Health inspection·December 3, 2025

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 12/03/2025, at 4:39 p.m. with ADM revealed all staff were trained on HIPAA at the time of hire by signing acknowledgements, and at least annually after that. He stated that if a computer is left open, it should be turned off to prevent unauthorized access. He stated that it is the responsibility of whoever works on the computer to make sure it is off before leaving the nursing station. He stated that ADON, clinical manager, and himself monitor the nursing station area all the time to prevent unauthorized personnel behind the nursing station. Record review of facility's staff in-service form dated 10/28/25 and titled: Use and disclosure of protected healthcare information revealed the following instructions to staff: Confidentiality/HIPAA Regulation: The Privacy Policy reflects practices that have been adopted by the facility to protect patients' privacy and security in relation to their Protected Health Information as defined under HIPAA regulation. It is the duty and responsibility of each staff person associated with this facility to be fully familiar with Privacy Policy and to comply with the requirements detailed within it. This in-service was signed by 28 nursing staff members and LVN B attended the training and acknowledged the completion of the HIPAA training. 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 12/03/2025 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 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 observations, interviews and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 (Resident #1, Resident #2) of 7 residents reviewed for infection control. 1. The facility failed to properly use EBP personal protective equipment during wound care for Resident #1 and Resident #2.2. The facility failed to follow hand hygiene procedure during direct care for Resident #1. This failure could place residents at risk for infection transmission, sepsis, and hospitalization. Findings included: Record review of Resident #1's face sheet, dated 12/02/2025, revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of rectum (rectal cancer occurs when cells in the rectum mutate and grow out of control), major depressive disorder (persistently low or depressed mood), colostomy status (surgery to create an opening for the colon (large intestine) through the belly (abdomen) to allows stool and gas to leave your body when they can't pass through anus, essential hypertension (high blood pressure). Observation on 12/03/2025 at 11:06 a.m. revealed LVN A did not put on the personal protective equipment (gown) before starting the wound care, colostomy (surgical opening in the abdomen to allow stool to exit the body when part of the colon is not functioning properly) and urostomy (a surgical diversion that creates an opening (stoma) in the abdomen to redirect urine from the bladder to an external pouch) care for Resident #1. She did not sanitize her hands between change of the gloves and used contaminated gloves when reached for clean wound care supplies after she cleaned the area around the sacral wound (the triangular region at the base of the spine, just above the buttocks). Record review of Resident #1's order dated 11/4/2025, revealed Sacral wound to clean with normal saline. Pat dry. Apply Anapest with collagen powder. Skin prep peri wound. Cover with foam dressing daily and as needed.Record review of Resident's order dated 11/10/2025 revealed this resident was on contact precautions for urine and enhance barrier precautions (used for infection prevention and control intervention designed to reduce transmission of multidrug resistant organisms to other residents in nursing homes).During an interview on 12/03/2025, with LVN A, she stated that she had an in-service on enhanced barrier precautions and contact precautions protocol with infection control policies earlier this year. She said that enhanced barrier precautions include wearing a gown and gloves when conducting all invasive nursing procedures like wound care and stomas (surgical opening in the body). She stated that she was supposed to wear a gown and gloves when completing wound care and colostomy and urostomy care for Resident #1. She stated that it was too hot in the room and that's why she did not wear the gown, but she had it on earlier in the morning with this patient. She stated that she understood that the negative effect of not following proper EBP or contact precautions every time would be spreading infection and cross contamination. She stated that she is aware of the facility policy for sanitizing hands between gloves change. She stated that not sanitizing her hands could lead to spreading the infection.Observation on 12/03/25, at 1:15 p.m., revealed LVN B performed the wound care for Resident #2. He did not put on the personal protective equipment (gown) before the start of wound care procedure.Interview on 12/03/2025, at 1:25 p.m. with LVN B revealed that he was trained on following EBP protocol for all invasive procedures with residents. He had an in-service on EBP today, 12/03/2025. Nurses are responsible for following the policy He stated that he was aware of potential risk if not following the EBP protocol would be cross contamination and passing the infection to other residents which is detrimental for vulnerable populations in long term care facilitates. Record review of Resident #2's face sheet, dated 12/03/2025, revealed an 89-years-old female admitted on [DATE]. Resident's #2's diagnoses included hypothyroidism (underactive thyroid, happens Residents Affected - Few (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 12/03/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete when a thyroid gland doesn't make enough thyroid hormones to meet body's needs), essential hypertension (high blood pressure that is not due to another medical condition), gastro-esophageal reflux disease (a condition in which acidic gastric fluid flows backward into the esophagus, resulting in heartburn), malignant neoplasm of unspecified site of unspecified female breast (breast cancer).Observation on 12/03/25, at 1:15 p.m., revealed LVN B performed the wound care for Resident #2. He did not put on the personal protective equipment (gown) before the start of wound care procedure.Interview on 12/03/2025, at 1:25 p.m. with LVN B revealed that he was trained on following EBP protocol for all invasive procedures with residents. He had an in-service on EBP today, 12/03/2025. Nurses are responsible for following the policy He stated that he was aware of potential risk if not following the EBP protocol would be cross contamination and passing the infection to other residents which is detrimental for vulnerable populations in long term care facilitates. During an interview on 12/03/2025 at 4:21 p.m. with ADON, she said that the facility's policy on EBP required all nursing staff wear personal protective equipment including gowns and gloves to prevent transmission of infections to other vulnerable residents. The ADON stated the last training on infection control and hand hygiene was conducted last month and during annual skills training sessions, weekly audits, and in huddles. The ADON stated a potential negative outcome for the residents would be cross contamination.During an interview on 12/03/2025 at 4:39 p.m. with ADM, he stated that all staff were trained on infection control policy, hands hygiene and following enhanced barriers and contact precautions. He stated that it was his responsibility as administrator to make sure everybody follows those policies. He stated that ADON and clinical manager provide training to nursing staff on infection control. He said that it is very important to follow infection control policies to prevent cross contamination.The record review of Resident #2's order dated 12/3/2025 revealed right knee wound treatments on shower days: remove dressing for shower, cleans are w/soap and re-apply dry dressing every day shift every Monday, Wednesday and Friday for wound care. Review of facility's Infection Prevention and Surveillance Policy, dated 10/24/2022, reflected: The nurse leader designee shall track, trend and monitor infections on an ongoing basis to assist with the prevention, development and transmission of disease and infection. 6. Assist with implementation of infection control and prevention policies and procedures support associate compliance and resident safety. Record review of Handwashing/Hand Hygiene Policy dated 10/2015 indicated that alcohol-based hand sanitizer should be used after contact with a resident's intact skin. after removing gloves.Record review of Enhanced Barrier Precautions policy dated 9/2022 indicated that enhanced barrier precautions should be utilized to reduce transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are indicated along with other precautions ordered like contact precautions. Event ID: Facility ID: 455866 If continuation sheet Page 4 of 4