Health inspection·February 8, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 residents received services in the facility with reasonable accommodation of each resident's needs for 2 of 20 residents (Residents #73 and #126) reviewed for call lights. Residents Affected - Few Residents #73 and #126 were observed in their room with their call lights not in reach. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: 1. Record review of Resident #73's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing related problems), muscle wasting and atrophy (decrease in size and strength of muscles), unsteadiness on feet, and dependence on supplemental oxygen. Record review of Resident #73's MDS Resident Assessment and Care Screening dated 1/30/2024 reflected she had a BIMS score of 15 indicating intact cognitive status. Record review of Resident #73's Care Plan dated 01/26/2024 reflected she was at risk for falls related to deconditioning, gait/balance problems and incontinence. Goal: Will be free of falls through the rechew date 05/06/2024. Interventions/Tasks: Be sure the call light is in reach and encourage to use it to call for assistance as needed. Observation on 02/06/2024 at 10:01 AM revealed Resident #73's call light was on located on the floor underneath her bed. The resident was sleeping and not interviewable at the time. 2. Record review of Resident #126's undated Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (thinking and social symptoms that interfere with daily functioning), Muscle weakness, generalized, history of falling and unsteadiness on feet. Record review of Resident #126's Comprehensive MDS dated [DATE] reflected she had a BIMS score of 2 indicating severe cognitive impairment . Observation and interview on 02/06/2024 at 10:02 AM revealed Resident #126's call light was on the floor behind the headboard of Resident #73's bed. Resident #126 did not know where her call light Page 1 of 20 676267 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0558 was located . Level of Harm - Minimal harm or potential for actual harm Observation on 02/08/2024 at 8:33 AM revealed Resident #126's call light was on the floor beside her bed. Resident #126 leaned over the side of her bed to try to retrieve the call light until the surveyor requested she stop as she might fall out of the bed. Residents Affected - Few In an interview on 02/08/2024 8:35 AM with RN A stated she had worked at the facility since March 2023. She stated a call light being on the floor and not in reach of resident could lead to a fall . In an interview on 02/08/2024 at 8:40 AM LVN B stated she had worked at the facility for one and a half months . She stated if a resident cannot could not reach their call light they could fall and not get the help they need. In an interview on 02/08/2024 at 8:45 AM CNA C stated she had worked at the facility for one and one half years . She stated if a resident could not reach their call light they are at a high fall risk and the staff would not know if they needed anything . In an interview on 02/08/2024 at 4:45 PM the Acting ADM stated all call lights should be within reach some residents could fall it could maybe interfere with them having their needs met. Review of an undated facility Policy/Procedure- Nursing Administration subject: Accidents reflected It is the policy of this facility that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. 676267 Page 2 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on interview and observation, the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for 9 of 9 confidential residents reviewed for resident council. Residents Affected - Some The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in a private space without uninvited staff being present. Findings Included: Observation and interview on 02/07/24 at 03:15 PM, during a confidential resident group meeting held in the dining room with 9 residents revealed at various times during the resident group meeting 2 dietary staff entered the dining room while the residents were answering questions and voicing their opinions/concerns. There were signs on the doors entering the dining room that reflected do not enter resident group in progress. 1 dietary staff member was observed moving metal tray carts in the dining room, and there were loud noises coming from the metal tray carts being moved as well as dishes/pots and pans in the kitchen. The residents stated that happened frequently in their meetings which has made it difficult to hear one another and creates distractions. During an interview on 02/08/24 at 11:30 AM the Activities Director stated she would normally let management know during the 2 PM huddle and via email that resident council would be happening in the dining room, so their direct employees would know not to bother them. She stated there was not another area for the residents to meet in private. She stated she would place signs on the doors and sometimes stand at the door to prevent any staff from entering the dining room. She also stated she would notify dietary staff before the meeting not to come out of the kitchen until after the resident group meeting. She stated that the