bottle and she felt horrible about it. She stated all nurses and medication aides were in-serviced on review each medication that was delivered and updating the MAR as necessary. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 11 of 12 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 01/25/2024 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 01/25/24 at 1:28 PM, LVN G stated when a medication was delivered from the pharmacy, the nurses were to check the order to ensure the MAR was correct and updated it if the order had changed. She stated before dispensing medication, all orders should be reviewed. During an interview on 01/25/24 at 1:36 PM, RN H stated all medications should be reviewed against the resident's MAR before administering and when delivered to the facility. During an interview on 01/25/24 at 2:10 PM, MA I stated she always reviewed the medication orders before administering medications to residents. Review of an in-service entitled Proper Medication Verification, dated 11/17/23 and conducted by the DON, reflected nurses and medication aides were in-serviced on the following: When accepting a medication delivery, you must verify the order on the container with the order in our MAR and updated our MAR if necessary. When administering medications, you must compare the container to the order every time! *See attached 10 rights* 10 Rights for Safe Medication Administration: Right Drug, Right Patient, Right Dose, Right Time, Right to Refuse, Right Knowledge and Understanding, Right Questions or Challenges, Right Response or Outcomes, Right Advice Review of the facility's Documentation of Medication Administration Policy, revised April of 2007, reflected that it did not specifically address following physician orders. Review of the facility's Medication Orders Policy, dated January of 2020, reflected the following: Medication orders - When recording orders for medication, specify the type, route, dosage, frequency, strength, and the reason for administration. The policy did not specifically address following physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675943 If continuation sheet Page 12 of 12