Health inspection·June 9, 2023

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 2 Residents (Resident #59) reviewed for transmitting assessments in that: Residents Affected - Few Resident #59's quarterly MDS assessment was not completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required. The findings included: Record review of Resident #59's face sheet, dated 6/7/23 revealed an [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses that included dementia, muscle weakness, paroxysmal atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should), chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), seizures, and adult failure to thrive. review of the most recent quarterly MDS assessment for Resident #59 revealed the target date for completion was 5/4/23 and the assessment was in progress, meaning the assessment had not been completed or electronically transmitted to CMS. During an interview on 6/9/23 at 5:23 p.m., the MDS Coordinator revealed Resident #59's most recent quarterly MDS assessment with target date 5/4/23 was not completed and transmitted within the required 14 days. The MDS Coordinator revealed the facility had recently faced staffing challenges and lost 2 MDS Coordinators since the beginning of May 2023. The MDS Coordinator revealed, a delay in transmitting the MDS assessment would not have impacted the residents directly. The MDS Coordinator revealed the facility followed the RAI rules for completing and transmitting MDS assessments. Page 1 of 19 676131 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 2 of 15 Residents (Resident #142 and Resident #193) reviewed for accidents and hazards, in that: 1. The facility failed to prevent Resident #142 from having cigarettes and a lighter in a drawer attached to the bedside table next to the resident's bed and over the counter medications on the bedside table. 2. The facility failed to prevent Resident #193 from having a box cutter in his room. These deficient practices could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: 1. Record review of Resident #142's face sheet, dated 6/7/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included type 2 diabetes with foot ulcer (a chronic, long-lasting health condition that affects how your body turns food into energy), end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), cirrhosis of liver (scarring of the liver caused by long-term liver damage) , dependence on renal dialysis, heart disease, hypertension (high blood pressure) and muscle weakness. Record review of Resident #142's comprehensive care plan, dated 5/21/23 revealed the resident was at risk for complications/injury related to smoking with interventions that included to retrieve cigarettes and lighter when resident is done smoking. Record review of Resident #142's admission Smoking Data Collection document, dated 5/22/23 revealed the resident required direct supervision with smoking and retrieve cigarettes and lighter when resident is done smoking. Observation on 6/7/23 at 11:10 a.m. revealed Resident #142 with an open box of over-the-counter medication allergy pills and container of nasal spray in the half open drawer attached to the bedside table next to the resident's bed. Observation and interview on 6/7/23 at 11:18 a.m. revealed CMA A, when summoned to Resident #142's room, pulled the half open drawer attached to the bottom of Resident #142's bedside table and revealed, in addition to the open box of over-the-counter medication allergy pills and the container of nasal spray, a package of cigarettes and a lighter. CMA A revealed, the package of cigarettes and the lighter were not supposed to be in Resident #142's possession and those items were supposed to be locked and kept by nursing staff. CMA A revealed, cigarettes and lighters kept at the bedside was dangerous because Resident #142 could have decided to light up in the room and the lighter was a hazard because it could start a fire. The CMA A revealed medications on the bedside should not be left because he could overdose or double dose. During an interview on 6/7/23 at 11:31 a.m., the LVN Clinical Services Manager revealed, cigarettes 676131 Page 2 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and lighters must be locked up at the nurse's station because Resident #142 might have the temptation to smoke in his room and could start a fire or burn himself or another resident. During an interview on 6/7/23 at 5:24 p.m., the DON revealed Resident #142 was supposed to get his cigarettes and the lighter from nursing and after the smoke break the cigarettes and the lighter were locked and kept by the nurses. The DON revealed the resident was not supposed to have cigarettes and the lighter in his room due to safety concerns to others and it was a fire hazard. 2. Record review of Resident #193's face sheet, dated 6/7/23 revealed a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness, included type 2 diabetes without complications (a chronic, long-lasting health condition that affects how your body turns food into energy), anxiety disorder, other idiopathic peripheral autonomic neuropathy, hypertension (high blood pressure), and primary generalized arthritis. Record review of Resident #142's comprehensive care plan, dated 5/31/23 revealed, the resident had an ADL self-care deficit performance deficit and required a mechanical aide for transfer and other assistive devices. During an observation on 06/09/23 at 11:30 a.m. Resident #193 was sitting on his bed with an open cardboard box next to him. On the bed was a red box cutter. During an interview on 06/09/23 at 11:43 a.m., CMA H stated she saw the box cutter in the resident's room, and she thought he may have just received it in the mail. CMA H stated she would let the nurse know. LVN C stated Resident #193 did not have special permission to have a box cutter and no one was allowed to have a box cutter. Record review of the facility's admission agreement, dated 10/2020, stated I. Parties. This admission Agreement is made this .VI .6. Smoking. Smoking is not permitted in any of the provider facilities except in the designated outdoor areas. 