residents had expressed concerns about the interruptions before and staff interrupting were asked to leave the dining room. During an interview on 02/08/24 at 3:51 PM the Acting ADM stated that he thought residents should be able to hold resident council meetings in private without interruptions if they chose. He said sometimes they would allow staff to visit with the permission of the council president and other residents in the meeting. He said a negative outcome to resident council interruptions or loud noises would be the residents could lose their train of thought or not be understood correctly by one another. Policy: During an interview on 02/08/24 at 12:00 PM requesting facility policy on privacy related to resident council, the BOM stated they did not have any internal facility specific policy for it. During an observation on 02/07/2024 at 01:00 PM of a posting of Residents Rights located near the social workers office reflected: Privacy and Confidentiality You have a right to: 676267 Page 3 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0565 - Privacy, including privacy during visits, phone calls and while attending to personal needs. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676267 Page 4 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0575 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observation and interview the facility failed to post, in a form and manner accessible to the residents and resident representatives, the required information for the public and the entire facility for the required contact information (Resident Rights) to include: *HHSC phone number *Contact information for the Ombudsman. *A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal regulation, including but not limited to reside abuse, neglect, exploitation, misappropriation of property in the facility, and non-compliance with the advances directives requirements (42 CFR part 489 subpart I) requests for information regarding returning to the community. This failure affected residents and resident representatives by placing them at risk of being unaware of who to contact should they require advocacy services or investigations. Findings included: Observation on 02/07/2024 at 10:30 AM during a walking tour of the facility with the previous ADM revealed there was not a required contact information (Resident Rights) posting located for residents or the public to view in the facility. In a confidential group interview on 2/7/2024 at 3:15 pm the resident stated that on 02/07/2024 while sitting in the living room area/tv room, he observed staff posting the required contact information (Resident Rights Signage) on the wall to the right of the Social Worker's office. The residents all stated they had not seen the postings anywhere prior to it being posted on 02/07/24. In an interview on 2/8/2024 at 3:50 PM the acting ADM stated he was not sure a posting of required contact information (Resident Rights) was required. He stated he thought it used to be required. He further stated, We go over rights in our admission packet. We are required to review on admission and periodically. If it is a requirement, we want to comply with federal requirements on posting the required contact information sign. In an interview on 2/8/2024 at 3:50 PM the acting ADM stated, We posted a required contact information sign (Resident Rights) yesterday. Up until then, it was not posted. Not having a sign could possibly cause residents not to know their rights. Record review on 02/08/2024 at 2:08 PM reflected no policy on required postings. The previous ADM stated there were no policies for posting required contact information or how to contact the state or Ombudsman if they had a complaint. 676267 Page 5 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm Based on observation , interview, and record review, the facility failed to ensure all residents had a private place for telephone communications without being overheard. Residents Affected - Some The facility failed to ensure there was an area for residents to have private telephone communications. This failure could place residents at risk to lose their ability to communicate privately on the telephone, and could result in a decline in their psychosocial well-being and quality of life. Findings included: Observation on 02/07/2024 at 11:37 AM revealed a small table with a land line telephone, a sign that reflected, Resident Phone and a chair was located next to the nurse's station. In an interview on 02/07/2024 at 11:40 the Acting ADM stated the residents needed a private place to use a phone. He further stated when he was the ADM at the facility they had a portable phone the residents could take to a private area, and he was unsure when the current phone was set up. In a confidential interview during resident council on 0/2/07/2024 at 3:00 PM three residents stated there was not enough privacy for using the phone. They stated the only resident phone was located next to a busy and noisy nurse's station where a lot of people gathered to talk, and they were unable to hear the person they were attempting to speak with. The residents stated it was a concern among many of the