Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Apex Secure Care Brownfield during CMS and state inspections, most recent first.
An LPN failed to follow infection control practices during wound care for two residents with wounds, including using the same scissors and wound cleanser between residents, not performing hand hygiene between glove changes, and not using EBP correctly. One resident had bilateral leg ulcers with a positive wound culture for STAPHYLOCOCCUS AUREUS and STREPTOCOCCUS AGALACTIAE, and the other had a pressure ulcer. The facility also had not implemented EBP for the resident with the positive culture.
Unsafe resident rooms and inadequate visitation area: A resident in one room reported ceiling leaks and feared the ceiling could fall, while two other occupied rooms had bubbled, damaged ceilings with water dripping and one room had a sink filled with dark grey water. The maintenance log had no repair requests for the ceiling damage or clogged sink. A visitor also reported the facility was dirty and lacked indoor seating for visits, and the ADM acknowledged there was no private visitation area and only limited seating available.
Failure to Maintain Required RN Coverage: The facility failed to provide RN coverage for at least 8 consecutive hours a day on multiple days reviewed. Punch detail records showed no RN hours on several dates, and the ADM confirmed the scheduled RN did not work those shifts. The ADM also stated the facility had no DON at the time of the interview, and the BOM confirmed the coverage documents were blank for those dates.
Unsafe food storage and poor kitchen sanitation were observed throughout the kitchen and during meal service. Opened foods in the fridge, freezer, and dry storage were often undated or improperly stored, some refrigerated items were left out at unsafe temperatures, food carts and equipment were dirty, clean serving items were stored with food-contact surfaces exposed, and chemicals were kept on the floor in the prep area. Staff also failed to perform hand hygiene, wore no hair restraint, and used gloved hands and the same utensils across multiple food tasks, including ready-to-eat items.
Unsafe and Damaged Facility Environment: The dining room ceiling was leaking with buckets placed on the floor, the dining room floor and the floor around the nursing station had visible scratches and marks, Dry Pantry A ceiling was also leaking, and Hall C had water-damaged ceiling tiles outside Room C9. The Mnt Supv and ADM stated the roof and ceiling issues were ongoing, with quotes still pending from roofing companies and floor replacement work in progress.
Failure to provide privacy during wound care: An LVN performed wound care for a resident with dementia and a stage 2 pressure ulcer without closing the room door, privacy curtain, or window blinds. The resident was visible from the hallway, the roommate remained in the room, and the LVN stated she did not close the blinds because the facility was locked. The ADM said staff were expected to provide full privacy during care.
Food and nutrition services failed to ensure dinner trays were palatable, attractive, and served at a safe, appetizing temperature. Surveyors sampled regular, mechanical soft, and pureed trays and found items that were mushy, freezer-tasting, cold, or only lukewarm; two residents also reported concerns that the food was cold or not good. The DM said he tasted food only a few times a month and the ADM said he expected food to be tasteful and presentable, while the facility policy required tray inspection for palatability and proper temperature.
Expired Nursing License: The facility failed to ensure an LVN maintained an active license while working as a nurse. Record review showed the LVN worked multiple shifts during the review period, and the BOM stated the LVN was later sent home after the facility found the license had expired. The BOM and ADM stated the BOM was responsible for checking nursing staff licenses, and the facility policy required current licensure verification and recertification before expiration.
Kitchen oven door not maintained in safe operating condition. During observation, the left oven door would not close fully and a cardboard square fell out from between the stove and door, leaving a 2- to 3-inch gap. Staff stated the door spring had been broken for weeks and that towels and cardboard were being used to keep the door closed, while management acknowledged the issue and said the oven was expected to be operational.
Loose Handrail in Hall C: A hallway handrail between Rooms C3 and C4 was observed to be loose and wobbly rather than firmly secured to the wall. The Maintenance Supervisor stated he was not aware of the issue unless it was written in the maintenance logbook, and the work order log showed no related work orders. The facility policy states maintenance must keep the building safe and operable at all times.
