Health inspection·November 5, 2023

F 0689 Level of Harm - Actual harm Residents Affected - Few as negative. [Resident #1] voiced pain and was provided medication to relieve pain. During investigation, it was discovered that [CNA A] had forgotten to lock wheelchair brakes which resulted [Resident #1] needing to be lowered to ground. [CNA A] was suspended pending investigation. The report further reflected, After MD reviewed x-ray results, a CT scan was ordered and [Resident #1] was transferred to ER via non emergent transport on 8/31/23. On 9/1/23, results of CT scan were positive for a fracture to femur (bone that extends to the hip and the knee) and pubic bone. Record review of Resident #1's Progress Notes revealed on 8/29/23 at 4:54p.m. the LVN B documented, CNA reported to this nurse that resident had a near fall (in) the shower, but he was able to save her from falling, head to toe assessment completed resident complained of pain to right hip. Prn oxycodone (opioid, used to treat pain) 2.5 mg administered. The PCP was notified and responded with orders for a right hip x-ray. On 8/29/23 at 10:06 p.m. the LVN K documented in a follow-up for the fall without injuries, no swelling, bruising, or deformity noted. The resident was sitting up in bed. Complained of pain to hip. After pain medication was given, the resident stated 2 hours later she was no longer in pain. On 8/30/23 at 11 a.m. RN D documented that the x-ray results had been posted and were negative for a fracture. On 8/31/23 at 10 a.m. the facility NP documentation included, The patient was seen and examined in her room. She is sitting in her chair complaining about right hip pain and right groin pain. On examination no bruises or swelling noted to the site. Neurovascular check to right toes within normal limits. Patient is able to lift the right leg with moderate amount of pain. She had a fall on 8/29/23 evening. Per report the x-ray was negative for fracture. Personally reviewed x-ray which showed abnormal appearance of the femoral head neck junction (connection of the femoral bone head to the neck of the bone) which is suspicious for a nondisplaced (remains in proper alignment) fracture and in the appropriate clinical setting consider CT for further evaluation. Patient will be sent out to (local hospital name) for stat (immediate) CT scan of the right hip to rule out fracture since the patient is experiencing severe pain and she is not able to ambulate due to the pain. Record Review of the Facility Incident Reports from 8/1/23 through11/5/23 revealed no other incidents of falls during transfers with staff. Record review of the Provider Investigation Report dated 9/8/23 revealed the investigation summary included, on 8/29/23 around 4 p.m., Resident #1 was assisted by CNA A in a shower transfer. During the transfer, CNA A forgot to lock the wheelchair brakes which caused the wheelchair to roll away when Resident #1 was sitting down. Per CNA A, he caught Resident #1, had her lean against the wall, and grabbed the wheelchair for her to sit down. CNA A immediately reported this near fall to LVN B, who assessed the resident immediately after the incident. No redness, bruising or indication of a fall was noted except for voiced pain to Resident #1's hip. LVN B notified the physician and family. Orders were received for an x-ray and pain medications were prescribed. Record review of the facility Inservice records included on 9/1/23 and 9/2/23 for 23 CNAs and/or MAs. Training included falls, reporting falls and injuries. Fall prevention methods including rounding on residents, monitoring residents at risk, offering toileting, checking briefs, offering snacks, providing activities, low bed, call lights. Effective communication with nurses regarding resident fall/risk for falls. Resident transfers, wheelchair locked and secure prior to transfer. Mechanical lifts and a review of mechanical lift transfers, standby assistance. Facility RNs conducted twenty-eight observations, each on a different staff, utilizing check sheets for CNA and MA transfers. Safe surveys were conducted with all residents residing on the same unit. Record review of CNA A's personnel file revealed he was hired on 8/8/23. Review of training records (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455866 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 455866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Westlake Hills 1034 Liberty Park Dr Austin, TX 78746 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 0689 revealed on 8/15/23 CNA A completed a course titled Safe Resident Handling and Transferring. Level of Harm - Actual harm During an interview on 11/5/23 at 12:35 p.m. with CNA C revealed she had received training with hire, about a year ago, on transfers and multiple times since including on 9/2/23 when she also was observed by an RN doing a transfer. Residents Affected - Few During an interview on 11/5/23 at 12:45 p.m. with LVN D revealed she at times assist staff with transfers. LVN D stated that she has not had any concerns with staff transfers and that staff are aware of the need to lock a wheelchair before transfer. She also received training at hire and has had inservice recently regarding transferring. She is not aware of any instances of staff assisted transfers causing an injury while she was working. During an interview on 11/5/23 at 2:16 p.m. with CNA F revealed that he has worked for the facility for four months. He stated he received training on transfers at hire before working with residents and recently on 9/2/2023 another inservice and a nurse observing him doing a transfer. He stated he knows to lock the wheelchair prior to assisting resident transfer. During an interview on 11/5/23 at 2:25 p.m. with LVN F revealed he has been trained on transfers many times in the 15 years at the facility and has assisted CNA's frequently with transfers. LVN F stated he has done transfer observations many times and he has not witnessed a CNA transfer a resident without locking the wheelchair first. During an interview on 11/5/23 at 2:40 p.m. with CNA G revealed she has worked here for 13 years. She stated she knew and worked with Resident #1. She stated at the time of the incident Resident #1 was a one person transfer and there was not a problem with one staff transferring her because she was petite. CNA G stated everyone gets annual training on transfers that includes ensuring the wheelchair is locked. CNA G stated she worked with CNA A onetime and did not have concerns about his transferring of residents. She thinks he may have just made a mistake, but she was not working the day the incident occurred. She received an inservice and was observed doing a transfer on 9/2/23. During an interview on 11/5/23 at 3:19 p.m. with CNA H revealed he has received annual training on transfers since working at the facility. He stated on 9/2/23 he was inserviced on transfers and observed doing a transfer. CNA H stated all CNAs were inserviced after it was found Resident #1 was injured. During a telephone interview on 11/05/23 at 3:54 p.m. with the FM of Resident #1, he stated that he had just left the facility a few minutes before they called him and told him Resident #1 had fallen. The FM stated he was concerned he was not told initially by the facility that Resident #1's wheelchair had not been locked during a transfer. The FM stated he also did not understand how the first x-ray did not show a fracture. He stated Resident #1 complained of pain for 2 days before she was sent to the hospital where the fractures were discovered, one of which required surgery to place pins in the pelvic bone. He stated Resident #1 did not return to the facility but was currently living with her family receiving home health care and would not be interested in being interviewed. During an interview on 11/5/23 at 12:40 p.m. with the facility ED revealed CNA A was suspended pending investigation and did not return to work. The ED stated CNA A had received training on transfers when hired. The ED confirmed that at the time of the incident Resident #1's transfer requirements was one staff. The care plan was changed to include two staff after the incident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455866 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 455866 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/05/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Westlake Hills 1034 Liberty Park Dr Austin, TX 78746 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 0689 Level of Harm - Actual harm Record review of a Safe Living and Movement of Residents policy, dated 07/2018, indicated a Policy Overview In order to protect the safety and well-being of associates and residents, and to promote quality care, this community uses appropriate techniques and devices to lift and move residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455866 If continuation sheet Page 4 of 4