residents who used the phone near the nurse's station, because only a few had cell phones. In a confidential resident interview on 02/07/2024 at 3:15 PM, a resident stated having the phone located next to the nurse's station is an invasion of privacy. She stated, It is too loud to be able to hear or have a conversation. She said, There needs to be honor and respect for the residents, and the staff are not doing that. In a confidential resident interview on 02/07/2024 at 3:20 PM, a resident stated most of the time when they want to use the phones it is during rush hours and it is too loud near the nurse's station for them to be able to use it. He stated a lot of staff like to gather near the nurse's station and make noise or talk loudly. When using the phone, he gets frustrated because of all the noise and must hang up and plan for another time to make his call in the evening when there is no noise. In an interview on 02/08/2024 at 3:51 PM the Aacting ADM stated his expectation was residents should have the right to make a private phone call if they choose. He further stated it would be a violation of their rights to not have a private place for phone calls and could be upsetting to them. Record review of an undated facility Policy/Procedure- Nursing Administration Resident Rights reflected, 18. To have reasonable access to a telephone for private conversations while in the Nursing Center. Observation on 02/07/2024 at 12:14 PM of a posting of Residents Rights located near the Social Worker's office and posted on 02/07/2024 revealed: 676267 Page 6 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0576 Privacy and Confidentiality Level of Harm - Minimal harm or potential for actual harm You have a right to: Privacy, including privacy during visits, phone calls and while attending to personal needs. Residents Affected - Some 676267 Page 7 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation, and interview, and record review the facility failed to have the results of the most recent survey of the facility posted in a place readily available to residents, family members and legal representatives for 1 of 1 survey results books. Residents Affected - Many The facility failed to post the facility's most recent inspection reports. This failure could affect the residents who resided in the facility. Findings included: Observation on 02/07/2024 at 11:00 AM revealed the survey book was located in the front lobby and was not updated past 12/22/2024 . The facility had two citations written on 05/08/2024 that were not included in the survey book as reflected in a federal database of facility citations. In an interview on 02/07/2024 at 11:07 AM the Acting ADM stated the survey book was not up to date and he was unsure what staff that task was delegated to. Record review of an undated Policy/Procedure - Nursing Administration reflected the resident has the right to examine the results of the Nursing Center's most recent survey conducted by representative of the response to the survey. 676267 Page 8 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to ensure residents had the right to send and promptly receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 9 of 9 confidential residents reviewed for weekend mail delivery in that: Residents Affected - Some The facility failed to ensure residents received their mail on the weekend. These failures could place residents at risk for not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life. Findings included: During a confidential group interview on 02/07/24 at 03:00 PM 9 of 9 residents stated mail was not distributed on Saturdays. They stated mail did not get delivered until Monday or even picked up until Monday. The residents stated they had spoken to the Activities Director about this, and the residents were told it would be delivered by the weekend receptionist. In an interview on 02/08/2024 at 11:00 AM the Social Worker stated she was unsure who was responsible for delivering resident mail on the weekends. In an interview on 02/08/2024 at 11:30 AM the Activities Director stated the weekend receptionist was responsible for delivering the mail. In an interview on 02/08/2024 at 12:00 PM the BOM stated she was aware the weekend receptionist was not delivering mail to the residents. She stated she had noticed stacks of mail when she returned on Monday mornings and had asked the weekend receptionist about it and was told she does not deliver mail because she did not know it was within her duties. She further stated that the receptionist would be in-serviced, and they would address the issue of the residents not getting their mail. The BOM stated they would get someone to cover the front desk if they needed to while the mail was being distributed by the weekend receptionist. In an interview on 02/08/2024 at 3:51 PM the Acting ADM stated residents should be getting mail on the weekends and he thought the weekend receptionist was responsible for delivering the mail. He stated the possible negative outcome to the residents was there could be a delay in them getting a letter and they could be inconvenienced. Policy: Record review of an undated facility Policy/Procedure- Nursing Administration Resident Rights reflected, Residents have a right: To privacy in written communications including the right to send and promptly receive mail that is unopened, and to have access to stationary, postage and writing implements at the President's 676267 Page 9 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0583 expense. