Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookdale Lakeway Snf during CMS and state inspections, most recent first.
Outside Food Storage and Reheating Policy Not Followed: The facility failed to follow its policy for resident food brought in from outside sources. Residents reported they were denied access to a microwave and refrigerator for leftover food, while observations showed resident food mixed with staff items in the breakroom refrigerator, including unlabeled, undated, and expired items. Multiple nourishment station refrigerators were missing, and temperature logs were incomplete or inaccurate. Staff gave inconsistent accounts of how outside food was stored, labeled, discarded, and reheated, and the ADMIN and DON acknowledged confusion about the policy.
Pureed Diets Prepared Without Following Recipe Specifications: A dietary employee was observed adding an unmeasured amount of liquid to pureed chicken during meal service and stated she used broth and had not been shown how to use the recipe book for modified textures. The recipe card called for a specific amount of gravy mix, but the employee was unsure of the amount used. The DON was unsure what should be used to puree food, while the DSD and CDM described recipe-based preparation and staff training responsibilities.
Surveyors found multiple unlabeled and undated food items, expired products left in storage and self-service areas, and a mislabeled container of fish in the kitchen. An dietary staff member handled raw fish, removed gloves, and resumed food prep without washing hands. Interviews with the DSD, DON, CDM, and the staff member showed inconsistent understanding of food labeling, dating, discarding, and hand hygiene expectations.
A facility failed to maintain infection control during direct care for three residents. One CNA entered a room for peri-care without donning a gown even though the resident was on EBP for a PEG tube. Another CNA contaminated a clean brief with soiled gloves during peri-care and acknowledged improper technique. A third CNA provided Foley catheter care using only one wipe on the tubing and did not cleanse the peri-area, despite knowing the expected catheter care process.
Ombudsman contact information was not posted in a form and manner accessible to all residents and resident representatives. Surveyors found the notice in a glass shadow box near the elevator and other locations that were too high, in small print, or obstructed, making it difficult for residents in wheelchairs or with vision deficits to read. Residents stated they did not know where the Ombudsman information was posted, did not know how to contact the Ombudsman, and reported the Ombudsman had not attended Resident Council meetings. Interviews with the ADMIN, REM, and RED confirmed there was no policy on posting the information and that key leaders did not know the local Ombudsman.
A facility failed to keep the survey results binder readily accessible and complete for resident and family review. Survey results were located in the entry area without clear signage, and multiple 2025 complaint investigations were missing from the binder. Residents said they did not know where the survey book was or how to access it, and staff gave inconsistent accounts of its location and contents.
A significant number of resident rooms were found to have non-functioning heaters and thermostats, resulting in indoor temperatures well below the required range. Multiple residents with complex medical needs reported being cold for several days, and staff and visitors confirmed the uncomfortable conditions. Despite ongoing complaints and maintenance work orders, there was no evidence that residents were moved to warmer areas, provided with additional warming measures, or monitored for hypothermia as required by facility policy.
The facility failed to complete comprehensive care plans within the required timeframe for two residents, one with cognitive impairment and multiple medical conditions, and another with moderate cognitive impairment. The MDS Coordinator, responsible for the care plan process, worked remotely and did not respond to inquiries. The DON initially misunderstood the policy, which mandates completion within seven days of the MDS assessment.
A resident with cognitive impairment and fragile skin was not protected from abuse and neglect by their SO/AP, as the facility failed to enforce care plan interventions requiring the resident's door to remain open during visits. Staff reported witnessing aggressive behaviors by the SO/AP, but the facility's response was inadequate, leading to an Immediate Jeopardy situation.
A resident with multiple medical conditions was subjected to abuse by a significant other, with staff observing physical aggression and suspicious injuries. Despite reports, the facility failed to investigate or protect the resident, leading to an Immediate Jeopardy situation. Staff were unaware of care plan interventions, and the administration did not adequately address the abuse allegations.