A CMA documented that multiple residents received their evening medications, but unopened medication packages were later found in the medication cart, indicating the medications were not administered as recorded. The CMA stated she had not updated the MARs to reflect resident refusals, resulting in inaccurate medical records for residents with significant cognitive and medical conditions. The discrepancy was discovered by another CMA, leading to an internal review and confirmation of the documentation failure.
A treatment cart containing prescription medications and medical supplies was found unlocked and unsupervised in a hallway near the nurse's station, accessible to residents. The charge nurse on duty confirmed responsibility for the cart and acknowledged training on the requirement to keep carts locked when unattended. Facility leadership and policy both require that medication carts be locked at all times when not supervised.
The facility failed to inform 12 residents about their rights to file grievances, including access to forms and anonymous submissions. Residents were unaware of the grievance procedure, which was not posted in prominent locations or discussed in Resident Council meetings. The ADM, responsible for grievance oversight, acknowledged the lack of anonymous submission procedures and communication about the grievance process.
The facility failed to store and label food properly in the refrigerator and pantry, and did not maintain safe food temperatures during service. Observations revealed unlabeled and undated food items, and personal items stored with food, risking cross-contamination. A staff member served pureed chicken at an unsafe temperature, despite training on proper reheating procedures.
In a LTC facility, a CNA and an LVN failed to adhere to infection control practices. The CNA did not perform hand hygiene while assisting multiple residents with meals, and the LVN did not wash hands between glove changes during wound care. These actions were contrary to the facility's infection control policies, potentially risking resident safety.
The facility failed to maintain a safe and sanitary environment, with several hand sinks and toilets nonfunctional over three days. Observations revealed standing water in sinks and a toilet full of feces that could not be flushed. Interviews indicated a lack of communication and reporting of plumbing issues, with the Maintenance Supervisor unaware of the problems until informed by surveyors. The facility's maintenance policy requires timely reporting and resolution of such issues, which was not adhered to, leading to an unsanitary and potentially unsafe environment.
A resident with a history of mental health issues and legal blindness was found living in unsanitary conditions without daily cleaning, window coverings, or privacy curtains. The resident often refused care and destroyed property, but the facility failed to document these behaviors or address them in the care plan. Staff interviews revealed a lack of communication and follow-up on care refusals, compromising the resident's dignity and privacy.
A resident with severe cognitive impairment and legal blindness was repeatedly observed without access to a reachable call light system, despite facility policy requiring it. Staff interviews confirmed the call light should be within reach, but it was often tied up on the wall due to the resident's history of pulling it out. This failure compromised the resident's ability to call for help, potentially leading to unaddressed emergencies.
A resident with cognitive impairments and schizoaffective disorder was found living in an unclean and unsafe environment due to the facility's failure to provide adequate housekeeping and maintenance services. The resident's room was cluttered with trash, lacked privacy curtains, and had a clogged toilet. Despite the resident's refusal of care, staff did not consistently document or address the issues, leading to a deficiency in maintaining a homelike environment.
A resident with multiple mental health diagnoses, including Major Depressive Disorder and Intermittent Explosive Disorder, was admitted to the facility without an accurate PASRR Level I assessment. The facility failed to update the assessment to reflect the resident's mental illness, despite active diagnoses and ongoing psychiatric services. Interviews with staff revealed a lack of awareness and oversight regarding the accuracy of the PASRR Level I screening.
The facility failed to provide scheduled activities, affecting residents' physical, mental, and psychosocial well-being. Residents reported that activities were often canceled without alternatives, leaving them feeling let down and bored. The Activities Director was frequently unavailable due to other duties, and no communication was provided regarding cancellations.
The facility failed to follow the prescribed menus for two lunch services, substituting items due to shortages and resident preferences. On one day, mashed potatoes replaced rice pilaf, and on another, biscuits were omitted due to space constraints. These deviations could potentially affect residents' nutritional intake.
The facility failed to ensure safe storage of food items in residents' personal refrigerators in Rooms D6, D8, and E9, as there were no temperature logs and some food items had illegible or expired dates. Housekeeping staff were responsible for checking and cleaning these refrigerators but did not maintain logs or know the required temperatures, risking residents' health.
