Inspection visit

InspectionJanuary 14, 2025

Brookdale Lakeway SNFCMS #6761311 citation on this visit

1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment and maintain a temperature range of 71' to 81' Fahrenheit for 38 (room numbers 2, 6, 8, 9, 11, 14, 16, 17, 23, 25, 28, 31, 32, 33, 46, 48, 49, 50, 51, 55, 64, 65, 66, 68, 72, 73, 74, 75, 78, 81, 84, 86, 87, 91, 94, 96, 97, 98) of 58 rooms on the 1st and 2nd floor reviewed for temperature of the environment, in that: The facility failed to ensure resident rooms had working heaters, working thermostats, and residents were warm. The facility failed to screen residents for signs and symptoms of hypothermia. For an unknown period of time: Rooms 2, 6, 8, 11, 14, 16, 17, 23, 25, 28, 32, 33, 46, 48, 49, 50, 51, 64, 65, 66, 72, 73, 74, 75, 78, 81, 87, 97, 98 occupied with residents did not have working heaters. room [ROOM NUMBER] occupied with a resident did not have a working thermostats. Rooms 2, 8, 9, 16, 23, 25, 31, 32, 49, 51, 55, 68, 74, 75, 84, 86, 87, 91, 94, 96, 97, 98 had observed temperatures of less than 71 degrees Fahrenheit. room [ROOM NUMBER] displayed the lowest temperature of 57.7 degrees Fahrenheit. An Immediate Jeopardy (IJ) was identified on 01/11/25 at 5:00 PM. The IJ template was provided to the facility on 1/11/25 at 5:00 PM. While the IJ was removed on 01/14/25 at 4:32 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of shivering, confusion, slurred speech, numbness, and hypothermia (occurs when your body temperature drops below 95°F (35°C). Findings included: Review of Resident #1's (room [ROOM NUMBER]) face sheet dated 01/13/25 reflected an [AGE] year-old male who was originally admitted to the facility on 014/23, readmitted on [DATE], and on 08/05/24 with diagnoses that included chronic kidney disease stage 3, dependence on renal dialysis (a procedure that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly), and chronic respiratory failure. Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 14, which indicated intact cognition, mobility device of wheelchair, and active diagnosis of medically complex conditions including respiratory failure. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 676131 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Review of Resident #1's order dated 08/06/24 revealed renal dialysis, 5 days a week. Level of Harm - Immediate jeopardy to resident health or safety Interview on 01/10/25 with Resident #1 at 8:10 pm reflected he had been very cold for several days in his room, but he can't remember when. He stated, it was like a refrigerator, it actually felt like a refrigerator. When asked if he told anyone he was cold he said, hell yes, he told everyone. He told the CNAs, the nurses (he could not recall staff names) and the staff all commented on how cold it was in his room. Residents Affected - Some Review of Resident #2's (room [ROOM NUMBER]) face sheet dated 01/13/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia (a medical condition where the lungs are not effectively exchanging oxygen from the air into the bloodstream), pulmonary fibrosis (a lung disease that causes scarring, making it difficult to breathe), and dependence on supplemental oxygen. Review of Resident #2's MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition, mobility devices of walker and wheelchair, active diagnosis of debility (physical weakness, especially as a result of illness), cardiorespiratory conditions, including respiratory failure. Interview on 01/10/25 with Resident #2 at 7:28 pm reflected he was very cold when the cold front came through for about 2 or 3 days and complained numerous times. He said he, felt like he was camping out in the mountains and could not stay warm, and his nose felt cold. He said he complained numerous times and they kept saying they were going to fix it. He said he did not want to get up and go to the bathroom it was so cold. He said they did not offer to move him to another room and every one knew it was cold but did not provide the name of people he discussed the cold with. Review of Resident #3's (room [ROOM NUMBER] ) face sheet dated 01/13/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure and dependence on renal dialysis (a procedure that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly). Review of Resident #3's MDS dated [DATE] reflected a BIMS score of 11, which indicated moderate cognitive impairment, active diagnosis of medically complex condition and respiratory failure. Review of Resident #3's order dated 12/22/24 revealed renal dialysis. Interview on 01/10/25 with Resident #3 at 8:17 pm reflected he had no