7. Weapons. Weapons as defined by us are not allowed in the provider or on property. Weapons include but are not limited to firearms, explosive materials, knives, chemical weapons, and collectible or antique weapons . Attachment F Medication: no medications or drugs may be brought into the provider unless the medications or drugs are labeled accordingly to the requirements of state and federal law. Packaging of medications must be compatible with the provider medication distribution system no drugs or medications may be brought into the provider unless they are delivered directly to the nurse's station. All over the counter medications including, but not limited to, the following are prohibited in the Resident's room . 676131 Page 3 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 6 residents (Resident #28) reviewed for pain management in that: Residents Affected - Few Resident #28 requested pain medication from staff and had to wait 2 hours and 45 minutes for a nurse to assess her for pain and administer pain medications. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life. The findings included: Record review of Resident #28's face sheet, dated 6/7/23 revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] and 6/6/23 with diagnoses that included acute and chronic respiratory failure, congestive heart failure, muscle weakness, age-related physical debility, and chronic pain syndrome. Record review of Resident #28's most recent admission MDS assessment, dated 4/27/23 revealed the resident was cognitively intact for daily decision-making skills, received pain medications as needed, and had pain frequently. Section G revealed the resident required extensive assistance with med mobilty and transfers, required two + person physical assisst, and used a wheelchair. Record review of Resident #28's comprehensive care plan, revision date 6/9/23 revealed the resident experienced pain and interventions included to administer pain medication as ordered and the resident was able to call for assistance when in pain, ask for medication, tell how much pain was experienced and what could increase or alleviate pain. Record review of Resident #28's Order Summary Report, dated 6/8/23 revealed the following: -Pain Observation and Non-Pharmacological Interventions every shift, Intervention Codes: 0=Denied pain, 1=Redirect, 2=1:1, 3=See nurses notes -Gabapentin 600 mg, 1 tablet every 6 hours as needed for nerve pain with order date 6/6/23 and no end date -Norco 5-325 mg (hydrocodone-acetaminophen), 1 tablet every 4 hours as needed for pain with order date 6/6/23 and no end date -Norco 5-325 mg (hydrocodone-acetaminophen), 2 tablets every 4 hours as needed for pain with order date 6/7/23 and no end date. Record review of Resident #28's medication administration record for 6/9/23 revealed LVN E had marked under pain observation/pain level as 0, which indicated the resident had denied pain. Further review of Resident #28's medication administration record revealed the resident had not received Gabapentin as needed since the order date, had not received Norco 5-325 mg 1 tablet every 4 hours as 676131 Page 4 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few needed since the order date and had last received Norco 5-325 mg 2 tablets every 4 hours as needed on 6/8/23 during the morning shift. Observation and interview on 6/9/23 at 9:36 a.m., during the medication pass, LVN E revealed, Resident #28 was to receive a narcotic and 2 pills, hydrocodone, for pain. As the Surveyor stood outside of Resident #28's room with LVN E, the resident could be heard loudly saying, I'm in pain and Please give me my pain medication. Resident #28 rated her pain level at an 8 out of 10, was yelling, making crying noises without tears, and was apologizing over and over for yelling. Resident #28 stated she was in so much pain and had been asking for pain medication since that morning. During an interview on 6/9/23 at 9:36 a.m., Resident #28 revealed she had been asking for pain medication since before breakfast, but nobody ever gave her a pain medication. Resident #28 revealed she had told an aide, and another person that she was in pain and needed pain medication. Resident #28 revealed she was unable to identify who the aide or other person she talked to about wanting pain medication. During an interview on 6/9/23 at 9:41 a.m., LVN E revealed her shift started at 6:00 a.m. and made quick rounds. LVN E did not reveal if she had assessed Resident #28 for pain, only that the CNA's go into each room to obtain the vital signs and then would review them. During a follow up interview on 6/9/23 at 9:42 a.m., Resident #28 stated she had not seen LVN E at all this morning until just now (during the medication pass with the Surveyor at 9:36 a.m.) Resident #28 revealed once again, she had told an aide earlier in the morning about wanting pain medication, was not sure what time, but indicated it was before breakfast. Resident #28 described the pain as neck and shoulder pain from a previous surgery to that area. During an interview on 6/9/23 at 9:58 a.m., CNA F revealed her shift started at 6:00 a.m. and recalled Resident #28 was asking for pain medications. CNA F revealed she went into Resident #28's room and the resident told her she had been asking for pain medications. CNA F revealed she went into the resident's room at approximately 6:45 a.m. CNA F revealed she told LVN E Resident #28 was asking for pain medication and was told by LVN E she would check on the resident. During an interview on 6/9/23 at 10:14 a.m., CNA G revealed she was distributing breakfast trays at approximately 8:00 a.m. when Resident #28 activated the call light. CNA G revealed she went into Resident #28's room and the resident complained about having pain and wanting pain medication. CNA G revealed, after she de-activated the call light, she