Inspection·June 2, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plan dated 06/02/2025 reflected Resident had ineffective coping related to bipolar, schizophrenia and depression. Interventions included psych services as indicated and ordered. Review of Resident #1 progress note by RN A dated 05/31/2025 at 11:43 PM reflected a CNA called RN A into Resident #1's room and that Resident #1 had tied her neck with belt of her nightgown and tied it to the bed rail and applied slight traction and stated she did not want to live. RN A's note read that the belt was removed, and Resident #1 was assessed with no changes in her vital signs. RN A's note read that on-call (ADON) was contacted and Resident #1 was put on 15-minute checks. Further review of Resident #1 progress note, by DON dated 06/01/2025 reflected that 1:1 was initiated, and DON notified NP at 8:32 AM. Review of 15-minute check sheet for Resident #1 dated 05/31/2025 to 06/01/2025 reflected Resident #1 had no further incidents and remained on 15-minute checks until 8:30 AM on 06/01/2025 and was put on 1:1 supervision. Review of Resident #1's PHQ-9 assessment date 05/30/2025 reflected she had no signs or symptoms of depression or thoughts she would be better off death. Review of Resident #1's psychological progress note date 05/23/2025 reflected Resident #1 indicated no risk factors of suicide or self-injury. Review of statement by CNA B dated 06/01/2025 reflected that CNA B reported RN A placed CNA B on 1:1 with Resident #1 after her self-harm attempt. CNA B reported that she remained on 1:1 with Resident #1 throughout her shift and during her 30-minute break RN A was 1:1 with Resident #1. During an interview on 06/02/2025 at 1:20 PM, LVN F stated that she did not observed any changes or signs or symptoms of depression or anxiety with Resident #1. LVN F stated that during her shift on 06/01/2025 Resident #1 stated she was okay and appeared relaxed. LVN F stated that she assessed Resident #1 for suicidal ideation and Resident #1 stated she would never do it again. An interview was attempted with CNA B on 06/02/2025 at 1:35 PM, but no call was returned on 05/30/2025. During an interview on 06/02/2025 at 2:02 PM, CNA C stated he worked with Resident #1 stated that Resident #1 was pleasant during his shift and denied that Resident #1 was tearful. During an interview on 06/02/2025 at 2:18 PM, LVN D stated that Resident #1 was not tearful during her shift on 05/29/2025. LVN D stated Resident #1 returned from the hospital on this day. LVN D stated that Resident #1 was alert and talkative during her shift. LVN D stated that Resident #1 did not mention wanting to harm herself and did not mention not wanting to live during her shift. During an interview on 06/02/2025 at 2:26 PM CNA E stated that she worked with Resident #1 on 06/01/2025 following the incident. CNA E stated Resident #1 was in a good mood and CNA E asked Resident #1 how she was feeling and what happened the evening before (05/31/2025). CNA E stated that Resident #1 stated that she wanted to harm herself last night but no longer felt that way. CNA E stated that she felt Resident #1 was sad when she talked about her family. CNA E stated Resident #1 was not tearful or crying during their conversation. CNA E stated that she and LVN F alternated 1:1 with Resident #1. CNA E stated that someone was in the room with Resident #1 at all times and if other residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 2 of 4 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 676373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor Bee Cave 14058 Bee Caves Parkway, Bldg B Bee Cave, TX 78738 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 0580 had needs she and LVN F would switch. Level of Harm - Minimal harm or potential for actual harm During an interview on 06/02/2025 at 2:43 PM, NP stated that she saw Resident #1 on 05/30/2025 and there were no indications of suicidal ideation or self-harm. NP denied that the facility reached out to the on-call provider on 05/31/2025 after Resident #1 was found with a belt around her neck. NP stated if there was a self-harm attempt, she would have expected the facility to communicate to the provider, but not for suicidal ideation. Residents Affected - Few During an interview on 06/02/2025 at 2:58 PM, RN A stated that the CNA reported that Resident #1 had the belt from the nightgown around her neck and the bed rail. RN A stated that the belt was loose around Resident #1's neck and he assessed Resident #1 for any injuries, and none were noted. RN A stated Resident #1 had no redness or bruising on her neck and her vitals were