heat at all the night he was admitted into the facility and he froze. He said he complained about it, and he heard a lot of people complained about it because they were cold at night. Resident #3 said he knew Resident #1 complained about the cold. Review of Resident #4's (room [ROOM NUMBER]) face sheet dated 01/13/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included cutaneous abscess of buttock (a pus-filled pocket that develops under the skin on the buttocks) and personal history of other diseases of respiratory system. Review of Resident #4's MDS dated [DATE] reflected no diagnosis or assessment information. A review of Resident #4's MDS section 3 dated 01/14/25 reflected a BIMS score of 12, which indicated moderate cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some An observation on 01/10/25 of Resident #4's room at 10:32 pm revealed it was very cold in his room and the thermostat had a reading of 57.5 degrees Fahrenheit. He was wearing a jacket over his pajamas and socks beneath a blanket. Interview on 01/10/25 with Resident #4 at 10:32 pm revealed, I am cold. Review of Resident #5's (room [ROOM NUMBER]) face sheet dated 01/13/25 reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, stage 5, cognitive communication deficit, and end stage renal dialysis (a procedure that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly). Review of Resident #5's MDS dated [DATE] reflected a BIMS score of 15, which indicated intact cognition, mobility device of wheelchair, active diagnosis of medically complex conditions. Review of Resident #5's order dated 10/01/24 revealed renal dialysis 5 days a week. Interview on 01/10/25 with Resident #5 at 9:09 pm reflected she had been freezing cold all day and she wore gloves and a coat all day. Resident #5 said a family member came to visit and it was so cold in her room, her family member left the coat and gloves she was wearing for her to wear. She said everyone who entered her room, including staff (she could not recall their names) remarked on how cold it was. Review of weather underground url: https://www.wunderground.com reflected the following temperatures in Fahrenheit: Sunday January 5, 2025 high of 75, low of 36 Monday January 6, 2025 high of 46, low of 29 Tuesday January 7, 2025 high of 48, low of 26 Wednesday January 8, 2025 high of 41 low of 35 Thursday January 9, 2025 high of 41, low of 36 Friday January 10, 2025 high of 44, low of 35 According to the National Institute on Aging, indoor temperatures as low as 60 to 65 degrees Fahrenheit can lead to hypothermia in older adults. Observations of thermostats and resident room temperatures (in Fahrenheit) 01/10/25 revealed: room [ROOM NUMBER] 10:16 pm - thermostat completely black, unable to read room [ROOM NUMBER] 10:17 pm - 66 degrees room [ROOM NUMBER] 10:19 pm - 65 degrees room [ROOM NUMBER] 10:21 pm - 65 degrees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 room [ROOM NUMBER] 10:23 pm - 66.5 degrees Level of Harm - Immediate jeopardy to resident health or safety room [ROOM NUMBER] 10:24 pm - 68.5 degrees Residents Affected - Some room [ROOM NUMBER] 10:27 pm 69 degrees room [ROOM NUMBER] 10:25 pm - 67 degrees room [ROOM NUMBER] 10:29 pm 65 degrees room [ROOM NUMBER] 10:31 pm 69 degrees room [ROOM NUMBER] 10:32 pm 57.7 degrees room [ROOM NUMBER] 10:34 pm 67.5 degrees room [ROOM NUMBER] 10:35 pm 70 degrees room [ROOM NUMBER] 10:39 68.5 degrees room [ROOM NUMBER] 10:40 pm 68 degrees room [ROOM NUMBER] 10:41 pm 69.5 degrees room [ROOM NUMBER] 10:43 pm 68 degrees room [ROOM NUMBER] 10:43 pm thermostat completely black, unable to read room [ROOM NUMBER] 10:45 pm 70.5 degrees room [ROOM NUMBER] 10:48 pm 69 degrees room [ROOM NUMBER] 10:51 pm 66 degrees room [ROOM NUMBER] 10:52 pm 70 degrees room [ROOM NUMBER] 10:54 pm 68 degrees Observations on 01/10/25 7:06 pm until 01/11/25 12:05 am of no direct care staff or administrative staff observed offering hot beverages, additional sweaters, or blankets to the residents. Review of facility TELS - reflected: work order number 12023 room [ROOM NUMBER] this room is very cold family is in the room and are very upset that it is so cold open date 12/3/24 11:57 am closed dated 12/3/24 3:43 pm work order number 11978 the room temp is cold room [ROOM NUMBER] open dated 11/21/24 8:29 am closed dated 11/22/24 11:09 am (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 work order number 12019 the resident said the room is [to] cold room [ROOM NUMBER] open date 12/03/24 9:10 am closed dated 12/07/24 am Level of Harm - Immediate jeopardy to resident health or safety work order 12035 this room is cold room [ROOM NUMBER] dated 