sent to LVN E to tell her Resident #28 was in pain and was requesting pain medication. CNA G revealed, LVN E said she would be in Resident #28's room soon. CNA G stated, I actually went into Resident #28's room and told her that I had notified the nurse. During an interview on 6/9/23 at 2:53 p.m., the DON revealed she had asked LVN E about Resident #28 and revealed LVN E told her an aide notified her via text at 8:44 a.m. that Resident #28 was requesting pain medication. The DON determined, when reviewing documentation in Resident #28's electronic record, LVN E documented at 9:27 a.m. the resident was given pain medication and documented at 10:11 a.m. the resident had a pain level of 0, which was after the resident received pain medication. The DON determined from the electronic record, the last time the resident was assessed for pain was on 6/9/23 at 4:24 a.m. by the night nurse. Record review of the facility's policy titled Medical Management Overview, dated 07/2015, last 676131 Page 5 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0697 Level of Harm - Minimal harm or potential for actual harm revised 03/2019, stated policy overview: the community will adopt pharmacy services and procedure manual for skilled nursing communities for medication and pharmacy related policies and procedures, unless otherwise indicated. Additional company policy this year may be added as needed or required for safety federal regulations. Medicine shall be administered as prescribed by the health care provider Residents Affected - Few 676131 Page 6 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 3 of 6 Residents (Resident #28, Resident #142 and #146) reviewed for medication administration in that: 1. Resident #142 was observed with 4 pills in a medication cup, an open box of over-the-counter allergy pills, a container of nasal spray and an open package with a lidocaine patch at the bedside. 2. Resident #146 was observed with a prescription box of Ondansetron (prescribed to prevent nausea/vomiting) and a prescription bottle of Trazadone (prescribed for treatment of depression and used as a sedative) at the bedside. 3. Resident #28's breathing treatments were documented as administered at 9:21 a.m. The order was to administer them at 7:00 a.m. These deficient practices could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction or a decline in health. The findings included: 1. Record review of Resident #142's face sheet, dated 6/7/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included type 2 diabetes with foot ulcer (a chronic, long-lasting health condition that affects how your body turns food into energy), end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), cirrhosis of liver (scarring of the liver caused by long-term liver damage) , dependence on renal dialysis, heart disease, hypertension (high blood pressure) and muscle weakness. Record review of Resident #142's comprehensive care plan, dated 5/21/23 revealed the resident experienced pain with interventions that included to administer pain medication as per orders. Record review of Resident #142's Order Summary Report, dated 6/8/23 revealed the following: -Lidocaine External Patch 4%, apply to area of pain topically one time a day for pain, remove after 12 hours of application, with order date 5/20/23 and no end date. -Melatonin 3 mg, give 3 tablets by mouth at bedtime for insomnia, with order date 5/20/23 and no end date. -Protonix 40 mg delayed release one time daily for GERD (gastroesophageal reflux- occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach/esophagus) with order date 5/20/23 and no end date. -Fluticasone Propionate Suspension 50 mcg, 1 spray in each nostril one time a day for allergic rhinitis, with order dated 6/6/23 and no end date. 676131 Page 7 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0755 -Resident #142 did not have a physician's order for allergy pills Level of Harm - Minimal harm or potential for actual harm Observation on 6/6/23 at 11:11 a.m., during initial tour, revealed Resident #142 with an open box of over-the-counter allergy pills and a container of nasal spray in a half open drawer attached to the bedside table on the right of the bed. Further observation revealed an open package with a lidocaine patch (a local anesthetic used to relieve pain) on top of the same bedside table. The lidocaine patch was marked with a black marker and, Call for help! was written on the package with a smile drawn on the package. Residents Affected - Many During an interview on 6/6/23 at 11:11 a.m., Resident #142 revealed he had taken a dose of the over-the-counter allergy pills the night before and administered the nasal spray the night before last. Resident #142 revealed the lidocaine patch had been on the bedside table about a week and he was unable to put the patch on without help. Resident #142 revealed the lidocaine patch was supposed to be placed over his liver or on the back by staff. Resident #142 could not identify which staff had left the lidocaine patch at the bedside. Observation the following day on 6/7/23 at 11:10 a.m. revealed Resident #142 with a medication cup with 4 pills in it on the bedside table to the right of the resident's bed, and the same open box of over-the-counter allergy pills, the same container of nasal spray and the same open package with the lidocaine patch observed on 6/6/23. During an interview on 6/7/23 at 11:10 a.m., Resident #142 revealed the pills in the medication cup were from the other day. Resident #142 revealed he was given pills by an unidentified nursing staff and took the big pills first then fell asleep. Resident #142 revealed he still planned on taking the pills from the medication cup later. During an observation and interview on 6/7/23 at 11:18 a.m., CMA A revealed she was able to identify the pills in the medication cup as a melatonin pill and a protonix pill. CMA A could not identify 2 of the 4 pills in the medication cup. CMA A revealed, Resident #142 was not supposed to have any medications at the bedside, including the pills in the medication cup, the lidocaine patch, the box of over-the-counter allergy pills and the container of nasal spray. CMA A revealed, medications left at the bedside could result in the resident double dosing or overdosing. During an interview on 6/7/23 at 11:25 a.m., RN B revealed Resident #142 should not have had medications left at the bedside because the person dispensing the medication had to ensure the resident took the medications. RN B revealed an order had to be obtained for over-the-counter medications. RN B revealed, medications left at the bedside could results in the resident taking the medication incorrectly, possibly overdosing, could be taking more than the recommended dose, and could be contraindicated with other prescribed medications. 