The facility failed to update comprehensive care plans for two residents following changes in their medical conditions. One resident's care plan did not reflect a new wound, while another's care plan still indicated tube feeding despite its discontinuation. Interviews revealed a lack of clarity and responsibility among staff for updating care plans, potentially leading to inadequate care.
The facility failed to properly store and label food items in the kitchen, as observed during a survey. Unsealed bags containing croutons and romaine lettuce were labeled and dated but not sealed, while a bag of uncooked bacon was neither labeled nor dated. Staff interviews confirmed that all kitchen staff were responsible for food storage, yet acknowledged potential risks such as foodborne illness and gastrointestinal issues. The facility's policy requires all food items to be labeled and dated before storage.
A facility failed to ensure a resident with an indwelling catheter had appropriate physician orders for its presence, care, and maintenance. The resident, with multiple medical conditions, was at risk of infection due to the absence of these orders. Staff interviews revealed that the oversight might have occurred when the resident returned from the hospital, and the interim DONs acknowledged the risk posed by the lack of proper documentation.
A resident was administered Seroquel, an antipsychotic medication, without a proper diagnosis justifying its use. The resident, with severe cognitive impairment and no documented behavioral symptoms warranting antipsychotic use, was monitored for side effects and behaviors. Facility staff acknowledged that the diagnosis of behaviors or acute encephalopathy was not appropriate for antipsychotic medication, and the facility's policy requiring specific conditions for psychotropic use was not followed.
The facility failed to post daily nurse staffing information accurately and maintain records for the required 18 months. For several days, the staffing logs lacked the total number and actual hours worked by nursing staff. Observations showed outdated information was posted, and interviews revealed a lack of prepared forms and missing records. The facility's policy mandates daily posting and retention of staffing data, which was not followed.
Outside Food Storage and Reheating Policy Not Followed
Penalty
Summary
The facility failed to implement its policy for storage and handling of foods brought in by family and other visitors for resident consumption. During observations, no refrigerator was present at multiple nourishment stations on the 2nd floor and 1st floor halls 1, 2, and 3. In a confidential resident council meeting, residents voiced concern that they no longer had access to the breakroom, refrigerator, or microwave for outside food. A resident stated that after returning with leftover pizza from a restaurant, a CNA refused to warm it and said residents were no longer able to use the microwave or refrigerator, and the resident was told to eat the pizza cold. The facility was observed using the staff breakroom refrigerator to store resident food items brought from outside sources, mixed together with staff food and drink items. The refrigerator contained resident-labeled items alongside unlabeled and undated items, including expired liquid nutrition formula and expired snack bars, as well as other food items without names or dates. The DON stated the facility had been using the staff breakroom refrigerator for resident food and that the facility struggled with reheating resident food safely. The ADMIN stated he had been mistaken about the policy and that residents had not been allowed to use the microwave or refrigerator as they had previously done. Record review showed the facility policy required a designated unit refrigerator for perishable foods, daily temperature recording, labeling with resident name, item, preparation date, and discard date, and safe handling standards for foods brought in from outside sources. However, temperature logs were incomplete or inaccurate, with entries showing temperatures recorded without actual dates, missing logs at some locations, and no temperature record for one refrigerator at the time of observation. Staff interviews showed inconsistent understanding of the policy, with some staff stating residents could not bring in outside food, others stating food was stored in the employee breakroom, and others stating residents could bring food in and have it labeled and discarded after 24 to 72 hours. The report also noted that staff had not been trained on the outside food policy in some cases, and that the facility had not maintained a consistent system for storing or reheating resident food brought from outside sources.
