Inspection·September 10, 2025

F 0684 Level of Harm - Actual harm Residents Affected - Few dated [DATE] reflected Resident #1's family had concerns regarding frequency of checks and new redness to perineal area. Resolution reflected that the DON spoke with family and implemented check and change for frequent rounding. Review of visual/bedside Kardex (electronic health record) report for Resident #1 dated [DATE] reflected under the skin section resident needed monitoring/remining/assistance to turn or reposition. Review reflected Resident #1 required 2 person mechanical lift for all transfers. Review of POC (plan of care) response history for Resident #1 reflected incontinence care was marked as provided on [DATE] at 3:32 AM and 11:41 PM. Review reflected incontinence care was marked as not provided on [DATE] at 11:38 AM. Review of 1 hour checks for Resident #1 reflected sections titled Check, Change, Suctioning and Trach Care. Review for 09-05-2025 hour checks reflected change was not selected between 9:00 am and 6:00 PM. Note on the document reflected Qhour Checks: Please indicate care provided during rounding. Review reflected Resident #1 was checked each hour between 9:00 am and 6:00 pm. Review reflected resident had suctioning completed at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM,6:00 PM, 7:00 PM, 8:00 PM, 9:00 PM, 10:00 PM and 11:00 PM. Review reflected tracheostomy care was provided at 4:00 AM, 8:00 AM, 10:00 AM (nebulizer treatment), 2:00 PM (nebulizer treatment), 6:00 PM (nebulizer treatment), 7:00 PM (nebulizer treatment), 8:00 PM, 9:00 PM, 10:00 PM and 11:00 PM. Review of occupational therapy treatment encounter note dated [DATE] reflected OT checked Resident #1's brief and it was dry and fresh. Review reflected OT then transferred Resident #1 with mechanical lift from bed to geriatric chair. OT then informed ADON that Resident was in chair with mechanical lift sling beneath her. Observation of facility recorded camera footage for Resident #1 room dated [DATE] revealed footage started at 5:53 AM and ended at 6:30 PM. Observation revealed mechanical lift was taken into Resident #1's room by OT at 8:45 AM. OT exited Resident #1's room at 9:07 AM. Observation of footage revealed a mechanical lift was not returned into Resident #1's room until 5:45 PM. Observation of Resident #1 video camera footage dated [DATE] at 10:48 AM revealed Resident #1 sat in a geriatric chair in the room. Observation of Resident #1 video camera footage dated [DATE] at 6:00 PM revealed Resident #1 sat in a geriatric chair in the room. Observation of Resident #1 video camera footage dated [DATE] at 6:55 PM revealed Resident #1 was transferred from geriatric chair to bed. Observation of picture dated [DATE] at 6:07 AM reflected sacral area (area at the base of the spine) revealed a shallow, broken skin that was light pink with spots of darker red and white flakey skin on the gluteus area. A darker spot shallow opening in the skin was observed in the fold of the gluteus. Review of change of condition evaluation dated [DATE] reflected upon discharge Resident #1 had a rash to right buttock and left buttock. Review of the hospital notes dated [DATE] reflected Resident #1 had wound care evaluation on [DATE]. Resident #1 was admitted with small area of partial skin thickness injury from moisture and from flaky skin loss due to fungal irritation. Orders placed for groin, perineal and perianal/wound areas to decrease fungal irritation. During an interview on [DATE] at 11:49 AM, the FM stated that Resident #1 was no longer at the facility and FM had requested Resident #1 be sent to the hospital. The FM stated that on [DATE] Resident #1 was left in her wheelchair for hours and had not been changed. The FM stated that there was a camera in Resident #1's room and Resident #1 was not transferred into bed until other family arrived on [DATE]. During an interview on [DATE] at 3:27 PM, the OT stated that he transferred Resident #1 from bed to wheelchair on [DATE] in the morning. The OT stated that he checked Resident #1's brief prior to transfer and that Resident #1 was dry and did not observe any skin redness. The OT stated that after Resident #1 was placed in the geriatric chair he notified ADON as ADON was right outside Resident #1's room. The OT stated that usually therapy did not put resident back in wheelchair after assisting them unless nursing staff specifically asked. The OT stated, it sounds like she was up in the chair all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 2 of 16 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 09/10/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few day from what I was told. The OT stated he was unsure where he heard this information from or who. During an interview on [DATE] at 3:29 PM, CNA B stated she was familiar with Resident #1. CNA B stated that Resident #1 was not able to talk and wore briefs. CNA B stated that she noticed normal irritation on Resident #1's perineal area and denied any open areas or bleeding. CNA B stated normal irritation was some redness. CNA B stated that she put barrier cream on Resident #1 during brief changes for the redness. CNA B stated the last time she worked with Resident #1 was the day she went to the hospital ([DATE]). CNA B stated that any changes or open areas observed were reported to the nurse immediately. CNA B stated Resident #1 had an extra list that every time she was changed or checked the staff were required to mark off on a piece of paper. During an interview on [DATE] at 4:08 PM, CNA A state she recalled working with Resident #1 and providing care for Resident #1. CNA A stated that the last time she worked with Resident #1 was on [DATE] during the 6:00 PM to 6:00 AM shift. CNA A stated when she arrived Resident #1 was sitting in the geriatric chair in her room. CNA A stated when she arrived CNA C tried to put Resident #1 in the bed, but the mechanical lift's battery was dead. CNA C stated she charged the battery and the put Resident #1 into bed. CNA A stated she changed Resident #1's brief and the only skin issues were some redness, but it was not open or bleeding. CNA A stated that any new redness or open areas would be reported to the charge nurse. During an interview on [DATE] at 4:21 PM, CNA C stated she was familiar with Resident #1. CNA C stated that she took over the shift on [DATE] around 3:00 PM for CNA D. CNA C stated that she was unsure why CNA D did not tell her that Resident #1 was in the geriatric chair. CNA C stated Resident #1 never came out of her room and it was her first day getting up out of bed. CNA C stated that she did not know Resident #1 was out of bed in the geriatric chair that day. CNA C stated Resident #1's family would notify staff if they needed something and they did not call CNA C until around 5:30 PM because they wanted Resident #1 to be transferred in bed. CNA C stated that she tried to use the mechanical lift, but the battery was dead and she went to find another mechanical lift, but they were being used. CNA C stated it was after 6:00 PM and she let the next shift know Resident #1 needed to be transferred and then left. CNA C stated that prior to 5:30 PM she had not seen Resident #1 during the shift and did not provide care to Resident #1. CNA C stated that CNA D told her all the residents had already been changed. CNA C stated that Resident #1's FM told her that Resident #1 had been in the chair all day. CNA C stated she wished CNA D told CNA C that Resident #1 was in the chair before CNA D left the shift so Resident #1 could have been transferred back in bed. During an interview on [DATE] at 6:45 PM CNA E stated she normally works 6:00 am to 6:00 pm shifts. CNA E stated she was familiar with Resident #1 and had worked with Resident #1 several times. CNA E stated the most recent time she worked with Resident #1 was when she was going to leave her shift and the night she needed help to put Resident #1 in bed. CNA E stated that she had changed Resident #1's brief and did not observe any open area or bleeding. CNA E stated that residents who required a mechanical lift to transfer would have to be laid back down in bed to have their brief changed. CNA E stated residents cannot be left in a chair for nine hours as the resident could be really soaks and get a skin rash or they could slip out of the chair and fall. CNA E stated that rounds were done every two hours and during rounds residents were checked and changed and laid down for a nap with they were up. CNA E stated changes in a Resident's skin would be reported to the nurse. During an interview on [DATE] at 1:29 PM, RN F stated she was the wound care nurse. RN F stated that residents who required mechanical lift should be checked on at least every two hours and this included checking their brief and more frequently if needed. RN F stated perineal care cannot be performed in a chair and the resident would have to be transferred with the mechanical lift to complete perineal before bed. RN F stated residents who required a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 3 of 16 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 09/10/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few mechanical lift were not able to reposition themselves and would be more vulnerable for skin breakdown. RN F stated that it was not okay for a resident to be in a chair for 9 hours and not changed for 9 hours. RN F stated a resident that was left in a chair for hours could have issues with their skin integrity and that risk for skin breakdown. RN F stated that residents need to be turned and have perineal care. RN F stated that she was familiar with Resident #1 and that she had some redness in her perineal area and it was blanchable (skin turns pale or white when pressure is applied and then returns to normal color). RN F stated Resident #1's last skin assessment was done on [DATE] and she had redness to her sacral area, but it was not open. During an interview on [DATE] at 2:08 PM, RN G stated that residents who required a mechanical lift to transfer were supposed to sit in their wheelchair between one to two hours at a time, but no more than 2 hours. RN G stated 9 hours was way too long and that the position could be challenging for a resident. RN G stated that perineal care could not be done unless a resident was transferred via mechanical lift back to their bed. RN G stated residents who used a mechanical lift for transfers were at a higher risk for skin breakdown and are often incontinent which can mean skin is more prone to breakdown. RN G stated he worked with Resident #1 on [DATE] from 6:00 pm to 6:00 am. He stated that he did not provide any perineal care or incontinent care and that the aides provided that care. RN G stated that he worked with CNA A and that she did not report any changes in skin to him. RN G stated during his shift rounds were conducted hourly for Resident #1 and that he and CNA A alternated the rounds. RN G stated that any changes would have been reported to the DON or ADON. During an interview on [DATE] at 3:07 PM, LVN H stated that resident who required the mechanical lift to transfer were usually laid back down in bed to give their bottom a rest, but the resident required incontinent or perineal care every two hours. LVN H stated it was not okay for a resident to be in a wheelchair for nine hours as sitting on their bottom would not allow for good circulation. LVN H stated residents who used a mechanical lift to transfer were at a higher risk for skin breakdown. During an interview on [DATE] at 3:31 PM, CNA D stated that she worked with Resident #1 on [DATE] and she left early. CNA D stated that Resident #1 was in her room most of the day. CNA D stated the last time she saw Resident #1 was before breakfast time and she did not see Resident #1 after breakfast at all as CNA D left around 10:00 am or 11:00 am. CNA D stated she did not change Resident #1's brief during her shift on [DATE]. CNA D stated she worked with Resident #1 in previous days and she did not observe any skin breakdown or redness that she could recall. CNA D stated she never transferred Resident #1 in or out of bed. CNA D stated the amount of time residents remain in their wheelchair depended on what therapy said how long the resident could tolerate. CNA D stated that nine hours was too long to be in the chair and stated I bet it is uncomfortable. CNA D stated Resident #1 would have to be transferred with the mechanical lift to have her brief changed in bed. CNA D stated rounds were done at least every two hours and during that time residents were turned and their brief was checked. CNA D stated when she checked on Resident #1 during rounds she was usually went and needed to be changed. CNA D stated it was everyone's responsibility to ensure that a resident was transferred back into bed. CNA D stated any skin changes would be documented and reported to the charge nurse. During an interview on [DATE] at 4:11 PM, the ADON stated that Resident #1's family requested that she be checked on every hour for tracheostomy care and suctioning and in general to ensure Resident #1 was okay. The ADON stated on [DATE] therapy, aides and the ADON were in Resident #1's room. The ADON stated she did not change Resident #1's brief on [DATE]. The ADON stated therapy provided perineal care for Resident #1 on [DATE] and that it was around 10:30 AM or 11:00 AM. The ADON stated that CNA D was the aide for half the shift and then CNA C took over. The ADON stated that Resident #1 was in the geriatric chair when her family arrived and they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 4 of 16 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 09/10/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few asked to have her put to bed around 5:00 PM. The ADON stated that Resident #1's family around after lunch time. The ADON stated they were not able to transfer Resident #1 at that time because the mechanical lift battery died and the other lifts were being used so she informed the family the next shift would be notified. The ADON stated that she did not know if any transfers occurred for Resident #1 between 11:00 am to 5:00 pm. The ADON stated she assumed the check off for Resident #1 was for the nurses until she looked at the document and saw it had check and change. The ADON stated that Resident #1 would have had to be transferred from her wheelchair to her bed within an hour to be changed. The ADON stated that typically residents who rely on mechanical lift to be transferred are in the wheelchair for a couple of hours and then they are put in bed, laid down and changed. The ADON stated if a resident cannot verbalize that they want to stay in bed or get back up staff will leave the resident laying down to rest and then get them back up. The ADON stated that residents who required the mechanical lift for transfers were at a high risk for skin breakdown. The ADON stated if they are sitting on that spot of a long time they have decrease circulation and boney areas have pressure. The ADON stated that it was not acceptable for a resident to be in the wheelchair from 10:00 am to 5:00 pm. The ADON stated she left around 6:30 pm on [DATE] and that night shift went into Resident #1's room around 6:00 pm and transferred her. During an interview on [DATE] at 4:35 PM, the NP stated that she saw Resident #1 the day after she admitted to the facility. She stated that it was not generally okay for Resident #1 to sit in a wheelchair for nine hours unless Resident #1 was