2. Record review of Resident #146's face sheet, dated 7/7/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included fracture of left lower leg, depression, anxiety, pain, age-related physical debility, and unsteadiness on feet. Record review of Resident #146's comprehensive care plan, revision date 6/3/23 revealed the resident experienced pain with interventions that included to administer pain medication as per orders. Record review of Resident #146's Order Summary Report, dated 6/8/23 revealed the following: 676131 Page 8 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0755 Level of Harm - Minimal harm or potential for actual harm -Ondansetron 4 mg, give 1 tablet every 12 hours as needed for nausea and vomiting, with order date 5/29/23 and no end date. -Trazadone 50 mg, give 1 tablet at bedtime for insomnia, monitor for agitation, lethargy, with order date 5/29/23 and no end date. Residents Affected - Many During an observation and interview on 6/6/23 at 10:48 a.m. during initial tour, revealed Resident #146 with a box of Ondansetron with a pharmacy label stored in an open top drawer of the resident's nightstand on the left of the bed. Resident #146 revealed staff were aware of the box of Ondansetron. Resident #146 could not reveal when she had last taken the Ondansetron stored in the open top drawer of the resident's nightstand and had complained that she had not been receiving pain medications. During an observation and interview the following day on 6/7/23 at 9:45 a.m., Resident #146 with the same box of Ondansetron with a pharmacy label stored in an open top drawer of the resident's nightstand on the left side of the bed. Resident #146 revealed she had taken the Ondansetron several days ago and again revealed staff were aware of the box of Ondansetron. During an observation and interview on 6/7/23 at 11:42 a.m., CMA A was summoned into Resident #146's room and identified the box of Ondansetron in an open top drawer of the resident's nightstand on the left of the bed. CMA A then pulled on the same top drawer and a large prescription bottle of Trazadone was observed at the back of the drawer. CMA A revealed, Resident #146 was not supposed to have medications at the bedside because it could result in the resident double dosing or overdosing. Resident #146 stated, go ahead and take it, I haven't used the Trazadone. During an interview on 6/7/23 at 11:31 a.m., the LVN Clinical Services Manager revealed, leaving medications at a resident's bedside was unacceptable and if the resident did not take the medications as prescribed, such as blood pressure medications, it could have caused the resident's blood pressure to elevate. The LVN Clinical Service Manager stated, we are not doing our job. During an interview on 6/7/23 at 5:24 p.m., the DON revealed, medications left at the bedside was a hazard and other residents could possibly wander into the resident's room and take medications not prescribed to them. 3. Record review of Resident #28's face sheet, dated 6/7/23 revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] and 6/6/23 with diagnoses that included acute and chronic respiratory failure, congestive heart failure, muscle weakness, age-related physical debility, and chronic pain syndrome. Record review of Resident #28's most recent admission MDS assessment, dated 4/27/23 revealed the resident was cognitively intact for daily decision-making skills. Record review of Resident #28's comprehensive care plan, revision date 6/9/23 revealed Resident #28 had impaired airway clearance. COPD, recent acute respiratory failure with history of chronic respiratory failure. Interventions include Nebulizer as ordered Inhalation Nebulization Ipratropium Albuterol Solution 0.5-2.5 (3) MG/3ML Inhalation Suspension 0.5 MG/2ML (Budesonide (Inhalation)). Record review of Resident #28's Order Summary Report, dated 6/8/23 revealed the following: Brovana Inhalation Nebulization Solution 15 MCG/2ML (Arformoterol Tartrate) 2 ml inhale orally two times a day for SoB/Wheezing -Start Date- 06/07/2023 0700 and Budesonide Inhalation Suspension 0.5 MG/2ML 676131 Page 9 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0755 Level of Harm - Minimal harm or potential for actual harm (Budesonide (Inhalation)) 2 ml inhale orally two times a day for SoB/Wheezing -Start Date- 06/07/2023 0700. Record review of Resident #28's MAR, dated 06/09/23, revealed LVN E marked both nebulizer treatments as administered at 7 a.m. on 06/09/23. Residents Affected - Many During an observation/interview at 9:10 a.m. this surveyor observed LVN E at a medication cart in a hallway. This surveyor asked LVN E if she had any medications to administer that morning. LVN E stated she was done passing medications and had no more medications to administer that morning. This surveyor asked LVN E if she had access to the eMAR to see who or if any residents had medications due that morning. LVN E stated this surveyor should ask the medication aide because she did not have access to see the eMAR. During an observation on 06/09/23 at 9:24 a.m. LVN E was observed at a nursing cart dispensing narcotics in front of Resident #28's room. This surveyor asked