12/06/24 1:30 pm closed 12/06/24 12:00 pm Residents Affected - Some work order 12037 this room is cold room [ROOM NUMBER] dated 12/6/24 1:31 pm closed 12/6/24 4:13 pm work order 12039 this room is cold room [ROOM NUMBER] dated 12/06/24 4:14 pm closed 12/06/24 4:14 pm work order 12040 this room is cold room [ROOM NUMBER] dated 12/06/24 1:34 pm closed 12/06/24 4:14 pm work order 12041 this room is cold room [ROOM NUMBER] dated 12/06/24 1:34 pm closed 12/06/24 4:15 pm work order 12083 rooms in SNF are too cold main building SNF 2nd floor, dated 12/06/24 1:34 pm closed 12/21/24 11:53 pm closed 12/26/24 12:18 pm work order 11927 . the A/C heater are not working room [ROOM NUMBER] dated 11/07/24 10:49 am closed 11/08/24 10:31 am work order 12092 . it is cold in this room check A/C window unit, make sure it is sealed room [ROOM NUMBER], dated 12/26/24 1:18 pm closed 12/31/24 11:51 am work order 12096 check the room temp in this room room [ROOM NUMBER], dated 12/26/24 1:18 pm closed 12/31/24 11:51 am work order 11926 the a/c heater is not working in this room, room [ROOM NUMBER], dated 11/07/24 10:49 am closed 11/08/24 10:31 am work order 11979 check the heater in this room room [ROOM NUMBER], dated 11/21/24 10:33 am closed 11/23/24 8:35 am work order 11983 the temp is cold in this room room [ROOM NUMBER], dated 11/21/24 1:16 pm closed 11/22/24 12:11 pm work order 11986 the heater in this room is not working room [ROOM NUMBER] dated 11/22/24 10:36 am closed 11/22/24 12:13 pm work order 12044 this room is cold room [ROOM NUMBER] dated 12/09/24 9:06 am closed 12/16/24 3:02 pm Review of facility maintenance policy checklist revealed steps need to be taken during the winter months to minimize disaster related preparation checklist. It should be used in conjunction with this document prior to all extreme cold/inclement weather events to ensure we are prepared in each department for every event and signed by the MD and Administrator on 11/14/24. Checklist document reflected, Resident and vacant rooms should keep their apartment heat sources set to minimum of 75 degrees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 during freezing weather in case of power outage checked as complete. Level of Harm - Immediate jeopardy to resident health or safety Review of in-service dated 01/07/25 given by the DCS topic cold/inclement weather at 3:30 pm reflected extreme heat and cold measures policy was discussed including monitoring temperatures every 2 hours, if there are areas that fall below 68 degrees Fahrenheit, residents must be moved to common areas that meet the proper temperature , all staff should be familiar with the symptoms of cold related illnesses and the initial treatments that should be initiated and, if the minimum temperature is not maintained, the emergency evacuation plan must be activated. The direct care staff was not included in this in-service. Signatures on the in-service reflected only the following administrative staff members attended: Residents Affected - Some The Administrator The manager for clinical services, LVN The Director of Admissions The Social Services Assistant The Assistant Director of Clinical Services The Director, Human Resources Interview on 01/13/25 with the MD at 3:43 pm revealed the facility had a what to do during cold weather policy and a checklist to follow to implement during cold weather. He revealed he felt there was some miscommunication between residents and staff about room temperatures and Resident #4's room should never have been 57.5 degrees. Interview on 01/13/25 with LVN A at 7:08 pm revealed she had worked at the facility for about 12 years and the heating system had not worked for the last couple of years and the facility had been putting a bandage on the problem. Interview on 01/10/25 with CNA A at 9:15 pm revealed that the heaters are not working in every room, and she knew for sure that the heaters were not working in rooms [ROOM NUMBERS] and there were residents in the rooms. She said she was concerned about the residents because the heaters were not working, and she was concerned residents were cold. Interview on 01/10/25 with LVN C at 12:16 am revealed, when asked the signs and symptoms of hypothermia LVN C listed: Cold skin Slower breathing Blue/pale skin Shivering Any signs of distress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Immediate jeopardy to resident health or safety Interview on 01/10/25 with CNA D at 12:12 am revealed, when asked the signs and symptoms of hypothermia CNA D listed: Shivering Change in mental status Residents Affected - Some Blue lips/fingers/cloudy skin Hyperventilating Interview on 