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 676267 Page 10 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 the facility failed to provide the necessary services to maintain grooming and personal care for 1 of 20 residents (#134) reviewed for ADL care. Residents Affected - Few The facility failed to ensure Resident #134 received his bath three times a week as per his shower schedule. These failures could place residents at risk of skin breakdown, infection, and loss of self-esteem. Findings included: Record review of the undated Face Sheet for Resident #134 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Pressure Ulcer sacral (lower back and spine) regions, Stage 4 (the largest and deepest of all pressure ulcers. Muscles bones and or tendons may be visible at the bottom of the ulcer) and acquired absence of left leg above knee amputation. Record review of a Comprehensive MDS dated [DATE] for Resident #134 reflected he had a BIMS score of 15 indicating intact cognitive status. His functional abilities reflected he required substantial/maximal assistance for tub/shower transfer. Record review of a Care Plan for Resident #134 dated 1/10/2024 and revised on 1/27/2024 reflected there were no tasks for bathing. On 02/07/2024 an intervention/task for bathing was initiated, and reflected Resident asks to be place in the shower gurney in room and then taken to the shower room versus being placed into gurney in the shower room. Record review of a facility shower schedule revealed Resident #134 was scheduled to receive a shower three times a week on Mondays, Wednesdays, and Fridays on the 2-10 PM shift. In an interview on 02/06/2024 at 2:28 PM Resident #134 stated he had not received a bath and had not received any care or trimming for his beard. He stated he needed deodorant and had not received any. He further stated he was supposed to get a bath three times a week and 02/05/2024 was his bath day and he did not get one. He stated he had not received a bath for a week, and he could smell his own body odor. He stated he had a pressure ulcer on his sacral area where the bone could be seen in the bottom. In an interview on 02/08/2024 at 9:10 AM Resident #134 stated he had not refused any baths. He stated he finally received a shower on 02/07/2024. Record review of a shower document for Resident #134 located in the EHR reflected he had received his last shower/bath on 01/31/24 and did not receive another shower/bath until 02/07/2024. In an interview on 02/08/2024 at 1:18 PM the LVN Education Resource Nurse stated CNAs were responsible for bathing and then they completed a written shower sheets to turn in to the charge nurses. In an interview on 02/08/2024 at 1:30 PM the acting DON, stated there were only shower sheets from 676267 Page 11 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few last year available. She stated infection control was an issue if a resident had not received a bath and especially with Resident #134 as he had multiple open wounds. She stated the regular charge nurse was out on sick leave for the past week. In an interview on 02/08/2024 at 1:33 PM the RN ICP stated there was a potential for infection if a resident does not receive a bath in a week. She stated it could affect Resident #134's dignity. She further stated the CNAs had a bathing schedule they were supposed to follow. In an interview on 02/08/2024 at 1:37 PM LVN D stated she had worked as an agency LVN for one year and then started full-time at the facility in August 2023. She stated Resident #134 needed a shower because of his wounds and being clean was good for healing his wounds. She stated there was a potential for infection if he did not receive a bath and it could affect his dignity. She stated an agency nurse had worked in her position the previous week as she was out on sick leave. In an interview on 02/08/2024 at 4:45 PM the acting ADM stated not bathing a resident could affect their dignity and be against their rights. A policy or procedure for ADLS was requested from administration and was not presented at the time of exit from the facility. 