to observe LVN E administer the medications. LVN E stated she would like a 2nd person to witness the medication pass. Another surveyor came moments later to the area to observe the medication pass. LVN E stated she had pain medication and antianxiety medication ready to administer to Resident #28. The top of the nursing cart contained 3 plastic vials of nebulizer treatments. This surveyor requested to see the package the vials came from. LVN E declined to show this surveyor and stated she planned to administer the nebulizer breathing treatments to Resident #28 after she administered the other medications to Resident #28. LVN E then entered the room to administer the pain and antianxiety medications to Resident #28. Resident #28 expressed she had waited all morning for her medications. LVN E stated she was sorry it took her forever to bring her medications. During an interview on 06/09/23 at 9:41 a.m. Resident #28 stated she had not seen LVN E at all that morning until the medication pass observed by the surveyors. The resident stated she had asked other staff for pain medication all morning but had not seen LVN E until the medication pass at 9:36 a.m. During an interview on 06/09/23 at 2:53 p.m., the DON stated LVN E had spoken with her about the situation and stated she had woken Resident #28 up that morning to give her the breathing treatments. This surveyor informed the DON 3 vials of breathing treatments were observed on the nursing cart at 9:24 a.m. and LVN E stated she planned to administer them after administering the pain medications. The DON stated she would need to get her laptop to access the times the medications were given. At 3:24 p.m. the DON returned with her computer. The DON's computer showed LVN E documented the breathing treatments as administered at 9:21 a.m. and 9:22 a.m. The breathing treatment scheduled at 11 am was documented as administered at 10 a.m. The DON stated she guessed LVN E was just late on her documentation. The DON stated staff was expected to document at the time the medication was administered, and they were able to enter a note for late documentation. During a follow up interview on 06/09/23 at 4:20 p.m. Resident #28 stated she received her breathing treatments that morning from LVN E a short time after LVN E provided her pain medications while the surveyors were observing medication pass (After 9:36 a.m. on 06/09/23). Resident #28 revealed she usually gets two breathing treatments, the first one in the morning, and the second one is given usually after supper. Resident #28 stated the breathing treatment consisted of the nurse putting several vials, double sometimes triple, depending on the need. Record review of the facility's policy titled Medical Management Overview, dated 07/2015, last 676131 Page 10 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many revised 03/2019, stated policy overview: the community will adopt pharmacy services and procedure manual for skilled nursing communities for medication and pharmacy related policies and procedures, unless otherwise indicated. Additional company policy this year may be added as needed or required for safety federal regulations. Medicine shall be administered as prescribed by the health care provider . Record review of the facility's admission agreement, dated 10/2020, stated I. Parties. This admission Agreement is made this . Attachment F Medication: no medications or drugs may be brought into the provider unless the medications or drugs are labeled accordingly to the requirements of state and federal law. Packaging of medications must be compatible with the provider medication distribution system no drugs or medications may be brought into the provider unless they are delivered directly to the nurse's station. All over the counter medications including, but not limited to, the following are prohibited in the Resident's room . 676131 Page 11 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions for 1 of 7 residents (Resident #192) reviewed during the medication pass for medication labeling, and the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 3 of 4 medication carts (nursing cart 1, medication cart 2, and nursing cart 3) medication storage in that: 1. The pharmacy label on Resident #192's insulin pen did not match the dosage prescribed by the physician. 2. Nursing cart 1, medication cart 2, and nursing cart 3 were unlocked and unattended at various times. These failures could place residents at risk for not receiving the therapeutic effects of their medications and receiving the wrong amount of medication. The findings included: 1. Record review of Resident #192's face sheet, dated 6/7/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included cellulitis (inflammation) of left lower limb and muscle weakness. Record review of Resident #192's comprehensive care plan, initiated 6/5/23 revealed the resident had diabetes with interventions that included diabetes medication as ordered by doctor. Record review of Resident #192's Order Summary Report, dated 6/8/23 revealed the following: -Insulin Lispro 200 units/ml, inject 8 units subcutaneously with meals for diabetes care with order date 6/6/23 and no end date. Observation during the medication pass on 6/8/23 at 4:44 p.m. revealed LVN C removed Resident #192's insulin Lispro from the medication cart. Resident #192's insulin Lispro had a pharmacy label that indicated to inject 5 units with meals which did not match the physician's order to inject 8 units. The insulin Lispro had an open date of 6/4/23. During an interview on 6/8/23 at 5:13 p.m., LVN C revealed, the insulin Lispro prescribed to Resident #192 had been used since the open date indicated on the insulin pen. LVN C revealed the order did not match the label on the insulin Lispro and there should have been a label attached to indicate the order had been changed. LVN C revealed, the label to indicate there was an order change was to avoid a medication error. LVN C stated, somebody could just look at the label (on the insulin Lispro), see that it says 5 units, but the order is for 8 units. LVN C revealed, Resident #192 could be under dosed, and it could result in his sugar to continue to elevate because he did not get enough insulin and could show signs and symptoms of hypoglycemia (low blood sugar). 