verbally able to say she did not want to get into bed. The NP stated that Resident #1 was not able to verbalize her needs when she saw Resident #1. The NP stated Resident #1 was a higher risk for skin breakdown because she was not able to care for herself. The NP stated that Resident #1 was able to move around a bit, but required a mechanical lift to transfer. The NP stated at her visit Resident #1 had not been out of bed. The NP stated if Resident #1 sat in a chair she could have had breakdown and irritation for nine hours and for sure MASD was possible. The NP stated redness would have most likely occurred. During an interview on [DATE] at 4:51 PM, the DON stated that Resident #1 was dependent on the mechanical lift for transfers. The DON stated that typically when a resident was in a wheelchair it was for a max of two hours unless therapy has cleared the resident for [NAME] time or they have wound care. The DON stated that she expected Resident #1 to be transferred with the mechanical lift to bed for any type of care they might have needed. The DON stated that residents who were dependent on mechanical lift for transfers were at higher risk for skin breakdown and if they were not used to being up. The DON stated that the resident could also be at a risk if they were incontinent and if they urinated the entire time they were up in the chair. The DON stated that it did not meet her expectation that resident be up in a wheelchair for nine hours. The DON stated it was ultimately the responsibility of the charge nurse to ensure the resident was transferred up to the wheelchair or laid down. The DON stated the house checks came about because on [DATE] the family was concerned regarding perineal care. Resident #1 was assessed by wound care and had slight excoriation (irritation) on her perineal area and frequent rounding was implemented. The DON stated that it was designed for the nurse or CNA to check and/or change Resident #1 and to see if she needed anything or was okay. The DON stated that staff checked off if they performed care listed for Resident #1. The DON stated that she interviewed staff and staff sated that they went in and did checks and changes with Resident #1 on [DATE]. The DON stated that some staff said they forgot to check it off, but she could only speak to what the staff told her. The DON stated no change of condition was reported to her prior to Resident #1 going out to the hospital and it was by family request that she went to the hospital on [DATE]. The DON stated Resident #1 returned within 4 hours and family refused any care and requested (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 5 of 16 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 09/10/2025 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 0684 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete she be sent out again to the hospital. The DON stated that when she spoke with Resident #1's family they referenced [DATE] and that Resident #1 was up in the chair all day. The DON stated that it was reported to her about Resident #1 being in the chair mid-morning on [DATE]. During an interview on [DATE] at 5:15 PM, the ADM stated that there were hour checks for Resident #1 because her family had concerns about frequency of checks and wanted continuous care and more one-on-one level. The ADM stated that from his understanding and based on the logs she was checked on hourly. The ADM stated that staff were expected to see if the resident or family needed anything and if Resident #1's brief was dry. The ADM stated that when he tried to speak with Resident #1 she could not respond verbally. The ADM stated on [DATE] therapy put Resident #1 in her wheelchair and she had not been put in a chair before. The ADM stated that staff reported she was more responsive and able to use her call light after she was up. The ADM stated that when he reviewed the hourly check he believed there was a gap on that particular day. The ADM stated that he did not know how long Resident #1 was in her chair that day and stated he knew she was in chair a good part of the day and did not think she was in the chair for nine hours. The ADM stated that Resident #1 used a mechanical lift to transfer and would have expected staff to have transfer her from her wheelchair to provide care as they could not do if she was in her chair. The ADM stated the risk of Resident #1 being in her chair for an extended time was skin breakdown, pressure, ulcers, pain and being uncomfortable in general. The ADM stated that he did not think Resident #1 was able to make her needs known. Review of facility policy dated 02/2025 titled Resident Rights reflected residents had the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality. Review of facility in-services for last sixty days [DATE], [DATE] and [DATE] reflected no in-services were conducted on rounding or check and change rounding for Resident #1. Event ID: Facility ID: 676373 If continuation sheet Page 6 of 16 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 09/10/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for three (Resident #2, Resident #3, and Resident #4) of six residents reviewed for respiratory care. The facility failed to ensure RN G did not test the yankauer (tool for suctioning) in an open container of water prior to suctioning Resident #2's tracheostomy. The facility failed to ensure RN G monitored Resident #2's oxygen during tracheostomy care. The facility failed to ensure RN G did not continue with tracheostomy care when the yankauer was not functioning for Resident #2. These failures could place residents at risk of inadequate care, respiratory distress and hospitalization. Review of Resident #2's face sheet dated 09/09/2025 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of anoxic brain damage (occurs when brain is deprived of oxygen for an extended period), acute respiratory failure (life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide), dysphagia (difficulty swallowing), and tracheostomy status (surgical procedure that creates an opening in windpipe to help with breathing). Review of Resident #2's physician orders dated 09/09/025 reflected an order for an x-ray due to increased secretions. Review reflected and order dated 07/01/2025 to check and record oxygen saturation every shift while suctioning for Resident #2. Further review reflected an order dated 07/01/2025 for tracheostomy care as needed and every shift. Review reflected continuous oxygen at 8 liters per minute to maintain oxygen saturation of 92% and above dated 07/22/2025. Review of Resident #2's September 2025 MAR reflected oxygen saturation was checked each shift (twice a day) from 09/01/2025 through 09/09/2025. Further review reflected Resident #2's oxygen saturation was checked while suctioning every shift from 09/01/2025 to 09/09/2025 and remained above 92%. Review reflected tracheostomy care was provided for Resident #2 each shift from 09/01/2025 to 09/09/2025. Review of Resident #2's quarterly MDS dated [DATE] reflected Resident #2 had a short term and long-term memory problem and having tracheostomy present. Review of Resident #2 care plan dated 08/15/2025 reflected a goal to have no signs of symptoms of infection with interventions of administer oxygen as ordered. Further review of care plan reflected Resident #2 has oxygen therapy with no signs or symptoms of poor oxygen absorption with interventions to provide oxygen per physician orders. Review of chest x-ray results for Resident #2 dated 09/09/2025 reflected lungs are clear and well inflated bilaterally with no findings. Observation on 09/09/2025 at 12:45 PM revealed Resident #2 laid in bed with continues oxygen via tracheostomy flowing at 8 liters per minute. Resident #2 was observed