01/10/25 with CNA E at 12:14 am revealed, when asked the signs and symptoms of hypothermia CNA E listed: Shaking Feverish Interview on 01/10/25 with CNA F at 12:15 am revealed, when asked the signs and symptoms of hypothermia CNA F did not know the signs and symptoms of hypothermia. Interview on 01/14/25 with the dialysis nurse at 3:30 pm he revealed that residents have complained to him that it had been cold and he had put three separate work orders for the receptionist and spoken to the nurses. He said Resident #1's room was, like a meat locker. He said dialysis residents are frailer because of the dialysis treatment and that it is important to keep them warm. Interview on 01/13/25 with a family member of Resident #5 at 12:23 pm stated she visited Resident #5 on 12/31/24. She revealed it was freezing cold when in Resident #5's room. She said the staff said they were having trouble with the heat in some of the rooms. She said she stayed about 4 hours and was told by facility staff that they were working on getting the heater fixed. She left her coat and gloves with Resident #5 to wear because it was so cold. She said that everyone who entered Resident #5's room on 01/31/24 commented that the room was cold. She said she assumed that the heater was going to be fixed because she was told that the heater would be fixed. Resident record reviews of progress notes for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5 of reflect no monitoring of room temperatures and no monitoring for sign/symptoms of hypothermia were being conducted. Review of email dated 01/13/25 from facility heater repair provider at 3:13 pm reflected the findings on each resident room HVAC unit as of 1/12/25: The Following 43 rooms have bad compressors and control boards and are not operational, due to the age and overall condition of the units compressor replacement is not recommended. 4, 5, 6, 7, 16, 18, 23, 24, 25, 26, 27, 28, 29, 33, 36, Dialysis, Conference Room, 39, 40, 41, 43, 45, 46, 49, 50, 51, 54, 56, 58, 64, 66, 67, 72, 73, 75, 78, 80, 81, 83, 87, 88, 90, 95 The Following 5 units have active refrigerant leaks, the units were charged up but due to the size of the system the added freon is only a temporary fix and heating/cooling is temporary 8, 10, 11, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 22, 32 Level of Harm - Immediate jeopardy to resident health or safety The following 2 units have bad Blower motors and will need further diagnostics once repaired 14, 44 The following 6 units have bad reversing valves and will need further diagnostics, Due to the age and condition of the unit I do not recommend making this repair Residents Affected - Some 17, 48, 65, 74, 94, 98 The following 2 units only have a bad thermostat 13, 82 The Following unit has a cracked loop and will need to be replaced 97 Review of facilty resident list report dated 01/13/25 revealed that the following rooms were occupied with residents: 1, 2, 3, 6, 8, 9, 11, 14, 15, 16, 17, 19, 21, 23, 25, 28, 30, 31, 32, 33, 34, 46, 48, 49, 50, 51, 53, 55, 57, 59, 60, 61, 62, 63, 64, 65, 66, 68, 69, 71, 72, 73, 74, 75, 77, 78, 80, 81, 82, 84, 86, 87, 89, 91, 94, 96, 97, 98. A review of the facilty resident list report dated 01/13/25 and the email dated 01/13/25 from facility heater repair provider reflected that room numbers 2, 6, 8, 11, 14, 16, 17, 23, 25, 28, 32, 33, 46, 48, 49, 50, 51, 64, 65, 66, 72, 73, 74, 75, 78, 81, 87, 97, 98 occupied with residents, did not have working heaters. Interview on 01/13/25 with the facility employed contract HVAC technician at 3:30 pm revealed on 01/08/25 he knew that there was no heat in rooms [ROOM NUMBERS] and there were residents in the rooms. He said the residents said they were cold but did not add additional comments. He said he had been employed as a HVAC technician for 15 years and was deeply concerned about it getting colder and the residents not being warm. He said the problem was the heat exchanger because it had been dirty for such a long time it caused permanent damage to the HVAC in all the resident rooms. He said the best the facility could do was to offer vented heating/cooling units for all the resident rooms. He said he brought the problem with the heating/cooling to the attention of the facility about a year ago and they were dealing with the consequences of them not being proactive. Interview on 01/10/25 with the Administrator at 9:56 pm revealed that if residents were cold, they were offered a change of room, but that residents could make their own choices, and had the option to decline, and did decline room changes when offered. The administrator revealed staff did