Cycle 1
Health 2025-08-21 · Fire 2025-08-21
6 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Electrical (1 deficiency)
Lakeway, TX
Brookdale Lakeway SNF
2-star overall rating with 2-star inspections with $91,420 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1917 Lohmans Crossing Rd, Lakeway, TX
(512) 261-3211
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brookdale Senior Living
Operator or chain grouping
Approved since
2007-03-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.89
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.29
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.17
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.94
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.53
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
486
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.04
Composite VBP score used to determine payment impact.
Payment multiplier
1.0219
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.12
Baseline 20.80% · Performance 17.67% · Measure score 8.12 · Achievement 8.12 · Improvement 7.81
Healthcare-associated infections
10
Baseline 5.22% · Performance 4.79% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
6.87
Baseline 50.00% · Performance 35.59% · Measure score 6.87 · Achievement 6.87 · Improvement 5.23
Adjusted total nurse staffing
2.62
Baseline 4.84 hours · Performance 3.82 hours · Measure score 2.62 · Achievement 2.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 384 · Observed rate 10.42% · Lower 95% interval 8.68% |
| Discharge to community | 64.35% |
50.57%
13.8 pts better
|
Better than the National Rate · Eligible stays 350 · Observed rate 58.57% · Lower 95% interval 58.72% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 92.15% |
95.27%
3.1 pts worse
|
Numerator 176 · Denominator 191 |
| Falls with major injury | 0.52% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 191 |
| Discharge self-care score | 49.62% |
53.69%
4.1 pts worse
|
Numerator 65 · Denominator 131 |
| Discharge mobility score | 41.98% |
50.94%
9 pts worse
|
Numerator 55 · Denominator 131 |
| Pressure ulcers or injuries, new or worsened | 1.57% |
2.29%
0.7 pts better
|
Numerator 3 · Denominator 191 · Adjusted rate 1.67% |
| Healthcare-associated infections requiring hospitalization | 4.79% |
7.12%
2.3 pts better
|
No Different than the National Rate · Eligible stays 206 · Observed rate 2.43% · Lower 95% interval 2.91% |
| Staff COVID-19 vaccination coverage | 3.85% |
8.2%
4.3 pts worse
|
Numerator 3 · Denominator 78 |
| Staff flu vaccination coverage | 15.38% |
42%
26.6 pts worse
|
Numerator 16 · Denominator 104 |
| Discharge function score | 54.96% |
56.45%
1.5 pts worse
|
Numerator 72 · Denominator 131 |
| Transfer of health information to provider | 95.69% |
95.95%
0.3 pts worse
|
Numerator 111 · Denominator 116 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 55 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 36.23% |
25.2%
11 pts better
|
Numerator 25 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
97.1%
1.6 pts worse
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.3% · Q2 100.0% · Q3 100.0% · Q4 92.3% · 4Q avg 95.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
97.9%
0.9 pts worse
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.3%
1.2 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 7.4% · Q4 7.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
3.3%
4.2 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 13.6% · Q3 13.0% · Q4 0.0% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
18.9%
4.2 pts better
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 17.4% · Q3 12.5% · Q4 13.6% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
10.8%
3.5 pts worse
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 12.0% · Q3 15.0% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.6% |
15.4%
5.8 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
16.1%
3.9 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 5.0% · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
0.5%
2.9 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
15.0%
9.9 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 38.6% · Q3 12.8% · Q4 17.8% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.2%
1 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 3.0% · Q3 0.0% · Q4 3.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.7% |
89.7%
12 pts worse
|
81.7%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.7% · Q2 72.9% · Q3 95.9% · Q4 93.6% · 4Q avg 77.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
12.0%
1.2 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 12.5% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 1.1% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.4% |
88.0%
14.6 pts worse
|
79.7%
6.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
25.9%
7.1 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 22.1% · Expected 28.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-31 · Fire 2024-07-31
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-06-09 · Fire 2023-06-09
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-21
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-08-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-21
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-08-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-08-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-29
C · Minimal harm
2025-08-21
F575 · Resident Rights Deficiencies
Health
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.
Corrected 2025-08-29
C · Minimal harm
2025-08-21
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-08-29
K · Immediate jeopardy
2025-01-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-11
D · Potential for more than minimal harm
2024-10-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-12
J · Immediate jeopardy
2024-09-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-05
J · Immediate jeopardy
2024-09-01
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-07-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-08
E · Potential for more than minimal harm
2024-07-31
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-07-31
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-08-08
B · Minimal harm
2024-07-31
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-08
F · Potential for more than minimal harm
2023-06-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-01
F · Potential for more than minimal harm
2023-06-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-07-01
F · Potential for more than minimal harm
2023-06-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-01
E · Potential for more than minimal harm
2023-06-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-01
E · Potential for more than minimal harm
2023-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-06-09
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-06-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-06-09
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-07-01
Penalties and ownership
What sits behind the stars
$74,848
2025-01-14
Fine
Fine · fine $74,848
Fine
$16,572
2024-09-01
Fine
Fine · fine $16,572
Fine
Ownership
American Retirement Corporation
5% Or Greater Direct Ownership Interest · Organization
Brookdale Senior Living Inc
5% Or Greater Indirect Ownership Interest · Organization
Ibarra, Cynthia
Operational/Managerial Control · Individual
Kaestner, Henry
Corporate Director · Individual
Kaestner, Henry
Corporate Officer · Individual
Kussow, Dawn
5% Or Greater Indirect Ownership Interest · Individual
Kussow, Dawn
Operational/Managerial Control · Individual
La Marre, Kevin
Operational/Managerial Control · Individual
Leblanc, Jacob
Operational/Managerial Control · Individual
Leskowicz, Joanne
Corporate Officer · Individual
Munoz, Anna
Operational/Managerial Control · Individual
Pando, Edward
Operational/Managerial Control · Individual
Stengle, Nikolas
Operational/Managerial Control · Individual
Stengle, Nikolas
Corporate Officer · Individual
White, Chadwick
5% Or Greater Indirect Ownership Interest · Individual
White, Chadwick
Operational/Managerial Control · Individual
White, Chadwick
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Park Manor Bee Cave
Bee Cave, TX
1-star overall rating with 1-star inspections with $19,608 in total fines with 10 recent health deficiencies
#2
Longhorn Village
Austin, TX
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Querencia at Barton Creek
Austin, TX
4-star overall rating with 2-star inspections with $17,215 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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