to have drool around her mouth and oxygen mask with white colored mucus. Observation on 09/09/2025 at 1:16 PM revealed RN G donned surgical mask, donned gown and donned gloves without performing hand hygiene. RN G grabbed yankauer from packaging in Resident #2's bedside table and placed it in an open container of clear liquid that sat on Resident #2's bedside. Observation of the container reflected there was no label to indicate a date or contents of the container. RN G suctioned oxygen mask of Resident #2 and cleared mucus. RN G then placed yankauer in open container of clear liquid and placed it back in packaging in Resident #2's bedside table. RN G doffed the gown and gloves and washed his hands. Observation on 09/09/2025 at 2:29 PM revealed an open container of clear fluid placed on Resident #2's bedside table, the container was undated and unlabeled. Further observation revealed a container of normal saline placed on the beside table. Observation and interview on 09/10/2025 at 12:15 PM revealed RN G gathered 2 100 ml bottles of normal saline, 1 tracheostomy with [NAME] gloves kit and a vinyl gown. RN G entered Resident #2's room washed his hands in the bathroom and returned to the medication cart just outside Resident #2's room door. RN G donned a gown, surgical mask and gloves. RN Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 7 of 16 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 09/10/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few G proceeded to lock his medication cart with the gloves on, touch the light switch and closed Resident #2's room door with the same gloves on. RN G approached Resident #2's bedside and opened the tracheostomy kit over the bedside table. RN G did not sanitize the bedside table and had other items (towel, plastic syringe) that remained on the table. RN G raised the bedside table with the same gloves on and lowered the oxygen to 4 liters per minute. RN G laid a towel across Resident #2's chest. RN G opened a bottle of saline and poured contents in one side of a two-sided tracheostomy tray kit. RN G opened a second bottle of saline and poured contents into the other section of the tracheostomy tray kit that sat on the tray table. RN G turned his back to the sterile field (tray table with open saline) and disconnected tracheostomy oxygen mash (no hand hygiene or gloves changed prior). RN G grabbed yankauer from package in Resident #2's beside table ad attempted to suction thick light yellow secretions and it was revealed that no contents were suction out of the oxygen mask. RN G then placed tip of yankauer in open contain of clear fluid on Resident #2's bedside table. RN G then moved a switch on suction device and placed tip of yankauer again in open contain of clear fluid. RN G placed the yankauer back in packaging in Resident #2's bedside table and stated it was not working. Without performing hand hygiene or changing gloves, RN G removed dressing from around tracheostomy site and doffed gloves. RN G donned sterile gloves without performing hand hygiene and picked up q-tips and pipe cleaner from supplies and dropped in saline basin. RN G laid out the gauze, grabbed q-tip from saline solution and wiped the upper portion around the tracheostomy and disposed q-tip in trash. RN G grabbed a new q-tip from saline in trap and wiped the bottom part of Resident #2's tracheostomy, grabbed gauze and wiped the right side of the tracheostomy, then disposed of gauze and used his right hand to remove the inner cannula and placed it in the saline. RN G's gown was observed touching the outside of his gloves. RN G grabbed pipe cleaner from salutation and used the pipe cleaner to cleanse inside of the inner cannula. RN G used a dry pipe cleaner to dry the inside of the inner cannula twice and then disposed in the trash. RN G used his right hand to replace the inner cannula inside the outer cannula of the tracheostomy. Clear sputum (mixture of saliva and mucus) was observed handing from the tracheostomy. RN G picked up gauze and cleaned the sputum from the outer cannula and disposed of gauze. RN G picked up new gauze and placed under the flange of the tracheostomy. RN G adjusted the tracheostomy and it was observed to be secure on both sides. RN G cleaned oxygen collar with clean, dry gauze and disposed of the gauze. RN G placed oxygen collar over the tracheostomy, and doff gloves, donned new gloves (without performing hand hygiene). RN G increased oxygen to 8 liters per minute and placed call light on Resident's chest. RN G doffed gloves and washed his hands. RN G did not utilize pulse oximeter to monitor oxygen during care. Review of Resident #3'a face sheet dated 09/10/2025 revealed a [AGE] year-old male admitted on [DATE] with diagnoses of traumatic subdural hemorrhage with loss of consciousness (serious condition where blood forms between brain and inner layer of skull causing pressure and loss of consciousness), tracheostomy status (surgical procedure that creates an opening in windpipe to help with breathing), and chronic respiratory failure (condition where lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period. Review of Resident #3's physician orders reflected an order with a start date of 07/15/2025 for tracheostomy care every shift and as needed. Review of Resident #3's care plan dated 08/21/2025 reflected Resident #3 had a tracheostomy related to injury with a goal to have no signs or symptoms of infection. Review of Resident #3's admission MDS dated [DATE] reflected Resident #3 had a BIMS of 0 which indicated severe cognitive impairment. Observation of Resident #3 on 09/09/2025 at 4:38 PM revealed Resident #3 laid in bed and did not respond to questions. Further observation revealed an open container of clear liquid placed on Resident #3's bedside that was undated and unlabeled. Review of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 8 of 16 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 09/10/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #4's face sheet dated 09/10/2025 reflected a [AGE] year-old-man admitted on [DATE] with diagnoses of anoxic brain damage(occurs when brain is deprived of oxygen for an extended period), tracheostomy status (surgical procedure that creates an opening in windpipe to help with breathing) and compression of brain (increased pressure on the brain tissue caused by buildup of fluid, blood or a tumor). Review of Resident #4's physician orders reflected and order dated 07/03/2025 to provide tracheostomy care every shift and as needed. Review of Resident #4's care plan dated 07/08/2025 reflected Resident #4 had tracheostomy and pulled at tracheostomy with goal to be free from signs or symptoms of infection. Review of Resident #4's significant change MDS dated [DATE] reflected Resident #4 had a BIMS of 0 which indicated severe cognitive impairment. Observation on 09/09/2025 at 4:43 PM revealed Resident #4 laid in bed and did not respond to questions. Further observation revealed an open container of clear liquid on bedside that was unlabeled and undated. During an interview on 09/09/2025 at 2:17 PM, LVN H stated if she needed to suction a resident she would wash hands when she entered the room, get gloves and gather supplies. LVN H stated she would have saline ready and that you do not suction for a long time just a short time and allow the resident to recover. LVN H stated that you are supposed to check oxygen with a pulse oximeter after you suction the resident. LVN H stated that the yankauer is cleared with saline prior to use and you were supposed to clean it first before you suction and after you suction to ensure it was working properly. LVN H stated that it should be cleared with a new bottle of saline every time. LVN H stated it was important