Pureed Diets Prepared Without Following Recipe Specifications
Penalty
Summary
The facility failed to prepare pureed foods by methods that conserve nutritive value and flavor for 4 residents receiving pureed diets. During meal service on August 20, 2025, [NAME] G was observed adding an unmeasured amount of liquid from a pitcher into southwestern style chicken in a food processor and blending it. When interviewed, [NAME] G stated she used broth to puree the chicken and said she had not been shown how to use the recipe book for pureed and other modified diet textures. She also stated she had been trained by a previous supervisor who no longer worked at the facility. Further interview and record review showed the recipe card for the pureed item called for 2 ounces of poultry gravy or other gravy mix per 1 serving of chicken, but [NAME] G stated she was not sure how much bread she used and that she used enough so the product would stand on its own like mashed potatoes. The DON stated she did not prepare the food herself, was unsure what should be used to puree food, and relied on kitchen staff for information. The DSD stated each daily menu had a corresponding recipe with diet modifications and that dietary staff were expected to follow the recipes, while the CDM stated the Dietary Director was responsible for training staff on diet textures. The policy or protocol for pureeing food was not provided at the time of exit.
Food Storage, Labeling, and Hand Hygiene Failures in Kitchen Operations
Penalty
Summary
The facility failed to properly store, prepare, and distribute food in accordance with professional standards in the kitchen and self-service dining areas. During observations on 8/19/2025, 8/20/2025, and 8/21/2025, surveyors found multiple food items in the walk-in refrigerator, freezer, and dry pantry that were not labeled or dated, including hamburger buns, margarine, yogurt, liquid eggs, thawing meat, chicken breast, pizza crust, lentils, refried beans, elbow macaroni, and cornmeal. Surveyors also observed expired or past-discard-date items, including sun-dried tomatoes, ground beef, powdered sugar, toasted oat cereal, cheerios, and other food products that remained available in storage or self-service areas. In the kitchen, surveyors observed a clear plastic container of fish with water running over it that was incorrectly labeled as cheese with a prepared date and use-by date that had already passed. During the same observation, dietary staff [NAME] G handled raw fish, removed gloves, did not wash her hands, and then continued seasoning the fish. She stated she had been trained on proper handwashing and food safety protocols and acknowledged that she forgot to wash her hands after removing the gloves. Additional observations showed thawing meat in the refrigerator that was either mislabeled or not labeled, as well as a large pan of thawing sliced carrots with only a prep date. Interviews with the DSD, DON, CDM, and [NAME] G showed differing understanding of labeling, dating, and discarding practices. The DSD stated the second-floor dining hall was not used and that snack items were kept in self-service areas, while also describing labeling expectations for those items. The DON stated she had not reviewed the policy and expressed uncertainty about expiration dates, while the CDM stated all food products should be labeled and dated and that meat should be discarded 3 days after being pulled from the freezer. The facility policy required all food items to be labeled and dated before storage, and prepared hazardous foods to be discarded within 3 days and other prepared foods within 7 days.
Infection Control Failures During Peri-Care and Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for three residents during observed care. Resident #42 had Enhanced Barrier Precautions signage posted outside the room and PPE available, and the resident had a PEG tube, was incontinent of bowel and bladder, and required substantial to maximal assistance with all ADLs. During observed peri-care, CNA A entered the room without donning a gown, despite the resident being on Enhanced Barrier Precautions for the PEG tube. CNA A later stated she knew she had messed up by not putting on PPE before entering the room and said she got in a hurry and forgot. Resident #20, who had diagnoses including Alzheimer’s disease, hemiplegia and hemiparesis, dysphagia, and cognitive communication deficit, was observed during peri-care with CNA B and CNA D. CNA B removed the brief, performed handwashing, and used clean gloves, but then touched a clean brief with soiled gloves. CNA B then performed hand hygiene and changed gloves, but the sequence of care showed contamination of the clean brief during the peri-care process. CNA B acknowledged he knew he had touched the clean brief with contaminated gloves and knew he was not supposed to do peri-care that way. Resident #57, who had multiple sclerosis, neurogenic bladder, an indwelling catheter, and a history of UTI, was observed receiving catheter care from CNA D. CNA D cleansed the catheter tubing from the urethral meatus outward using only one wipe and did not cleanse the resident’s peri-area. CNA D stated he knew the tubing was supposed to be cleansed with three wipes and said the brief was not wet so peri-care was not needed at that time. The DON, ADON/IP, and ADMIN all stated staff were responsible for following infection control practices, and the ADON/IP stated catheter care included cleansing the tubing with three wipes and that EBP required gown and glove use during high-contact care activities such as peri-care and care involving body fluids.