normal. RN A stated he contacted on-call nurse manager who was ADON. RN A stated he did not contact the NP or MD and was instructed by ADON to initiate 15-minute checks. RN A stated that MD or NP is contacted when anything happens with a resident or if there was an emergency or change of condition. RN A stated in the moment he did not consider what happened with Resident #1 an emergency because she was stable, the belt was loose and there were no injuries. During an interview on 06/02/2025 at 3:10 PM, ADON stated that he received a call from RN A regarding suicidal ideation of Resident #1 and instructed RN A to initiate 15-minute checks. ADON stated that he understood that Resident #1 expressed suicidal ideation with no plan or action. ADON stated that RN A did not report that Resident #1 had a belt around her neck. ADON stated that he expected that RN A would have called the provider due to Resident #1's actions. ADON stated that 911 was contacted on 06/01/2025 and Resident #1 was declined to be taken by EMS. ADON stated that 911 was called again and Resident #1 wanted an evaluation, so she was sent out for further evaluation. During an interview on 06/02/2025 at 3L25 PM, SW stated that after a resident is readmitted from the hospital they were re-referred to psychiatric or psychological services. SW stated that Resident #1 struggled with depression and anxiety. SW stated that Resident #1 did not express wanting to harm herself or that she wanted to harm herself. SW stated she last saw Resident #1 on 05/23/2025 when she was re-referred to psych services after she returned from the hospital. During an interview on 06/02/2025 at 3:34 PM the DON stated that she was notified of the incident with Resident #1 the morning of 06/01/2025 after she checked in with ADON and ADON stated there was suicidal ideation with Resident #1. The DON stated she reviewed the notes and saw it was more than ideation at that point. The DON stated that upon investigation with RN A and CNA B that CNA B remained in the room with Resident #1 and RN A remained outside of Resident #1's room throughout the remained of their shifts. The DON stated she would have expected RN A to notify the provider that Resident #1 was found with a belt around her neck and tied to her bed. During interviews on 06/02/2025 between 2:00 PM and 4:12 PM, 4 CNAs, 2 LVNs and 1 RN stated that they received an in-service on signs and symptoms of depression, recognizing signs or symptoms of suicidal idea and in-service on what to do if a resident has suicidal ideation or suicidal attempt. Interviewed staff listed changes in behavior, isolation, stating someone wished they were no long here as signs or symptoms to look for. Interviewed staff stated that they would report any of these symptoms or signs to the charge nurse, ADON, DON and ADM immediately. Interviewed LVNs and RN stated they would notify the physician immediately, as well as the DON and ADM, initiate 1:1 with the resident, remain with the resident and call 911 for any attempted self-harm displayed by a resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 3 of 4 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 676373 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park Manor Bee Cave 14058 Bee Caves Parkway, Bldg B Bee Cave, TX 78738 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 0580 Level of Harm - Minimal harm or potential for actual harm During an interview on 06/02/2025 at 4:54 PM, the ADM stated that the difference between suicidal ideation were thoughts, loneliness, sadness and stating one did not want to be here versus a self-harm attempt was to have a plan and going from emotion to action. The ADM stated even if a resident could not execute the plan, even if they were bed bound, if the resident expressed they had a plan it would be considered an attempt. The ADM stated he expected staff to notify the provider for a self-harm attempt. Residents Affected - Few Review of in-services reflected in-services was completed with staff on what to do if a resident had suicidal ideation and suicidal attempt each dated 06/01/2025. In-service reflected any attempt or suicidal ideation need to notify the proper channels and included the resident's nurse, on-call provider, DON and ADM. Review of QAPI meeting sign-in dated 06/01/2025 reflected NP, DON, ADON, ADM and corporate leaders was held to discussed incident with Resident #1. Review of facility policy titled Change in Condition with revision date of 04/2025 reflected [t]here will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his / her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 4 of 4