to wash hands prior to doing tracheostomy care for infection control and that you did not want to introduce any infection and cause potential respiratory infection to the resident. During an interview on 09/09/2025 at 2:32 PM, RN I stated before suctioning a resident or before tracheostomy care, staff were supposed to wash their hands in the bathroom. RN I stated everything was supposed to be sterile. RN I stated that it was important to use sterile gloves because if you are doing anything respiratory staff had to prevent infection for the resident. RN I stated every time staff suctioned the resident, they were supposed to get new saline and that was located in the nurses cart. During an interview on 09/09/2025 at 6:06 PM, the RT stated that hand hygiene should be performed prior to providing tracheostomy care and between glove changes. The RT stated that sterile saline should be used during tracheostomy care and the yankauer should be flushed with saline and discarded after use. During an interview on 09/10/2025 at 1:29 PM, RN F stated she has received training on tracheostomy care and stated that she would knock, enter the resident's room, wash hands, don a gown, gloves and mask. RN F stated she would have a sterile field set up with tracheostomy cleaning supplies, but prior to placing the supplies she would sanitize the tray table. RN F stated she would then wash her hands again and don gloves. RN F stated she would clean around the trach area, check for signs of infection and then doff gloves and perform hand hygiene and don sterile gloves. RN F stated she would clean the outer trach and would rinse it, let it dry and would then doff gloves, perform hand hygiene and don gloves and insert the outer trach back in. RN F stated when staff wore sterile gloves the gown should not be over the gloves because the gown could have been contaminated. RN F stated that there was usually a canister of water at bedside, and it should be covered and dated and replaced every twenty-four hours. RN F stated that items should be grabbed from the medication cart with gloves on and then go to perform care because it was an infection control issue. RN F stated the yankauer should have been tested prior to started tracheostomy care and the value should be check and tested with water. RN F stated if the yankauer was observed to not be working staff were not to proceed with care. RN F stated staff were supposed to have a pulse oximeter on the resident because extra secretions can cause oxygen levels to decrease. RN F stated she would not turn oxygen down because it could decrease during care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 9 of 16 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 09/10/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 09/10/2025 at 2:08 PM, RN G stated that he worked at the facility PRN and started working full time again two or three weeks ago. RN G stated when he returned he did not complete tracheostomy care training. RN G stated that he usually turned lights on with his elbow and was not supposed to touch the environment or lights with gloves on then perform care. RN G stated that during tracheostomy care the dirty part (cleaning) happened first and then sterile gloves were put on. RN G stated that he had cleaned the tray table in the morning when he started his shift and that was why he put a paper down on the area next to the towel. RN G stated he did not sanitize the area and that it should have been sanitized. RN G stated when he changed gloves he was not supposed to wash his hands or use hand sanitizer only before he was going to start providing care. RN G stated that sterile gloves should not be touching anything including the gown. RN G stated he was supposed to stay facing the sterile field because you hafpve items there and it could be contaminated if you are not watching it. RN G stated that he normally turned the oxygen down because this was what he was taught in school for tracheostomy care. RN G stated he was supposed to check oxygen saturation during tracheostomy care and he did not check Resident #2's because he probably forgot. RN G stated that he usually checked oxygen when suctioning and stated he had a pulse oximeter in his pocked today (09/10/2025). RN G stated the yankauer was working previously and that he was supposed to check if it was working properly before providing care and that ias why there was water at the bedside. RN G stated he did not think the water had to be sterile and that he did not think the water had to be covered and it got changed out every shift and it was supposed to be dated and have the time. RN G stated he could tell the water was brand new just by looking at it. During an interview on 09/10/2025 at 3:07 PM, LVN H stated that staff should only have supplies for tracheostomy care on the tray table and it should be sanitized prior to laying the supplies down. LVN H stated the yankauer should be primed prior to use and a new cup of saline is opened for suctioning every time. LVN H stated staff would not want to primer the yankauer in an open container of water that was sitting out because it was unknown if it was sterile. LVN H stated that the yankauer should have been tested prior to suctioning if it was not working tracheostomy care should not be performed. LVN H stated sterile gloves should not have the gown pulled over them on the wrist or anything touching the outside of the gloves. LVN H stated that saturation should be checked and oxygen flow be increased a little bit. LVN H stated that it was important to hands to be washed in between gloves changes to prevent introduced more germs to the resident. During an interview on 09/10/2025 at 4:11 PM, the ADON stated that she expected hand hygiene to be performed prior to putting gloves on and after taking them off. ADON stated that the yankauer should be tested prior to tracheostomy care. The ADON stated it should have been tested by suctioning a small amount of water and that the water should be sterile. The ADON stated it was not acceptable for staff to test the yankauer in an open container on a resident's bedside table. The ADON stated that sterile water should be poured into a small basin to test. The ADON stated if a yankauer was not working tracheostomy care should be stopped and a new yankauer should be retrieved. The ADON stated that the yankauer should be tested prior to started tracheostomy care so if it is not working the sterile field is not broken. The ADON stated that oxygen should have been monitored during tracheostomy care with a pulse oximeter placed on the resident's finger. The ADON stated oxygen is not decreased or increased and stayed the same. The ADON stated that nothing besides the sterile field should be touching sterile gloves and a sterile field should never leave sight of vision. The ADON stated a gown should not have touched sterile gloves. The ADON stated gloves should have been changed after gathering supplies and hand hygiene performed when the gloves were changed. The ADON stated hand hygiene was important to prevent cross contamination because residents with tracheostomy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 10 of 16 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 09/10/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete had a decreased immune system. The ADON stated that the areas for sterile supplies should be sterilized before the supplies were laid out and that nothing else should be on the same area that is not being used for that care. During an interview on 09/10/2025 at 4:35 PM, the NP stated that the yankauer should be tested prior to use and staff can hear it was working by turning it on. The NP stated staff could use water to clear the link of the yankauer and