Ombudsman Contact Information Not Posted in an Accessible Manner
Penalty
Summary
The facility failed to post, in a form and manner available for all residents and resident representatives, the required contact information for the public and the entire facility, including the telephone number of the Long-Term Care Ombudsman program. Survey observations found the Ombudsman notice posted on the second floor by the entryway of the double doors in the foyer, positioned on the right side of the wall as a person exits the building and not readily visible to residents entering the facility. Residents in a confidential council meeting stated they did not know where the Ombudsman contact information was posted, did not know how to contact the Ombudsman, and reported that the Ombudsman had not been present at Resident Council meetings. Additional observations showed no visible Ombudsman contact information on the first-floor hallways, and the information in a glass shadow box near the elevator was in small lettering and out of view for individuals in wheelchairs to read. Water hydration stations were placed under the shadow box, which obstructed access and prevented individuals from getting closer to read the posting. On the second floor, the Ombudsman information was also not visibly accessible; a procedure notice with the Ombudsman phone number was posted about 6.5 feet from the floor in small print near the nursing station, making it not visible or accessible for residents in wheelchairs or with vision deficits. During interviews, the ADMIN stated there was no facility policy on posted Ombudsman information. The REM stated she had not provided residents information on the Ombudsman and had not invited the Ombudsman to a Resident Council meeting. The RED stated she had not invited the Ombudsman to a Resident Council meeting, did not know the name of the local Ombudsman, and believed the glass shadow box posting was accessible, though she later acknowledged it was not accessible to individuals. The ADMIN later stated the Ombudsman information was near the elevator downstairs and at the front entrance, but also said he could not tell whether it was at residents’ eye level and did not know who the Ombudsman was for the facility.
Survey Results Binder Not Readily Accessible or Complete
Penalty
Summary
The facility failed to ensure that the results of the most recent survey and any plan of correction were readily available for residents, legal representatives, and family members to examine. Survey results were found in an acrylic wall book holder in the entry foyer on the second floor, but there was no signage identifying the location of the survey book during multiple observations. The survey binder contained older survey results, including 2024 and 2023 materials, but the 2025 complaint investigations completed on January 15, February 5, March 3, March 17, April 7, May 20, and June 18, 2025 were not posted in the binder. During a confidential group interview, five residents stated they did not know where or how to access the survey results in the facility and were not aware the survey book existed or that they could review it. Residents also stated that posted information was not at eye level and that, because many used wheelchairs, they could not easily see items posted above them. They said they would appreciate postings being placed where they were visually accessible. Record review confirmed the facility completed multiple survey investigations in 2025, but those investigations were not maintained in the survey binder as required. Staff interviews showed inconsistent understanding of the binder’s location and contents. A CNA stated residents did not have access to the survey book and did not recall training on it. The ADON stated the book was between the double doors at the front entrance and believed it was accessible, while the ADMIN stated it was in a cubby hole in the vestibule and said a sign was present, although no sign was observed. The ADMIN also stated he was responsible for maintaining and updating the survey book and acknowledged that the 2025 survey investigations were missing from it.