676131 Page 12 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 6/8/23 at 5:59 p.m., the DON stated, we look at the label for the resident's name, date, name of drug and expiration date, but not the actual dosage for the insulin. We go by the order that's in the computer because insulin orders change all the time. We go by the orders in the computer. The DON further revealed, if LVN C had under dosed the resident it would have been a medication error. During an interview on 6/9/23 at 9:08 a.m., the RN Corporate Nurse revealed, Resident #192 had his insulin dosage changed and there should have been a change of order sticker on the insulin Lispro to avoid a medication error. The RN Corporate Nurse revealed, if Resident #192 was not getting enough insulin he could have become hypoglycemic. 2. During an observation on 06/07/2023 at 9:04 a.m. Medication cart 2 was observed unlocked and no staff is near the cart. During an observation on 06/07/2023 at 9:05 a.m. Nursing cart 1 was left unlocked and unattended. Staff is observed walking by the cart. During an observation and interview on 06/07/23 at 9:11 a.m. CMA A return to medication cart 2. CMA A stated she can open the drawers and the cart was unlocked. CMA A stated she was standing across the hall and was getting ready to administer medications. During an observation and interview on 06/07/23 at 9:15 a.m. RN B was informed by this surveyor nursing cart 1 in hallway 3 was left unlocked. RN B walked out from behind the nurses' station and over to the cart. RN B stated it was a cart she was used and had unlocked if for unknown staff to remove supplies. RN B stated she did not recall who she unlocked it for, but she will unlock it for the medication aides to get what they need out and they forgot to lock it. RN B stated it should stay locked so residents and anyone else can not get into the cart. During an interview on 06/07/23 at 5:26 p.m. the DON stated she did an in service on locking carts. The DON stated staff was expected to lock carts whenever they are away from the cart. The DON stated if they were standing with in arms distance it is ok to be unlocked. The DON stated the carts should be locked when they leave the carts, so residents don't grab items from it. During an observation on 06/08/23 at 8:26 a.m. a nursing cart 3 was unlocked near hallway 1. LVN E was observed exiting a resident's room and approached the cart. LVN E was asked if the cart was unlocked. LVN E pushed the lock on the cart into the locked position and stated it was half locked. LVN E confirmed the draws could still open in the half-locked position. LVN E stated she went to talk to a resident quickly so he could enjoy his breakfast. LVN E stated she called in the day before and did not receive the in-service on keeping carts locked. LVN E stated the cart should be locked to keep things secure. LVN E then walked away ending the interview. Record review of the facility policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, revision date 1/1/13 revealed in part, .3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . 676131 Page 13 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 facility reviewed for dietary sanitation in that: The facility failed to ensure the emergency water storage was located at least 6 inches above the ground. The facility failed to ensure the emergency food storage was located at least 6 inches above the ground and 18 inches below the ceiling of the storage room. The facility failed to ensure 2 ice makers were maintained for cleanliness. The facility failed to remove expired food found within 3 of 6 unit refrigerators. The facility failed to ensure 2 of 6 unit refrigerators operated below 41 degrees Fahrenheit. The facility failed to ensure 1 of 6 unit refrigerators maintained complete temperature logs. The facility failed to ensure all food contained a label and a date for 2 of 6 unit refrigerators. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation and interview on 6/7/23 at 11:09 AM of the emergency water storage revealed approximately 28 5-gallon water containers located on the floor of a shower in a vacant resident room that was utilized as a staff office. The DM stated she was aware of the water storage being in that room but was not aware it was not at least 6 inches off the ground and stated the emergency water storage was the responsibility of maintenance. Observation and interview on 6/7/23 at 11:14 AM of the emergency food storage revealed the location to be within an electrical support room of the nearby building adjacent to the facility with the food been stored on wire shelving racks 1-2 inches above the ground and an air duct >6-10 inches above the food storage. The DM stated the emergency food storage was moved several months ago because of flood history in the facility. The DM stated the maintenance of the room that the emergency food storage was in was the responsibility of maintenance. Observation and interview on 6/7/23 at 11:41 AM of the downstairs kitchen ice maker revealed a black substance buildup inside of the equipment. The Dietary Manager stated the dietary department completed a documented monthly cleaning of the ice makers in both kitchens. In addition, the maintenance department completed a monthly undocumented interior cleaning of the ice makers. The Dietary Manager stated the black substance inside the ice maker was unidentifiable but would have been cleaned during the maintenance portion of the ice maker cleaning. The Dietary Manager stated the risk associated with not maintaining the cleanliness of the ice makers would be the potential for foodborne illness and macrobacteria afflicting residents. 