it was okay to use water and not saline since staff were not doing anything with the patient and just to clear the tube. The NP stated that when staff did deeper suctioning sterile gloves were used, but not when providing routine tracheostomy care and stated its an open hole so its not really sterile. The NP stated she used to have to have sterile gloves to clean the inner cannula, but she was not sure what the protocol was anymore. The NP stated that she expected staff to use hand sanitizer any time they walked into a resident's room and prior to donning gloves and after doffing gloves. The NP stated that gloves from a hallway or touching the environment was not generally a good thing and that staff really should not put on gloves until they were ready to perform care. During an interview on 09/10/2025 at 4:51 PM, the DON stated she expected staff to perform hand hygiene before and after patient care, before entering a room, when hands were soiled or dirty and in between glove changes. The DON stated she expected staff to use sterile gloves for tracheostomy care and foley changes. The DON stated she expected staff to test the yankauer prior to starting tracheostomy care and it could be tested by touching the tip of the yankauer to the staff's gloved thumb. The DON stated she personally would not test the yankauer in an open container of water and staff should have opened a new sterile water container. The DON stated that prior to set up, the area that items were paced on should have been sanitized and a sterile field should not have been taken out of the staff's line of vision. The DON stated staff should not have touched the nurse's cart or light switch without performing hand hygiene prior to providing resident care and changing gloves. The DON stated hand hygiene was important to not introduce infection to the resident. The DON stated that oxygen was monitored during tracheostomy care, before and after. The DON stated that she expected staff to preoxygenate before suctioning to ensure they have the appropriate amount of oxygen and she would not expect staff to lower the oxygen flow and would increase it during tracheostomy care. During an interview on 09/10/2025 at 5:15 PM, the ADM stated he expected staff to perform hand hygiene before they interact with residents, especially if they were on enhanced barrier precautions, handling meals, before and after perineal care and before and after putting on gloves. The ADM stated that he knew a tracheostomy was having a hole in the throat and from what he has learned they required regular suctioning, but he would defer to the DON. Review of facility in-services for last sixty days July 2025, August 2025 and September 2025 reflected no in-services were conducted on tracheostomy care. Review of facility policy with subject Tracheostomy, Care and Cleaning of with revision date of 05/2007 reflected This is a STERILE procedure. Further review reflected staff should wash hands prior to beginning the procedure, open plastic bag and cuff and place within reach so you do no to reach across the sterile field to discard items. Review of undated skills check off titled Tracheal Suctioning reflected perform hand hygiene and follow any necessary infection control guidelines, prepare suction equipment, turn on suction machine, open the suction catheter and sterile basin and fill with sterile normal saline. Review also reflected to preoxygenate the individual to maximize oxygen saturation in preparation for suctioning. Further review reflected remove gloves and perform hand hygiene. Event ID: Facility ID: 676373 If continuation sheet Page 11 of 16 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 09/10/2025 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 0880 Provide and implement an infection prevention and control program. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #2) of 6 residents observed for infection control. The facility failed to ensure RN G performed hand hygiene before and during tracheostomy care glove changes for Resident #2. The facility failed to ensure RN G did not test the yankauer in an open container of clear fluid and then suction Resident #2. The facility failed to ensure RN G sanitize the area prior to placing sterile supplies for tracheostomy care performed for Resident #2. These failures placed residents at an increased risk of exposure to infections, development of infections, decreased quality of life and/or hospitalizations.Findings included: Review of Resident #2 face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of anoxic brain damage (occurs when brain is deprived of oxygen for an extended period), acute respiratory failure (life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide), dysphagia (difficulty swallowing), and tracheostomy status (surgical procedure that creates an opening in windpipe to help with breathing). Review of Resident #2 physician orders dated 09/09/025 reflected an order for an x-ray due to increased secretions. Review reflected and order dated 07/01/2025 to check and record oxygen saturation every shift while suctioning for Resident #2. Further review reflected an order dated 07/01/2025 for tracheostomy care as needed and every shift. Review reflected continuous oxygen at 8 liters per minute to maintain oxygen saturation of 92% and above dated 07/22/2025. Review of Resident #2 September 2025 MAR reflected oxygen saturation was checked each shift (twice a day) from 09/01/2025 through 09/09/2025. Further review reflected Resident #2's oxygen saturation was checked while suctioning every shift from 09/01/2025 to 09/09/2025 and remained above 92%. Review reflected tracheostomy care was provided for Resident #2 each shift from 09/01/2025 to 09/09/2025. Review of Resident #2 quarterly MDS dated [DATE] reflected Resident #2 had a short term and long-term memory problem. Review of Resident #2 care plan dated 08/15/2025 reflected a goal to have no signs of symptoms of infection with interventions of administer oxygen as ordered. Further review of care plan reflected Resident #2 has oxygen therapy with no signs or symptoms of poor oxygen absorption with interventions to provide oxygen per physician orders. Observation on 09/09/2025 at 1:16 PM revealed RN G donned surgical mask, donned gown and donned gloves without performing hand hygiene. RN G grabbed yankauer from packaging in Resident #2's bedside table and placed it in an open container of clear liquid that sat on Resident #2's bedside. Observation of the container reflected there was no label to indicate a date or contents of the container. RN G suctioned oxygen mask of Resident #2 and cleared mucus. RN G then placed yankauer in open container of clear liquid and placed it back in packaging in Resident #2's bedside table. RN G doffed the gown and gloves and washed his hands. Observation on 09/09/2025 at 2:29 PM revealed an open container of clear fluid placed on Resident #2's bedside table, the container was undated and unlabeled. Further observation revealed a container of normal saline placed on the beside table. Observation and interview on 09/10/2025 at 12:15 PM revealed RN G gathered 2 100 ml bottles of normal saline, 1 tracheostomy with [NAME] gloves kit and a vinyl gown. RN G entered Resident #2's room washed his hands in the bathroom and returned to the medication cart just outside Resident #2's room door. RN G donned a gown, surgical mask and gloves. RN G proceeded to lock his medication cart with the gloves on, touch the light switch and closed Resident #2's room door with the same gloves on. RN G approached Resident #2's bedside and opened the tracheostomy kit over the bedside table. RN G did not sanitize the bedside table and had other items (towel, plastic Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 