Failure to Maintain Safe Room Temperatures and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by not maintaining resident room temperatures within the required range of 71 to 81 degrees Fahrenheit. For an unknown period, 38 out of 58 resident rooms on the first and second floors did not have working heaters or thermostats, resulting in room temperatures dropping as low as 57.7 degrees Fahrenheit. Multiple residents reported feeling extremely cold for several days, with some describing their rooms as being like a refrigerator or a meat locker. Staff and visitors also noted the cold conditions, and work orders regarding non-functioning heaters and cold rooms had been submitted over several months, indicating ongoing issues with the facility's heating system. Residents affected by the deficiency included individuals with complex medical conditions such as chronic kidney disease, dependence on renal dialysis, chronic respiratory failure, pulmonary fibrosis, and cognitive impairments. These residents reported being cold, wearing extra clothing indoors, and experiencing discomfort. Despite repeated complaints to staff, there was no evidence that residents were moved to warmer areas, provided with additional warming measures, or adequately monitored for signs and symptoms of hypothermia during the period of low temperatures. Observations confirmed that staff did not offer hot beverages, extra blankets, or other interventions to mitigate the cold environment. Facility records and interviews revealed that the heating system had longstanding issues, with many HVAC units having bad compressors, control boards, refrigerant leaks, or other mechanical failures. Maintenance and clinical staff were aware of the problems, and the facility's own policies required monitoring and interventions that were not implemented. Documentation showed that room temperatures were not consistently monitored, and there was no evidence of resident assessments for cold-related illnesses during the deficiency period. The failure to maintain appropriate room temperatures and to follow established protocols placed residents at risk for cold-related health complications.
Removal Plan
- Resident #1 was interviewed by Social Service Coordinator about the comfort of her room temperatures. This was documented on an interview sheet.
- The Maintenance Technician installed a portable [vented] heater in resident's #1 room.
- A licensed nurse completed vital signs and evaluated resident #1 for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted.
- Resident #2 was interviewed by Social Service Coordinator about the comfort of his room temperatures. This was documented on an interview sheet.
- The Maintenance Technician installed a portable [vented] heater in resident's #2 room.
- A licensed nurse completed vital signs and evaluated resident #2 for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted.
- A licensed nurse completed a vital sign temperature and evaluated all current residents for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted.
- The community received nineteen (19) portable [vented] heaters to install for residents that had concerns with room temperatures and/or to be installed in rooms in which the thermostat was not functioning.
- A licensed nurse reviewed the 24-hour Summary Report from the electronic medical record to determine if there was symptoms of hypothermia documented. No documentation was identified for symptoms of hypothermia.
- Social Services Coordinator completed 46 out of 58 resident interviews about the comfort of their room temperatures. Residents identified to have a grievance were provided with portable [vented] heaters, room change options, and/or extra blankets. The resident interviews were documented on an interview sheet.
- The Maintenance Technician audited every resident room to determine if the thermostat was functioning. Thirteen (13) rooms were determined to have thermostats that were not functioning correctly.
- The rooms identified were 58, 66, 72, 74, 75, 78, 81, 97, 8, 4, 7, 28, and 69. The Maintenance Technician installed portable [vented] heaters with the temperature display in the occupied resident rooms.
- Unoccupied rooms identified will not be used until a portable [vented] heater with a temperature display is installed or the room thermostat is replaced.
- The Regional Maintenance Technician ordered fifteen (15) additional portable [vented] heaters that display the room temperature.
- Social Services Director reviewed the Grievance Log to identify any grievances related to room temperatures.
- Clinical, Maintenance, and/or designee are auditing room temperatures of resident rooms every two (2) hours for the next five (5) days. If no occupied rooms are temping below 68 degrees the room temperature audits will continue three (3) times a day for two (2) weeks, daily for four (4) weeks, and daily for five (5) weeks. If the outside weather is at or projected to be below 40 degrees a baseline room temperature of each resident room will be obtained. If any occupied resident room temperature is below 68 degrees the House Temperature and Extreme Heat and Cold Policy will be followed. This audit includes documenting the room thermostat temperature, obtaining a room temperature with an infrared thermometer, and if applicable the portable [vented] heater room temperature. This audit is documented on an audit sheet.
- Based on the most recent audit results there are two unoccupied rooms below 68 degrees. These rooms will remain unoccupied until repairs are completed and room temperatures are above 68 degrees.
- The Administrator and/or designee will audit the room temperature log daily for five (5) days, three (3) times a day for two (2) weeks, daily for four (4) weeks, and daily for five (5) weeks to validate compliance.