676267 Page 12 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one (Resident #28) of eight residents reviewed, in that: The facility failed to follow Resident #28's smoking evaluation requiring 1:1 supervision while she smoked and failed to don her smoking apron in a safe manner which resulted in the resident obtaining a burn to her chest and a subsequent scar. This failure could place residents who smoke at risk for neglect, harm, pain, and injuries. Findings included: Review of the updated face sheet for Resident #28 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of anoxic brain damage (an oxygen deficient condition), muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue) multiple sites, reduced mobility, unspecified lack of coordination, aphasia (loss of ability to understand or express speech, caused by brain damage) following nontraumatic intracerebral hemorrhage a subtype of stroke), cognitive communication deficit, Review of the quarterly MDS assessment for Resident #28 dated 11/30/23 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section titled Functional Abilities and Goals reflected Resident #28 had functional limitation in range of motion both upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) and used a wheelchair. Review of care plan for Resident #28 reflected the following: Focus, undated, potential for injury related to Smoking. Focus 12/17/23 Resident #28 had a burn to anterior (front side) chest on 12/17/2023. Care plan interventions and tasks: Complete smoking assessment Date Initiated: 12/07/2023 Explain smoking policy Date Initiated: 12/07/2023 Maintain vape materials at nurses' station or other designated area. Date Initiated: 12/07/2023 Observe vaping while in designated area. No cigarette smoking. Date Initiated: 12/07/2023 Provide line of sight observation while in the smoking area. Preference to use a 676267 Page 13 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0689 vape. Level of Harm - Minimal harm or potential for actual harm Date Initiated: 12/07/2023 Residents Affected - Few Re-assess smoking safety and in-service regarding smoker apron. She chooses not to wear a smoker apron. Date Initiated: 12/18/2023 Report non-compliance or unsafe smoking habits to MD and responsible party. Date Initiated: 12/07/2023 Utilize smoking apron during smoking activities. She chooses not to use a smoker apron while using a vape. She is not to use cigarettes due to unsafe practices and physical contractures. Date Initiated: 12/07/2023 Focus dated 11/16/23 resident has activities of daily living self-care performance deficit related to limited mobility, activity intolerance, musculoskeletal impairment, limited range of motion, and Parkinson's disease. Review of Resident #28 admission smoking evaluation dated 10/20/23 reflected the resident had dexterity problems, she did not need adaptive clothing/device/assistance, resident used a vape. Review of Resident #28 admission smoking evaluation dated 12/03/23 reflected resident had a visual deficit, had dexterity problems, could not light her own cigarette, needed adaptive clothing/device/assistance - a smoking apron and one-on-one assistance. The evaluation reflected that the resident had an incident, cigarette had been dropped but did not fall on res due to smoking apron being worn. res hoyer pad had been burned. Review of Resident #28 admission smoking evaluation dated 12/07/23 reflected the resident had cognitive loss, resident had a dexterity problem, could not light her own cigarette, needed adaptive clothing/device/assistance - a smoking apron and one-on-one assistance. The evaluation reflected that the resident had an incident where resident, unable to properly discard of or tap ashes off of cigarette. Drops ash and end of cigarette onto apron and allows it to fall. Staff reports resident has burned a hole in a hoyer sling. Suggest not allowing resident to smoke unless 1:1 assistance available; resident should use vape as family has provided. Interview and observation on 02/07/2024 at 3:00 pm with Resident #28 revealed she no longer smoked cigarettes but uses a vape but when she did smoke cigarettes at the facility, she received a burn. She revealed she was outside during a smoke break and the ash from her cigarette fell under her blouse and burned her chest. She said she was wearing a smoking apron that one of the staff put on her, but it was not up far enough under her neck and allowed the ash to fall below her blouse and onto her skin. She said she did not have a staff member beside her watching her. She said staff were in the smoking area, but they were not standing right beside her, they were standing away from her. The resident pulled down the front of her blouse and revealed a pink mark on her skin approximately a quarter inch in length and an eighth of an inch in width. The resident revealed that it was the mark that was left by cigarette burn she received when she was at the facility. 676267 Page 14 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/06/2024 with on 3:25 pm with the Current ADM revealed that 1:1 intervention would indicate a staff member would be, just there with that resident and not simply in the area where the resident was residing. Interview on 01/07/2023 at 4:17 pm with the Acting ADM revealed that staff provided supervision of residents while she smoked and did not stand by Resident #28 the whole time she smoked. Interview on 021/08/2023 at 3:13 pm with the Acting ADM revealed the staff who took residents out to smoke were responsible for adjusting the apron on Resident #28 for her safety. Review of facility Smoking Policies and Procedures dated 12/2019 revealed it is the policy of this facility to provide to its residents a smoke free environment. It is also policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of others residing in the facility. The purpose of this policy is to satisfactorily address