12 of 16 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 09/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some syringe) that remained on the table. RN G raised the bedside table with the same gloves on and lowered the oxygen to 4 liters per minute. RN G laid a towel across Resident #2's chest. RN G opened a bottle of saline and poured contents in one section of the tracheostomy tray kit and opened a second bottle of saline and poured contents into the other section of the tracheostomy tray kit that sat on the tray table. RN G turned his back to the sterile field (tray table with open saline) and disconnected tracheostomy oxygen mash (no hand hygiene or gloves changed prior). RN G grabbed yankauer from package in Resident #2's beside table and attempted to suction thick light yellow secretions and it was revealed that no contents were suction out of the oxygen mask. RN G then placed tip of yankauer in open contain of clear fluid on Resident #2's bedside table. RN G then moved a switch on suction device and placed tip of yanauer again in open contain of clear fluid. RN G placed the yankauer back in packaging in Resident #2's bedside table and stated it was not working. Without performing hand hygiene or changing gloves, RN G removed dressing from around tracheostomy site and doffed gloves. RN G donned sterile gloves without performing hand hygiene and picked up q-tips and pipe cleaner from supplies and dropped in saline basin. RN G laid out the gauze, grabbed q-tip from saline solution and wiped the upper portion around the tracheostomy and disposed q-tip in trash. RN G grabbed a new q-tip from saline in trap and wiped the bottom part of Resident #2's tracheostomy, grabbed gauze and wiped the right side of the tracheostomy, then disposed of gauze and used his right hand to remove the inner cannula and placed it in the saline. RN G's gown was observed touching the outside of his gloves. RN G grabbed pipe cleaner from salutation and used the pipe cleaner to clease inside of the inner cannula. RN G used a dry pipe cleaner to dry the inside of the inner cannula twice and then disposed in the trash. RN G used his right hand to replace the inner cannula inside the outer cannula of the tracheostomy. Clear sputum (mixture of saliva and mucus) was observed handing from the tracheostomy. RN G picked up gauze and cleaned the sputum from the outer cannula and disposed of gauze. RN G picked up new gauze and placed under the flange of the tracheostomy. RN G adjusted the tracheostomy tie and it was observed to be secure on both sides. RN G cleaned oxygen collar with clean, dry gauze and disposed of the gauze. RN G placed oxygen collar over the tracheostomy, and doff gloved, donned new gloves (without performing hand hygiene). RN G increased oxygen to 8 liters per minute and placed call light on Resident's chest. RN G doffed gloves and washed his hands. RN G did not utilize pulse oximeter to monitor oxygen during care. During an interview on 09/10/2025 at 3:07 PM, LVN H stated that staff should only have supplies for tracheostomy care on the tray table and it should be sanitized prior to laying the supplies down. LVN H stated the yankauer should be primed prior to use and a new cup of saline is opened for suctioning every time. LVN H stated staff would not want to primer the yankauer in an open container of water that was sitting out because it was unknown if it was sterile. LVN H stated that the yankauer should have been tested prior to suctioning if it was not working tracheostomy care should not be performed. LVN H stated sterile gloves should not have the gown pulled over them on the wrist or anything touching the outside of the gloves. LVN H stated that saturation should be checked and oxygen flow be increased a little bit. LVN H stated that it was important to hands to be washed in between gloves changes to prevent introduced more germs to the resident. During an interview on 09/09/2025 at 6:06 PM, RT stated that hand hygiene should be performed prior to providing tracheostomy care and between glove changes. RT stated that sterile saline should be used during tracheostomy care and the yankauer should be flushed with saline and discarded after use. During an interview on 09/10/2025 at 1:29 PM, RN F stated she has received training on tracheostomy care and stated that she would knock, enter the resident's room, wash hands, don a gown, gloves and mask. RN F stated she would have a sterile field set up with tracheostomy cleaning supplies, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 13 of 16 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 09/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some but prior to placing the supplies she would sanitize the tray table. RN F stated she would then wash her hands again and don gloves. RN F stated she would clean around the trach area, check for signs of infection and then doff gloves and perform hand hygiene and don sterile gloves. RN F stated she would clean the outer trach and would rinse it, let it dry and would then doff gloves, perform hand hygiene and don gloves and insert the outer trach back in. RN F stated when staff wore sterile gloves the gown should not be over the gloves because the gown could have been contaminated. RN F stated that there is usually a canister of water at bedside, and it should be covered and dated and replaced every twenty-four hours. RN F stated that items should be grabbed from the medication cart with gloves on and then go to perform care because it was an infection control issue. RN F stated the yankauer should have been tested prior to started tracheostomy care and the value should be check and tested with water. RN F stated if the yankauer is observed to not be working staff were not to proceed with care. RN F stated staff were supposed to have a pulse oximeter on the resident because extra secretions can cause oxygen levels to decrease. RN F stated she would not turn oxygen down because it could decrease during care. During an interview on 09/10/2025 at 2:08 PM, RN G stated that he worked at the facility PRN and started working full time again two or three weeks ago. RN G stated when he retuned he did not complete tracheostomy care training. RN G stated that he usually turned lights on with his elbow and was not supposed to touch the environment or lights with gloves on then perform care. RN G stated that during tracheostomy care the dirty part (cleaning) happened first and then sterile gloves were put on. RN G stated that he had cleaned the tray table in the morning when he started his shift and that is why he put a paper down on the area next to the el. RN G stated he did not sanitize the area and that it should have been sanitized. RN G stated when he changed gloves he was not supposed to wash his hands or use hand sanitizer only before he was going to start providing care. RN G stated that sterile gloves should not be touching anything including the gown. RN G stated he was supposed to stay facing the sterile filed because you have items there and it could be contaminated if you are not watching it. RN G stated that he normally turned the oxygen down because this is what he was taught in school for tracheostomy care. RN G stated he was supposed to check oxygen saturation during tracheostomy care and he did not check Resident #2's because he probably forgot. RN G stated that he usually checked oxygen when suction and stated he had a pulse oximeter in his pocked today (09/10/2025). RN G stated the yankauer was working previously and that he was supposed to check if it was working properly before providing care and that is why there was water at the bedside. RN G stated he did not think the water had to be sterile and that he