- The Maintenance Technician and/or designee will re-train designated associate(s) who are auditing room temperatures, on how to operate the infrared thermometer and that the designated associate needs to notify the licensed nurse immediately if the room temperature is below 68 degrees. If the resident room temperature is between 68 and 71 degrees an interview will be conducted by a licensed nurse or designee with the resident and/or representative to determine if this is their desired room temperature. If the resident and/or representative respond no; offer a room change, extra blanket, move to the common area, or warm beverage until heater can be evaluated by Maintenance. This retraining shall occur prior to the associate conducting a room temperature audit. The associates not available will receive the re-training prior to being assigned to audit room temperatures. This training will be documented on an in-service sheet and a teach back will be used to verify knowledge of content.
- The Director of Clinical Services (DCS) and/or designee re-educated licensed nurses and certified nursing assistance on the Homelike Environment Policy, emergency evacuation and transfer agreement process, and House Temperature and Extreme Heat and Cold Policy including symptoms of hypothermia, notification to Healthcare Provider and resident representative if the resident is having symptoms of hypothermia, the measures to take if an occupied resident's room temperature is below 68 degrees, and notification to the Administrator and/or designee if low room temperature can't be resolved.
- The associates not available will receive be re-educated prior to working their next scheduled shift. This training will be documented on an in-service sheet and a teach back will be used to verify knowledge of content.
- If a resident's room temperature is below 68 degrees the following items will be initiated until the resident is located to another room with a room temperature above 68 degrees, appropriate repairs are completed to the resident's room heater, and/or a portable [vented] heater is installed in that resident's room. A licensed nurse or certified nursing assistant will obtain the residents temperature every hour, and a licensed nurse will evaluate the resident every hour for symptoms of hypothermia and document this in the medical record. If symptoms of hypothermia are identified this change of condition will be documented in the medical record, and the Healthcare Provider and Resident Representative will be notified. If the room temperature is not corrected the Administrator or designee will be notified to provide further direction related to initiating an emergency transfer plan to another location.
- New admissions rooms will be checked by Maintenance and/or designee to validate that the heater and thermostat are working and that the room temperature is in the correct range. If a repair needs to be made this will be documented on a work order. Work orders will be entered into the electronic system by the Administrator, Maintenance associates, or concierges. Paperwork orders will be available at each nurse's station and concierge's desk.
Failure to Complete Comprehensive Care Plans Timely
Penalty
Summary
The facility failed to develop comprehensive care plans within seven days after the completion of comprehensive assessments for two residents. Resident #1, a cognitively intact male with multiple medical conditions including unspecified angina pectoris and pressure ulcers, had a care plan started but not completed, as nursing, resident programs, and social services departments had not reviewed and completed their sections. Similarly, Resident #2, a female with moderate cognitive impairment and various medical diagnoses, had a care plan initiated but not finalized, with dietary, dietary leadership, and resident programs departments failing to complete their review sections. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for overseeing the care plan process, worked remotely and did not return calls for clarification. The Director of Nursing (DON) initially stated that care plans were to be completed within 14 days of admission, but later confirmed that the facility's policy required completion within seven days of the comprehensive MDS assessment. This discrepancy and lack of timely completion of care plans could potentially place residents at risk of not receiving necessary care.