A resident with severe cognitive impairment and tremors sustained a burn injury while smoking due to inadequate supervision and failure to use required safety devices. The staff member assigned to monitor the resident was on a cell phone, and the resident was not using a cigarette extender or smoking apron as per her care plan, leading to a burn on her finger.
A facility failed to implement its abuse prevention policies when two monitoring techs mishandled a resident with cognitive impairments. The resident, who was a fall risk, was aggressively redirected to his room, resulting in a fall. The incident was not reported immediately, violating the facility's policies on abuse prevention and reporting.
A resident with multiple medical conditions, including bilateral above-the-knee amputations, did not receive proper wound care as per physician orders. The resident's left stump wound was found uncovered while out of bed, contrary to orders. The LVN and DON were unable to explain the oversight, and no policy was provided for following physician orders or care plans.
A resident with a history of multiple health issues, including bilateral leg amputations, was found with an uncovered wound on the left stump, contrary to physician orders requiring coverage when out of bed. The resident reported that staff often neglected to cover the wound, causing discomfort. The LVN responsible for wound care was unsure why the wound was uncovered, and the DON acknowledged the oversight and potential negative outcomes. The facility's wound care policy was not followed, resulting in a deficiency.
A resident in a long-term care facility was found to be using an oxygen humidification bottle that had not been changed as per policy, posing a risk of infection. Additionally, CNAs and an LVN failed to follow proper hand hygiene and PPE protocols during incontinent and wound care, despite the resident being on barrier precautions. These lapses were acknowledged by the staff, who cited being in a hurry or focused on other tasks.
Infection Control Failures During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents who were receiving wound care. Resident #36 had a history of Alzheimer’s disease, chronic venous hypertension with bilateral lower-extremity ulcers, type 2 diabetes, and COPD, and had a severely impaired BIMS score. Resident #32 had dementia, a stage 2 pressure ulcer of the left buttock, and muscle weakness, and was also severely cognitively impaired. Both residents had wound care orders, and both had enhanced barrier precautions (EBP) documented in their care plans. During wound care observations, LVN A handled wound care supplies in a manner that did not follow the facility’s infection control practices. For Resident #36, LVN A gathered dermal wound cleanser, gauze, kerlix, calcium alginate, xeroform, and scissors from Treatment Cart A, placed supplies on a bedside table that had not been cleaned, and performed wound care without EBP signs or PPE available outside or inside the room. LVN A used the dermal wound cleanser directly on the resident’s bilateral leg wounds, changed gloves without hand hygiene, used scissors to open dressing packages, touched the wound while applying dressings, and returned the scissors and wound cleanser to the treatment cart after use without sanitizing them. For Resident #32, LVN A retrieved the same scissors and dermal wound cleanser that had just been used for Resident #36 and brought them into the room. Although EBP signage and PPE were present for Resident #32, LVN A did not wear a gown, placed the contaminated items on the resident’s bed and dresser, and again used the wound cleanser directly on the wound. LVN A changed gloves without hand hygiene and completed the dressing change without performing hand hygiene afterward. The report also states that the facility had not implemented EBP for Resident #36 after the positive wound culture showed STAPHYLOCOCCUS AUREUS and STREPTOCOCCUS AGALACTIAE, and that the immediate jeopardy was identified because of these infection control failures.
