Health inspection·October 7, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment and no more than 21 days after admission for two (Resident #1 and #2) of five residents reviewed for care plans. The facility failed to ensure Resident #1's and #2's comprehensive care plans were completed within seven days after completion of their comprehensive assessments. This deficient practice could place residents at risk of not receiving assistance with activities of daily living and sustaining a serious injury, impairment or death. Findings included: Resident #1 Review of Resident #1's face sheet, dated 10/07/24, reflected he was a [AGE] year-old male who was initially admitted to the facility on [DATE], readmitted on [DATE], and his own RP. Review of Resident #1's medical diagnoses, dated 10/07/24, reflected he had unspecified angina pectoris (A type of chest pain caused by reduced blood flow to the heart), unspecified hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), pressure ulcer of right heel that was unstageable and sacral region that was stage three, and anemia in chronic kidney disease (a common condition that occurs when the kidneys can't produce enough erythropoietin, a hormone that signals the bone marrow to make red blood cells). Review of Resident #1's comprehensive MDS assessment, dated 09/07/24, reflected he had a BIMS score of 15, which indicated he was cognitively intact. Review of Resident #1's care plan log, dated 10/07/24, reflected he had a comprehensive care plan started Review of Resident #1's care plan review, started on 09/28/24, reflected nursing, resident programs, and social services departments have not reviewed and completed their review sections of Resident #1's comprehensive care plan. Resident #2 Page 1 of 3 676131 676131 10/07/2024 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #2's face sheet, dated 10/07/24, reflected she was a [AGE] year-old female who was initially admitted to the facility on [DATE], readmitted on [DATE], and her own RP. Review of Resident #2's medical diagnoses, dated 10/07/24, reflected she had acute posthemorrhagic anemia (a condition that develops when you lose a large amount of blood quickly), postprocedural hemorrhage of a genitourinary system organ or structure following a genitourinary system procedure (bleeding that occurs after a medical procedure performed on any part of the urinary or reproductive system), hydronephrosis with renal and ureteral calculous obstruction (a condition where one or both kidneys swell due to a blockage in the urinary tract), other abnormalities of gait and mobility, neoplasm of unspecified behavior of bladder (abnormal growth of tissue in the bladder), and an unspecified chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breathe by restricting airflow to the lungs). Review of Resident #2's comprehensive MDS assessment, dated 09/21/24, reflected she had a BIMS score of 8, which indicated she had moderate cognitive impairment. Resident #2 was dependent on staff for toileting and showering, partial-moderate assistance with oral hygiene, and supervision/touching assistance with eating. Review of Resident #2's care plan log, dated 10/07/24, reflected she had a comprehensive care plan Review of Resident #2's care plan review, started on 09/24/24, reflected dietary, dietary leadership, and resident programs departments have not reviewed and completed their review sections of Resident #2's comprehensive care plan. During an interview on 10/07/24 at 11:25 a.m., LVN A stated nurses participated in residents' care plan process. LVN A stated the MDS Coordinator was responsible for overseeing residents' care plan process. LVN A stated if residents did not have a comprehensive care plan, then staff would not know how to care for the residents. During an interview on 10/07/24 at 11:37 a.m., the Clinical Records Supervisor stated the facility had an offsite MDS Coordinator who was responsible for working on residents' comprehensive care plans. During an interview on 10/07/24 at 11:40 a.m., the DON stated the MDS Coordinator worked remotely on residents' comprehensive care plans. An attempt to contact the MDS Coordinator was made on 10/07/24 at 11:46 a.m. A voicemail and call back number was left. The MDS Coordinator did not return the call before exit conference. During an interview on 10/07/24 at 11:51 a.m., the DON stated she needed to ask her staff when residents' comprehensive care plans were to be completed. During an interview on 10/07/24 at 12:11 p.m., the DON stated residents' comprehensive care plans were to be completed within 14 days of a residents' admission to the facility. During an interview on 10/07/24 at 12:19 p.m., the DON stated she reviewed the facility's comprehensive care plan policy and found that residents' comprehensive care plans were to be completed within 7 days of the completion of residents' comprehensive MDS assessments. 676131 Page 2 of 3 676131 10/07/2024 Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734

F 0657 Review of the facility's comprehensive care plans policy, effective 11/2017, reflected: Level of Harm - Minimal harm or potential for actual harm 8. The resident's comprehensive care plan will be developed within seven (7) days of the completion of the resident's comprehensive MDS assessment in accordance with the CMS RAI completion guidelines. Residents Affected - Few 676131 Page 3 of 3