676131 Page 14 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Observation on 6/7/23 at 11:47 AM of the upstairs kitchen ice maker revealed a black substance buildup inside of the equipment. Observation on 6/9/23 at 9:14 AM of Hall 84-98 unit refrigerator revealed: one unit of fruit yogurt with a best by date of 6/4/23, and a pint of dairy ice cream without a listed expiration date or use by date apart from an identifiable date of 3/15/23. Observation on 6/9/23 at 9:19 AM of Hall 38-52 unit refrigerator revealed: an internal temperature of 44 degrees Fahrenheit, an undated sandwich for room [ROOM NUMBER], and an undated and unlabeled green produce. Observation on 6/9/23 at 9:24 AM of Hall 20-37 unit refrigerator revealed: a container of red fruit produce with a sell by date of 5/24/23, 2 units of dairy milk with best by dates of 6/8/23, and the unit refrigerator temperature log sheet on 6/8/23 was not completed. Observation on 6/9/23 at 9:46 AM of Hall 1-19 unit refrigerator revealed: an internal temperature of 48 degrees Fahrenheit, a single unit of dairy milk with a best by date of 6/8/23, and single unit of dairy yogurt with a best by date of 5/24/23. Interview on 6/9/23 at 10:47 AM, the MS stated he was responsible for repairing inoperable essential equipment at the facility. The MS stated he was not aware of the unit refrigerators operating outside of expected temperatures or the cleanliness of the kitchen ice makers. The MS stated the frequency of cleaning the ice makers was every other month and that he just cleaned the ice makers in April. The MS stated the cleaning of the ice maker is recorded digitally. Interview and observation on 6/9/23 at 1:54 PM, the ADON stated she was not aware of the failures observed within the unit refrigerators. The ADON stated the unit refrigerators were inspected daily by the nursing night shift and when items were in the unit refrigerators for more than 3 days, they should have been disposed of regardless of listed date. The ADON stated all items within the unit refrigerators were expected to be dated and labeled and that best by dates are treated as expiration dates. The ADON stated the risk associated with the failures identified within the unit refrigerators would be a potential for foodborne illness in residents. During the interview, the ADON observed the unit refrigerators with the surveyor and confirmed the findings. Interview on 6/9/23 at 5:37 PM, the ADM stated it was her expectation that food served to residents be maintained in properly operating refrigerators and outdated items be disposed of immediately. The ADM stated she was not aware of the failures identified within the unit refrigerators and expected nursing night staff to complete the temperature logs accurately and inform Maintenance immediately either in a paper work-order or notify the Maintenance Supervisor directly. The ADM stated she was aware of the emergency food and water storage but not the location of them with respect to their distance to the floor or ceiling and expected them to be stored properly. The ADM stated she was unaware of the cleanliness of the ice makers and expected them to be cleaned on their routine basis. The ADM stated the failures have a risk to residents of potentially causing foodborne illness. Record review of the Ice Machine Cleaning Log reflected the last date of cleaning date for the Downstairs ice maker to be 5/27[23]. Record review of the nutritional policy titled Storage of Non Perishable Food, dated 2005, reflected 1. All non perishable foods shall be dated upon delivery indicating (month/day/year) product was 676131 Page 15 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many received. 2. All non perishable foods shall be stored on storeroom shelving that is no less than 6 [inches] from the floor and 18 [inches] from the ceiling or according to state regulations. All new products shall be placed behind existing stock to assure utilization of current stock first (first in/first out.) 3. The storeroom shall be maintained free from dirt, dust, insects, rodents or any potential sources of contamination. The storeroom should be maintained as close to optimal temperature (70 [degrees] Fahrenheit) as possible. The storage area should be well ventilated. 4. Dry storage must have a thermometer placed towards the rear of the storeroom. 5. Open boxes or cans shall be stored, sealed, labeled and dated. Dry goods should be stored according to dry storage guidelines. Record review of US Food Code, dated 2017, revealed (F) MEAT and POULTRY that is not a READY-TO-EAT FOOD and is in a PACKAGED form when it is offered for sale or otherwise offered for consumption, shall be labeled to include safe handling instructions as specified in LAW, including 9 CFR 317.2(l) and 9 CFR 381.125(b). Record review of US Food Code, dated 2017, revealed The shelf life of ROP foods is based on storage temperature for a certain time and other intrinsic factors of the food (pH, aw, cured with salt and nitrite, high levels of competing organisms, organic acids, natural antibiotics or bacteriocins, salt, preservatives, etc.). Each package of food in ROP must bear a use-by date. In some cases such as cook chill or sous vide processing when none of these intrinsic factors are present, a temperature lower than 3ºC (38ºF) must be the controlling factor for C. botulinum and L. monocytogenes growth and/or toxin formation. This use by date cannot exceed the number of days specified in one of the ROP methods in Section 3-502.12 or must be based on laboratory inoculation studies. The date assigned by a retail repacker cannot extend beyond the manufacturer's recommended expiration or pull date for the food. The use-by date must be listed on the principal display panel in bold type on a contrasting background for any product sold to consumers. Any label on packages intended for consumer sale must contain a combination of a sell-by date and use-by instructions which makes it clear that the product must be consumed