not explain the room change would not be permanent and residents could return to their room when the heating could be adjusted in their regular rooms. Interview on 01/14/25 with the Administrator at 2:24 pm revealed if residents were too cold the largest issue would be hypothermia, which would lead to an emergency visit to the hospital and residents could die if the hypothermia was extreme. When asked why staff did not follow through with making sure the actions in the in-service dated 01/07/25 were taken by his staff, he said he did not know and said the whole situation had brought a concern to the facility. Review of facility House Temperature & Extreme Heat and Cold policy last revised 05/2022 reflected (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Policy overview - Level of Harm - Immediate jeopardy to resident health or safety A comfortable community temperature is maintained for the residents per state or Federal regulations. A safe and comfortable indoor temperature range is generally defined for the older adults as 71-81 degrees or per state regulation. Follow the [facility] Emergency Plan and begin resident monitoring for possible adverse effects from extreme cold or heat. Residents Affected - Some Policy Detail Temperature Falls outside the safe comfortable range. The executive director/designee should notify the district director of operations and regional maintenance technician when the community indoor temperature falls outside the safe and comfortable range. A nurse should evaluate resident symptoms of physical distress related to extreme temperatures outside the safe and comfortable range as soon as possible and notify the physician/healthcare provider of findings. Evacuation is an emergency and determining an alternate healthcare setting. In the instance of temperatures that could adversely affect a residents' health and safety, the community should follow the emergency plan and determine an alternate and temporary healthcare setting. Notify appropriate parties. A nurse should evaluate resident symptoms of physical distress related to extreme temperatures outside the safe and comfortable range as soon as possible and notify the physician/ health care provider of findings. Follow the emergency plan for preparing, managing, and potentially evacuating from the community. Resident monitoring: the health and Wellness director, director of clinical services /designee/charge nurse is responsible for the monitoring of resident health conditions during times of community emergencies and/ or during indoor temperatures outside of the safe and comfortable ranges. Monitoring should include observing residents every one to two hours for signs and symptoms of heat or cold related conditions as indicated in the extreme heat and cold measures document. Reporting adverse effects to the executive director and the health and Wellness director, director of clinical services. Providing warming or cooling measures, as indicated in the extreme heat and cold measures document. Check resident temperatures every one- two hours is indicated for clinical judgment. Notifying the physicians/health care provider and family/responsible party of resident condition changes in agency per state regulation (conditions that pose a threat). The ADM and CSD were notified on 01/11/25 at 5:00 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 01/13/25 at 2:00 PM: Facility Policy Dated 10/2015 Quality of Life - Home Like Environment. The community associates and management shall maximize, to the extent possible, the characteristics of the community that reflect a personalized, home like setting. These characteristics include: comfortable temperatures Facility policy dated 1/2018 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 temporary excessive cold measures: Level of Harm - Immediate jeopardy to resident health or safety monitor indoor temperatures every one to two hours Residents Affected - Some initiate resident checks every one to two hours to offer hot beverages/ fluids and evaluate for and assess signs and symptoms of hypothermia encourage residents to dress in layers and use blankets for warmth check all doors and windows for drafts. Eliminate drafts when possible by drawing a curtain/shades on days when the temperatures are below freezing. Encourage residents to sit away from window slash drafts. Encourage residents to wear appropriate winter clothing while indoors and to dress in layers with appropriate outerwear when leaving the building. Residents should also wear a hat or ear covering or gloves when going outdoors. Encourage residents not to partake in outdoor activities