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from abuse and neglect, as evidenced by the failure to implement care plan interventions designed to keep the resident safe from their significant other/authorized person (SO/AP). The resident, who had a history of brain cancer, cognitive impairment, and fragile skin due to medication, was subjected to alleged physical and verbal abuse by the SO/AP. Despite the care plan requiring the resident's door to remain open during visits for safety, staff did not consistently enforce this intervention, allowing the SO/AP to be alone with the resident behind closed doors. Multiple staff members reported witnessing the SO/AP engaging in aggressive and potentially harmful behaviors towards the resident, such as shaking, slapping, and force-feeding. These incidents were not adequately addressed by the facility, as staff were either unaware of the care plan requirements or did not intervene when the door was closed. Additionally, the facility's internal investigations into reported incidents were inconclusive, and there was a lack of communication and training among staff regarding the resident's care plan and abuse prevention protocols. The facility's administration and nursing leadership did not take sufficient action to ensure the resident's safety, despite being aware of the allegations and concerns raised by staff. Interviews with staff revealed a lack of awareness and enforcement of the care plan interventions, and the facility's response to the allegations of abuse was inadequate. The failure to protect the resident from potential abuse and neglect resulted in the identification of an Immediate Jeopardy situation, highlighting significant deficiencies in the facility's ability to safeguard its residents.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to report, prohibit, and prevent abuse for a resident who was subjected to abuse by a significant other/authorized person (SO/AP). Despite staff observations and reports of the SO/AP slapping, hitting, punching, grabbing, kicking, yelling, and shaking the resident, as well as the presence of suspicious bruises, skin tears, and a burn on the resident's body, the facility did not adequately report or investigate these incidents. The facility's failure to act on these reports and protect the resident from further abuse led to the identification of an Immediate Jeopardy situation. The resident involved was an elderly male with a history of glioblastoma, cerebral edema, muscle wasting, seizures, hypertension, and cognitive communication deficit. He was dependent on staff for self-care and required assistance with activities of daily living due to his medical conditions. The resident was at high risk for aspiration and had a history of skin fragility due to medication use. Despite these vulnerabilities, the facility did not ensure the resident's safety from the SO/AP, who was reported to have been non-compliant with dietary orders and aggressive in feeding practices. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan, which included keeping the resident's door open during visits for monitoring purposes. Staff members reported witnessing abusive behavior by the SO/AP but did not consistently intervene or report these incidents to the appropriate authorities. The facility's administration and nursing leadership did not take adequate steps to investigate or address the allegations of abuse, resulting in a failure to protect the resident from harm.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were updated by the interdisciplinary team following changes in their medical conditions. Resident #14, a cognitively intact male with a history of kidney removal, epilepsy, and dementia, had a new wound on his left knee that was not reflected in his care plan. Despite physician orders for wound care, the care plan remained unchanged, potentially leading to inadequate care. Similarly, Resident #58, also cognitively intact, had his external feeding discontinued and transitioned to a regular diet, but his care plan still indicated a need for tube feeding, which was not updated in a timely manner. Interviews with facility staff, including an LVN, MDS nurse, and DON, revealed a lack of clarity and responsibility in updating care plans. The LVN stated that she did not update care plans, while the MDS nurse acknowledged her responsibility but noted that updates were not always made promptly. The DON and ADM expressed that care plans not reflecting current resident needs did not meet expectations and could result in residents not receiving necessary care. The facility's policy requires care plans to be revised as resident conditions change, but this was not adhered to in these cases.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage and labeling, as observed during a survey of the kitchen. On the specified date, several food items in the refrigerator were found improperly stored. An unsealed Ziploc bag containing croutons was labeled and dated but not sealed. Similarly, another unsealed Ziploc bag containing romaine lettuce was labeled and dated but left unsealed. Additionally, a large, unsealed clear plastic bag containing uncooked bacon was found without any labeling or dating. These observations indicate a lack of compliance with the facility's policy on food labeling and storage. Interviews with various staff members, including dietary staff and the Director of Nursing, revealed a consensus that all kitchen staff were responsible for ensuring proper food storage and labeling. Despite this shared responsibility, the staff acknowledged the potential adverse outcomes of improper food storage, such as foodborne illness, bacteria exposure, and gastrointestinal issues for residents. The facility's policy, effective since 2005 and last revised in 2010, mandates that all food items must be labeled and dated before storage, highlighting a clear deviation from established protocols.