Unsafe Resident Rooms and Inadequate Visitation Area
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in rooms E2, E9, and F3, and failed to provide a designated visitation area with adequate seating. During observation and interview, Resident #37 in room F3 stated there was water leaking from the ceiling and that he worried about the ceiling falling down. The ceiling in front of the closet had bubbled paint with large holes, and water was dripping from the holes. In room E9, which was occupied by two residents, there was a 1 to 2 inch hole in the ceiling above the bed near the window, and the restroom sink was filled with dark grey water with nothing observed to prevent drainage. In room E2, which was occupied by one resident, the ceiling in front of the window had bubbled paint with a large hole, and water was dripping from the hole and along the privacy curtain rails secured to the ceiling. Record review of the Maintenance Work Order Log showed no repair requests for the ceiling repairs in rooms E2, E9, and F3, and no repair request for the stopped-up sink in room E9. The Maintenance Supervisor stated he assessed the building for daily repairs and that all staff were trained to write needed repairs in the maintenance logbook, which was kept at the monitoring station. He stated he was aware about a month earlier of a leak in a resident room on E-hall, but he was not aware of leaks in the other resident rooms. He also stated he was not aware of the stopped-up sink in room E9. He said the roof needed to be repaired before the ceiling repairs could be completed, and that the ceiling repairs would be done after the roof was fixed. A visitor stated the facility was dirty and needed to be cleaned, updated, and repainted. The visitor also stated there was no place for visitors to sit inside the facility and that the only place to sit was outside, which was not always an option because it could be too hot and people smoked outside. The Maintenance Supervisor stated visitors usually visited residents in their rooms or the dining room, and there was also a gazebo outside. The Administrator stated there was no private area for visitation, though there were a couple of recliners in the lobby and chairs could be brought from the dining room if requested. The Administrator also stated there were no many visitors at the facility and acknowledged that having chairs for visits was important for a more homelike visitation experience.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week on 6 of 67 days reviewed for RN coverage. Record review of the facility's employee survey roster dated 4/12/26 showed three RNs were employed at the facility, but Punch Detail Reports for 10/4/2025, 10/5/2025, 10/11/2025, 10/12/2025, 10/19/2025, and 11/9/2025 showed no hours logged for RN coverage on those dates. An email dated 4/13/2026 from the ADM stated the facility did not have RN coverage for the requested dates when punch-in details were requested. During an interview on 4/15/26, the ADM stated he was aware there was no RN coverage for 6 days in October and November 2025 and said the RN scheduled to work chose not to work on those days. He stated the RN was contracted through an agency and that the facility policy required RN coverage 7 days a week for 8 hours per day. He also stated there was no DON employed at the facility at the time of the interview, that the prior DON resigned without notice on 4/09/2026, and that the DON usually monitored RN coverage and contacted an agency to ensure coverage. The BOM stated the documents provided for RN coverage on the requested dates were blank to show there was no RN coverage on those dates.
Unsafe Food Storage and Poor Kitchen Sanitation
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in a safe and sanitary manner. During an initial kitchen observation, surveyors found opened food items in the refrigerator, freezer, and dry pantry without open or use-by dates, including dairy products, sauces, seasonings, breaded items, and other prepared foods. Some items that required refrigeration were left unrefrigerated, including opened precooked sausage patties sitting out in front of the refrigerator and a 5-gallon bucket of kosher dill slices labeled to keep refrigerated that was observed at 72 F. Unopened dinner rolls were also found expired, and an unopened case of orange juice that was labeled to thaw overnight in a 38 F cooler was being left in the dry pantry to thaw. Surveyors also observed multiple sanitation problems in the kitchen. Food transportation carts were dirty, clean plates and serving utensils were stored with food-contact surfaces facing upward, and some lids were stored wet. A reusable water bottle was found under the three-compartment sink. Refrigerator #2 did not have a thermometer inside, and Freezer #3 did not have a current temperature log. Chemicals including bleach, lime scale remover, and soak tank concentrate were stored on the floor near the sink in the food prep area. During lunch and evening meal service, staff did not follow hygienic practices. One dietary staff member put on gloves without performing hand hygiene, touched non-food surfaces while gloved, handled food, and moved between tasks without changing gloves or washing hands. Another dietary aide entered the kitchen without a hair restraint and did not wash hands until later. The aide also handled bread, lunch meat, cheese, jelly, peanut butter, utensils, and a coffee cup with keys while wearing the same gloves, and used the same knife for different sandwich items, with jelly residue later observed inside the peanut butter container. During evening meal service, another staff member used gloved hands instead of utensils to serve buns, fish patties, and chicken nuggets after touching plates, meal tickets, and utensil handles.