for extended period of time. Extreme or Extended Periods of Cold Monitor indoor temperatures at least hourly until the heating system has been repaired. Notify the district director of operations, regional maintenance technician, and district director of clinical services/ regional director of clinical operations. Communicate indoor temperatures with district or divisional leadership for possible evacuation. If there are areas that fall below 68°F, residents must be moved to common areas that meet the proper temperature. The area must be of sufficient size to safely accommodate the residents. Check residence temperatures every hour, offering hot beverages, evaluate for signs of hypothermia. All staff should be familiar with the symptoms of cold related illness and at the initial treatments that should be initiated. If the minimum temperature is not maintained, the emergency evacuation plan must be activated. Cold related illness What to look for - Hypothermia Shivering Confusion Memory loss Drowsiness Exhaustion Slurred speech (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Slow, irregular pulse Level of Harm - Immediate jeopardy to resident health or safety Numbness Residents Affected - Some Plan of Removal Immediate Threat Decreased level of consciousness On 1/11/2025 an abbreviated survey was initiated at the facility. On 1/11/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: F 584 Safe, clean, comfortable, home-like environment: The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Action: On 1/11/25, resident #1 was interviewed by Social Service Coordinator about the comfort of her room temperatures. This was documented on an interview sheet . On 1/11/25, the Maintenance Technician installed a portable [vented] heater in resident's # 1 room. On 1/11/25, a licensed nurse completed vital signs and evaluated resident # 1 for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted . On 1/11/25, resident #2 was interviewed by Social Service Coordinator about the comfort of his room temperatures. This was documented on an interview sheet. On 1/11/25, the Maintenance Technician installed a portable [vented] heater in resident's # 2 room. On 1/11/25, a licensed nurse completed vital signs and evaluated resident # 2 for symptoms of hypothermia and documented in the electronic medical record. No symptoms noted. On 1/11 -1/12/25 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. On 1/11/25, 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. On 1/11/25, a licensed nurse reviewed the 24-hour Summary Report from the electronic medical record from 1/3/25- 1/11/25 to determine if there was symptoms of hypothermia documented. No documentation was identified for symptoms of hypothermia. On 1/11/25, 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676131 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Lakeway Snf 1917 Lohmans Crossing Rd Lakeway, TX 78734 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 documented on an interview sheet. Level of Harm - Immediate jeopardy to resident health or safety On 1/11/25, 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. Residents Affected - Some Unoccupied rooms identified will not be used until a portable [vented] heater with a temperature display is installed or the room thermostat is replaced. On 1/11/25, the Regional Maintenance Technician ordered fifteen (15) additional portable [vented] heaters that display the room temperature. On 1/12/25, Social Services Director reviewed the Grievance Log for 12/15/24 to 1/11/25 to identify any grievances related to room temperatures. Starting on 1/11/25, 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 on 1/12/25 there are two unoccupied rooms (rooms [ROOM NUMBERS]) 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 1 or two (2) weeks, daily for four (4) weeks, and daily for five (5) weeks to validate compliance. On 1/11- 1/12/25, 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 [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676131 If continuation sheet Page 12 of 12

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Citations

1 citation recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0584SeriousS&S Kimmediate jeopardy
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

FAQ · About this visit

Common questions about this visit

What happened during the January 14, 2025 survey of Brookdale Lakeway SNF?

This was a inspection survey of Brookdale Lakeway SNF on January 14, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Brookdale Lakeway SNF on January 14, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·January 14, 2025