Failure to Ensure Physician Orders for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter was assessed for its removal as soon as possible, unless clinically necessary. This deficiency was identified for one resident who was reviewed for incontinent and catheter care. The resident, a male with intact cognition, had several medical conditions including cancer, coronary artery disease, and obstructive uropathy, which necessitated the use of an indwelling catheter. However, there were no physician orders for the catheter's presence, care, or maintenance, which could lead to infection or accidental dislodgement. Interviews with facility staff revealed that the lack of physician orders for the catheter was a significant oversight. The Licensed Vocational Nurse (LVN) acknowledged the absence of orders and suggested that they might have been lost when the resident returned from the hospital. The Minimum Data Set (MDS) Nurse confirmed that a physician order was necessary for the catheter, and the admitting nurse should have clarified the order. The Certified Nursing Assistant (CNA) and Medical Assistant (MA) both provided care to the resident and noted issues such as the catheter pulling, which was reported to the nurse. The interim Directors of Nursing (DON) expressed that it was their expectation for catheter orders to be in place and documented. They acknowledged that without proper orders and care, residents were at risk of infection. The facility's policy on urinary catheter care required a healthcare provider's order for the procedure, but this was not adhered to in the case of the resident. The lack of documentation and oversight in ensuring the presence of necessary orders contributed to the deficiency.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident, who had not previously used psychotropic drugs, was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Resident #56, a [AGE] year-old female with diagnoses including non-Alzheimer's dementia and anxiety disorder, was administered Seroquel, an antipsychotic medication, without a proper diagnosis warranting its use. The resident's admission MDS assessment indicated severely impaired cognition but no hallucinations, delusions, or behavioral symptoms that would justify the use of an antipsychotic. The physician's order for Seroquel was based on behaviors, which is not an appropriate diagnosis for antipsychotic medication. The facility's records showed that the resident was monitored for side effects and behaviors, with confusion documented as a side effect on three occasions and behaviors on two occasions. Despite this, the facility did not provide a specific diagnosed condition for the antipsychotic medication, and the resident was admitted already on the medication. Interviews with the interim DONs and the Clinical Supervisor revealed that the facility's process for monitoring psychotropic medications involved ensuring consent, documenting behaviors and side effects, and coordinating with the nurse practitioner. However, the diagnosis of behaviors or acute encephalopathy was not considered appropriate for antipsychotic medication. The facility's policy required that psychotropic medications be used only after non-drug interventions had failed and that a specific condition be documented in the clinical record, which was not adhered to in this case.
Failure to Post and Maintain Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily and accurately, as required. For three out of five days reviewed, the facility did not post the total number and actual hours worked by licensed and unlicensed nursing staff. Specifically, on 07/26/24, 07/27/24, and 07/28/24, the Daily Staffing log did not contain the necessary information for registered nurses, licensed practical or vocational nurses, and certified nurse aides. Additionally, the facility did not maintain the posted daily nurse staffing data for the required minimum of 18 months, with records missing from February 2023 through July 31, 2024. Observations and interviews revealed that the staffing information posted at the reception desk on 07/29/24 was outdated, showing the date 07/25/24, and lacked the actual hours worked. The Administrator (ADM) admitted that some staffing sheets were lost or discarded. The Scheduler, responsible for posting the staffing information, stated that she prepared the documents in advance for weekends, but the receptionist failed to display the correct forms due to a lack of prepared sheets. The interim Director of Nursing (DON) and the receptionist both acknowledged the importance of posting accurate staffing information for residents and visitors. The facility's policy required daily posting and retention of staffing data for 18 months, which was not adhered to, as evidenced by the incomplete records for the past 18 months.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 338 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lakeway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Manor Bee Cave | 3.1 mi | ★★★★★ | 8 | 0 |
| Longhorn Village | 3.9 mi | ★★★★★ | 0 | 0 |
| Querencia At Barton Creek | 7.7 mi | ★★★★★ | 6 | 0 |
| Stonebridge Health Rehab | 8.5 mi | ★★★★★ | 5 | 0 |
| Brush Country Nursing And Rehabilitation | 11.8 mi | ★★★★★ | 23 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.