the wishes of both smoking and non-smoking residents without compromising the safety of either. Upon admission (7-10 days) residents who desire to smoke will be assessed as well as their ability to do so safely. All new admissions will be on supervised smoking until assessment is reviewed by the interdisciplinary team. The interdisciplinary team will accomplish this using the smoking assessment form and their review of the resident clinical record. At the end of this period, it will be determined if the resident will be allowed to smoke either under supervision or independently with or without protective devices. The results of the evaluation will be placed in the resident's chart and the IDT recommendations will be care planned. Upon quarterly review by the IDT, or at anytime a significant change of condition occurs, smoking residents will be re-assessed as to their ability to smoke safely, either independently or under supervision, and their ability to understand and comply with facility non- smoking policy using the Smoking Assessment Form. The facility reserves the right to immediately confiscate smoking materials as well as to rescind the individual's smoking privileges if failing to take such measures would jeopardize resident safety. The facility reserves the right had any time to modify or change the smoking policy to maintain the safety of the facility in the residence. All smokers will be advised and given a copy of the new policy. 676267 Page 15 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

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 a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 of 3 residents (Residents #73, #129 and #131) reviewed for oxygen therapy. Residents Affected - Some 1. Resident #73's was receiving oxygen therapy and her oxygen humidifier water bottle was empty. 2. Resident #129 was receiving continuous oxygen therapy and did not have a filter on her oxygen concentrator. 3. Resident #131 had a C-Pap mask lying uncovered on her bedside table. These failures could place residents at risk for ineffective oxygen therapies and infection. Findings included : 1. Record review of Resident #73's undated Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing related problems), muscle wasting and atrophy (decrease in size and strength of muscles), unsteadiness on feet, and dependence on supplemental oxygen . Record review of Resident # 73's Care Plan dated 02/06/2024 reflected she had oxygen therapy related to COPD. Record review of Resident #73's Clinical Physicians Orders dated 01/14/2024 reflected Change oxygen tubing every Sunday night. Apply oxygen via NC at 3 LPM continuous. Observation on 02/06/2024 at 10:01 AM revealed Resident #73's oxygen humidifier bottle was empty, and she was receiving supplemental oxygen at the time. 2. Record review of an undated Face Sheet for Resident #129 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Acute and Chronic Respiratory Failure (not enough oxygen in the blood resulting in shortness of breath, anxiety, confusion, and some cardiac (heart) issues), Morbid Obesity with alveolar hyperventilation (greater than 80-100 pounds above ideal body weight with a dysfunction of the automatic respiratory system .). Record review of a Care Plan for Resident #129 dated 02/01/2024 reflected resident hads altered 676267 Page 16 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some respiratory status/difficulty breathing r/t sleep apnea and hx of Influenza A. Interventions/Tasks Provide oxygen as ordered. Record review of Physician orders dated 01/17/2024 for Resident # 129 reflected O2 at 3LPM via NC. Observation on 02/06/2024 at 11:50 AM revealed Resident #129 was receiving oxygen at 3 LPM and did not have a filter on her O2 concentrator . Observation 02/08/24 at 9:00 AM revealed Resident #129 had a filter in place on her oxygen concentrator. 3. Record review of an undated Face Sheet for Resident #131 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Acute and Chronic Respiratory Failure with Hypoxia (not enough oxygen in the blood resulting in shortness of breath, anxiety, confusion, and some cardiac (heart) issues), Morbid (severe) Obesity with alveolar hyperventilation (greater than 80-100 pounds above ideal body weight with a dysfunction of the automatic respiratory system.). Record review of the Comprehensive MDS dated [DATE] for Resident #131 reflected she had a BIMS score of 10 indicating moderate cognitive impairment . Observation and interview on 02/06/2024 at 1:52 PM revealed Resident #131's CPAP mask was sitting on top of her bedside table and not in a bag. Resident #131 expressed concern that her respiratory equipment was not being taken care of properly . In an interview on 02/08/2024 at 4:12 PM the Acting DON stated there should be a filter on the oxygen concentrators to prevent infection. She stated C-PAP masks should be bagged and not left open to air as there wasis an increased risk for a respiratory infection. She further stated keeping the humidifier water bottles full would keep nasal passages moist and some residents got a headache when their nasal passaged dried out. In an interview on 02/08/2024 at 4:45 PM the acting ADM stated all respiratory equipment that wasis designed to have a filter should have one to prevent infection as they filtered out contaminants and dirt. He stated keeping a humidifier water bottle full would keep nasal passages moist. Record review of an undated Policy/Procedure for oxygen therapy and respiratory equipment did not specify how often to change oxygen tubing and equipment. 