within the number of days determined to be safe as specified under Section 3-502.12 of the Food Code. Foods, especially fish, that are frozen before or immediately after packaging and remain frozen until use should bear a label statement, Important, keep frozen until used, thaw under refrigeration immediately before use. Raw meat and poultry packaged using ROP methods must be labeled with safe handling instructions found in 9 CFR 317.2(l) and 9 CFR 381.125(b) 676131 Page 16 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to dispose of garbage and refuse properly, for 1 of 1 trash compacter reviewed in that: Residents Affected - Few The trash compacter had encrusted black dirt and grease built up around the entire perimeter of the trash compacter restricting access. This failure posed a sanitary and safety hazard that could result in the attraction of vermin and affect all resident residing in the facility by exposing them to germs and diseases carried by vermin and rodents. The findings were: During an observation and interview on 6/9/23 at 10:53 AM, the trash compacter was revealed to contain a dense accumulation of encrusted dirt and grime around the perimeter of the equipment. The MS stated the trash compacter was used for all garbage from both the nursing facility and nearby assisted living. The MS stated housekeeping was responsible for cleaning around the trash compacter on an unknown frequency. The MS stated the housekeeping department reports to him directly. The MS stated he was not sure the last time it had been cleaned and did not feel the perimeter of the trash compacter had been cleaned recently due to the amount of garbage and refuse located around the equipment. The MS stated the risk associated with not maintaining the cleanliness of the trash compacter would be a risk for pests accumulating around the refuse and garbage and impacting resident health. Interview on 6/9/23 at 5:37 PM, the ADM stated it was her expectation that the trash compacter be cleaned and free of garbage, pests, and refuse as to not put the residents at risk of pests. The ADM stated she was not aware of the cleanliness of the trash compacter. Facility policy related to refuse and garbage was requested from the MS and ADM on 6/9/23 but not provided upon exit. 676131 Page 17 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

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 reviews, the facility failed to establish and 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 of 2 residents (Resident # 144) reviewed for infection control practices, in that: Residents Affected - Some CNA D failed to utilize appropriate infection control practices when entering Resident #144's room who was on isolation for an infection. This failure could place residents on contact isolation for infection at risk for spreading the infection or a decline in health. The findings included: Record review of Resident #144's face sheet, dated 6/7/23 revealed an [AGE] year-old female admitted on [DATE] with diagnoses that included laceration to left lower leg and muscle weakness. Record review of Resident #144's comprehensive care plan, initiated on 6/7/23 revealed the resident had c-diff (Clostridium difficile colitis, a bacterial infection that causes an inflammation of the colon and can be transmitted from person to person by spores), with interventions that included to educate resident/family/staff regarding preventative measures to contain the infection and place in private room with contact isolation precautions. Record review of Resident #144's Order Summary Report, dated 6/8/23 revealed the following order: -Contact Isolation C-Diff every shift, with order date 6/6/23 and no end date. Record review of Resident #144's laboratory results, dated 6/6/23 revealed the resident tested positive for c-diff and included to Continue contact enteric isolation. Observation on 6/6/23 at 11:27 a.m. revealed Resident #144 had a sign on the door indicating, STOP, CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated disposable equipment. Clean and disinfect reusable equipment before use on another person. Further observation revealed a cart just outside of Resident #144's room stocked with PPE (personal protective equipment). Observation on 6/6/23 at 11:48 a.m. revealed CNA D walked into Resident #144's room carrying the resident's lunch tray and failed to utilize appropriate infection control practices. CNA D entered Resident #144's room with the lunch tray and placed it on the resident's bedside table. CNA D was not wearing a gown or gloves when she entered Resident #144's room. During an interview on 6/6/23 at 11:49 a.m., CNA D stated, sorry. CNA D revealed, Resident #144 did not have the PPE cart or signage indicating the resident was on contact precautions earlier before delivering the lunch tray and had not been given any information the resident was on contact isolation. CNA D revealed the sign on the door and the PPE cart indicated Resident #144 was on contact 676131 Page 18 of 19 676131 06/09/2023 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some isolation and CNA D was supposed to put on a face mask, gloves and gown because it was considered cross contamination. During an interview on 6/7/23 at 5:12 p.m., the DON revealed, Resident #144 was confirmed positive for c-diff and if the precautionary measures were in place, i.e., PPE and signage, then staff should have followed those precautionary measures and following infection control protocol because c-diff is an infection that lives in a spore. Record review of the facility policy and procedure titled, Isolation Precautions, revision date 9/2022 revealed in part, .Transmission-Based Precautions should be used when caring for residents requiring infection control measures above and beyond standard precautions .1. Contact Precautions .Gloves to be worn upon entering the resident's room .Wear a gown for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment . 676131 Page 19 of 19