did not think the water had to be covered and it got changed out every shift and it was supposed to be dated and have the time. RN G stated he could tell the water was brand new just by looking at it. During an interview on 09/10/2025 at 3:07 PM, LVN H stated that staff should only have supplies for tracheostomy care on the tray table and it should be sanitized prior to laying the supplies down. LVN H stated the yankauer should be primed prior to use and a new cup of saline is opened for suctioning every time. LVN H stated staff would not want to primer the yankauer in an open container of water that was sitting out because it was unknown if it was sterile. LVN H stated that the yankauer should have been tested prior to suctioning if it was not working tracheostomy care should not be performed. LVN H stated sterile gloves should not have gown over them or anything touching the gloves. LVN H stated that saturation should be checked and oxygen flow be increased a little bit. LVN H stated that it was important to hands to be washed in between gloves changes to prevent introduced more germs to the resident. During an interview on 09/10/2025 at 3:15 PM, CNA E stated that hand hygiene should be performed before and after care. CNA E stated that when she wore glove, she performed hand hygiene put the gloves (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 14 of 16 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 09/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on, performed care, threw the gloves away, performed hand hygiene and put on new gloves. CNA E stated it was important to perform hand hygiene to prevent spreading germs. During an interview on 09/10/2025 at 3:31 PM, CNA D stated hand hygiene should be performed before and after working with a resident, before entering a resident room and after exiting. CNA D stated that in between glove changes hand hygiene should also be performed. CNA D stated that it was important to do hand hygiene to not spread any germs to the resident and get the resident sick. During an interview on 09/10/2025 at 4:11 PM, the ADON stated that she expected hand hygiene to be performed prior to putting gloves on and after taking them off. The ADON stated that the yankauer should be tested prior to tracheostomy care. The ADON stated it should have been tested by suctioning a small amount of water and that the water should be sterile. The ADON stated it was not acceptable for staff to test the yankauer in an open container on a resident's bedside table. The ADON stated that sterile water should be poured into a small basin to test. The ADON stated if a yankauer was not working tracheostomy care should be stopped and a new yankauer should be retrieved and that the yankauer should be tested prior to started tracheostomy care so if it is not working the sterile field is not broken. The ADON stated that oxygen should have been monitored during tracheostomy care with a pulse oximeter placed on the resident's finger. The ADON stated oxygen is not decreased or increased and stayed the same. The ADON stated that nothing besides the sterile field should be touching sterile gloves and a sterile field should never leave sight of vision. The ADON stated a gown should not have touched sterile gloves. The ADON stated gloves should have been changed after gathering supplies and hand hygiene performed when the gloves were changed. The ADON stated hand hygiene was important to prevent cross contamination because residents with tracheostomy had a decreased immune system. The ADON stated that the areas for sterile supplies should be sterilized before the supplies were laid out and that nothing else should be on the same area that is not being used for that care. During an interview on 09/10/2025 at 4:35 PM, the NP stated that the yankauer should be tested prior to use and staff can hear it was working by turning it on.The NP stated staff could use water to clear the link of the yankauer and it was okay to use water and not saline since staff were not doing anything with the patient and just to clear the tube. The NP stated that when staff did deeper suctioning sterile gloves were used, but not when providing routine tracheostomy care and stated its an open hole so its not really sterile. The NP stated she used to have to have sterile gloves to clean the inner cannula, but she was not sure what the protocol was anymore. The NP stated that she expected staff to use hand sanitizer any time they walked into a resident's room and prior to donning gloves and after doffing gloves. The NP stated that gloves from a hallway or touching the environment was not generally a good thing and that staff really should not put on gloves until they were ready to perform care. During an interview on 09/10/2025 at 4:51 PM, the DON stated she expected staff to perform hand hygiene before and after patient care, before entering a room, when hands were soiled or dirty and in between glove changes. The DON stated she expected staff to use sterile gloves for tracheostomy care and foley changes. The DON stated she expected staff to test the yankauer prior to starting tracheostomy care and it could be tested by touching the tip of the yankauer to the staff's gloved thumb. The DON stated she personally would not test the yankauer in an open container of water and staff should have opened a new sterile water container. The DON stated that prior to set up, the area that items were paced on should have been sanitized and a sterile field should not have been taken out of the staff's line of vision. The DON stated staff should not have touched the nurse's cart or light switch without performing hand hygiene prior to providing resident care and changing gloves. The DON stated hand hygiene was important to not introduce infection to the resident. The DON stated that oxygen was monitored during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676373 If continuation sheet Page 15 of 16 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 09/10/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete tracheostomy care, before and after. The DON stated that she expected staff to preoxygenate before suctioning to ensure they have the appropriate amount of oxygen and she would not expect staff to lower the oxygen flow and would increase it during tracheostomy care. During an interview on 09/10/2025 at 5:15 PM, the ADM stated he expected staff to perform hand hygiene before they interact with residents, especially if they are on enhanced barrier precautions, handling meals, before and after perineal care and before and after putting on gloves. The ADM stated that he knew a tracheostomy was having a hole in the throat and from what he has learned they required regular suctioning, but he would defer to the DON. Review of facility in-services for last sixty days July 2025, August 2025 and September 2025 reflected no in-services were conducted on tracheostomy care. Review of facility policy titled Infection Prevention and Control Program with revision date of 10/2022 reflected facility staff will conduct themselves and provide care in a way that minimizes the spread of infection and staff will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Review of facility policy titled Hand Hygiene with revision date of 04/2025 reflected hand hygiene is a general term that applies to hand washing antiseptic hand wash and alcohol-based hand rub. Review reflected to use alcohol-based hand rub before and after direct contact with residents, before performing any non-surgical invasive procedures, before donning sterile close, before handing clean or soiled dressings, after handling used dressings, and after removing gloves. Event ID: Facility ID: 676373 If continuation sheet Page 16 of 16