676267 Page 17 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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 in 1 of 1 kitchen reviewed for dietary services in that: 1) Dietary staff failed to label and date all food items located in the dry storage. 2) Dietary staff failed to dispose of expired foods items located in the reach-in refrigerator. 3) Dietary staff failed to effectively reseal, label and date items in the walk-in refrigerator. 4) Dietary staff failed to effectively reseal, label and date items in the walk-in freezer. 5) Dietary staff failed to wear hairnets while working in the kitchen. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During the initial tour of the kitchen on 02/06/2024 at 09:06 AM the following was observed: 1. The reach in refrigerator contained a plastic container with a strawberry glaze labeled with a prepared date of 01/25/24 and a shelf-life use by date of 01/31/24. 2. The reach in refrigerator contained a plastic squeeze bottle of strawberry glaze labeled with a prepared date of 01/25/24 and a shelf-life use by date of 01/31/24. 3. The walk-in refrigerator contained 2 separate bags of tortillas each in a clear plastic bag with no label or date. 1 of 2 bags was ripped exposing contents to air. 4. 676267 Page 18 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0812 The walk-in freezer contained a bag of vegan breakfast sausage patties in a clear plastic bag that was torn open and exposed to air. Level of Harm - Minimal harm or potential for actual harm 5. Residents Affected - Some The walk-in freezer contained cinnamon rolls in a clear plastic bag that was opened and exposed to air. 6. The dry storage room contained taco shells in cellophane located in a topless plastic bin, and taco shells not labeled or dated. During an observation on 02/06/24 at 12:16 PM Dietary Aide A was observed in the kitchen without a hairnet assisting other kitchen staff with meal trays. During an interview on 02/06/24 at 09:18 AM the DM stated that they tried to check the refrigerators every two days, checking for expired items. She said all items stored in the refrigerator, freezer, or dry storage should be sealed, placed in an airtight container, or in a zip top bag and that all items should be labeled and dated. She said the residents in the facility could get sick from food poising if they were exposed to expired items or items that were not sealed and exposed to contaminants. She stated, I only have two staff, they do the best they can. During an interview on 02/06/24 at 12:20 PM the Dietary Resource stated her expectation was for hairnets to be worn prior to entering the kitchen, and that everyone wore them. She said that failing to wear a hairnet could result in hair falling into the food which could negatively affect the residents. She stated, it would be unpleasant to find. Dietary Resource said that expired foods could cause a foodborne illness, and that items not properly sealed could expose food to contaminants in the air and make a resident sick. The Dietary Resource stated that it is her expectation for dietary staff to use zip top bags as needed as everything must be sealed and closed to air with labels and dates. During an interview on 02/06/24 at 12:25 PM the DM stated it was her expectation that staff wear a hairnet prior to entering the kitchen. During an interview on 02/08/24 at 03:51 PM with the Acting ADM he said he expects items to be sealed, labeled, and dated. He stated if there are items that are expired, they should be removed. He said he felt it needed to be a requirement that when staff are on duty in the kitchen that hairnets be worn. He said a negative outcome to items not being properly sealed is that food could spoil. In terms of a negative outcome to serving expired food he stated he didn't know what could happen but could potentially make residents sick. He said a negative outcome to not wearing a hairnet would be hair getting in the food. Policy: During an Interview on 02/06/24 at 12:20 PM with the DM and Dietary Resource when requesting policies for food storage, labeling and dating, and hairnets; the DM and Dietary Resource both stated they do not have any facility specific policies, and that they follow the TFER (Texas Food Establishment Rules). 676267 Page 19 of 20 676267 02/08/2024 Brodie Ranch Nursing and Rehabilitation Center 2101 Frate Barker Rd Austin, TX 78748

F 0812 Level of Harm - Minimal harm or potential for actual harm Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under § 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. Residents Affected - Some 2-402.11 Hair Restraints: (A) Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designated and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. 676267 Page 20 of 20