Unsafe and Damaged Facility Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in the dining room, Dry Pantry A, around the nursing station, and in Hall C. On 04/12/26, the dining room ceiling near the kitchen was observed leaking water, with 3 buckets on the floor containing water, 2 blankets on the floor around the buckets, and Caution Wet signs placed around the wet area. The dining room floor had large white and black scratches and marks in several areas on the brown flooring. In Dry Pantry A, the ceiling was also observed slowly leaking water with 2 buckets on the floor containing water. Around the nursing station, the flooring was observed to have several areas of white and black marks on the brown flooring. The Maintenance Supervisor stated on 04/12/26 that the dining room ceiling had started leaking that weekend with the rain and that the area was blocked off from residents while he waited for a roofing company to provide a quote. On 04/13/26, Hall C outside Room C9 was observed to have brown water spots on 5 ceiling tiles. During interview on 04/14/26, the Maintenance Supervisor stated the dining room and nursing station floors were being worked on for replacement and that the roof and ceilings were a chronic problem, with a company having previously gone out and quotes still pending. The ADM stated the facility had spoken with two companies about the roof damage and was still waiting on estimates. Record review of the Maintenance Work Order Log showed a 4/12 entry for a roof leak in the dining room, and the facility policy stated maintenance service shall keep the building, grounds, and equipment in a safe and operable manner and in good repair and free from hazards.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to ensure resident privacy during wound care for one resident with dementia, a stage 2 pressure ulcer of the left buttock, and muscle weakness. During an observed wound care treatment, an LVN entered the resident’s room and performed care without closing the room door, leaving the resident visible from the hallway. The LVN also did not close the privacy curtain between the resident and the roommate, who was sleeping in the room, and did not close the window blinds that faced the street and the facility exterior premises. During interview, the LVN stated she had been trained to provide privacy but was unsure when her last training occurred. She said she did not close the door because she believed the curtain was enough to prevent hallway visibility, did not close the curtain between the two residents because the roommate was sleeping and turned away, and did not close the blinds because the facility was locked. The administrator stated staff were expected to provide full privacy during care, including closing the door, blinds, and privacy curtain, and described the LVN’s actions as careless.
Food Not Served at Palatable or Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food served at dinner was palatable, attractive, and at a safe and appetizing temperature for regular, mechanical soft, and pureed meal forms. During observation, test trays delivered to the family dining room were sampled by surveyors and the regular meal fish sandwich was described as mushy with a freezer taste, the tator tots were cold to lukewarm, and the salad was okay. For the mechanical soft meal, the fish was lukewarm and the beans were cold. For the pureed meal, the fish was okay and smooth, the tator tots were lukewarm, and the beans were okay and smooth. During confidential interviews, 2 of 10 residents voiced concerns about the food, with one stating the food was cold and another stating the food was not good. The DM stated he tasted the food before and after it was served about two to three times a month, asked residents about the food, and had not heard a lot of negative feedback. He also stated he was trained to follow the recipe and was in contact with the Dietician regarding the food. The ADM stated he expected the food to be tasteful, at an appetizing temperature, and presentable, and he acknowledged that the Dietician had recently been at the facility and he was still awaiting her report on kitchen services. The facility policy stated that food and nutrition services staff will inspect food trays to ensure the correct meal is provided, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.
Expired Nursing License
Penalty
Summary
The facility failed to maintain sufficient nursing staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 5 nursing staff reviewed, LVN C. Record review showed LVN C had an LVN/LPN license with an expiration date listed in the employee record, and the facility's punch-detail report showed LVN C worked multiple shifts over the reviewed period, including 11.1 hours, 11.08 hours, 11.93 hours, 11.17 hours, 12.07 hours, 9.07 hours, 5.0 hours, 10.92 hours, 3.03 hours, and 12.82 hours. During interview, the BOM stated she had checked LVN C's license and the expiration date was correct, but also stated LVN C was sent home the day before the interview when the facility checked her license and found it was expired. The BOM stated it was her responsibility to check nursing staff licenses and certificates, that she checked licenses upon hire, and that she had been trained to do so. The ADM stated the BOM was responsible for checking nursing staff licenses/certificates and expected all licensed individuals to be up to date when required. The facility policy required employees who need a license, certification, or registration to present verification prior to or upon employment and to provide recertification before expiration.
Kitchen Oven Door Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the kitchen oven door in safe operating condition. During the initial kitchen observation, the left oven door was opened and a cardboard square fell out from between the bottom of the stove and the top of the oven door. The oven door would not close properly and had about a two- to three-inch gap between the door and the stove. During interviews, kitchen and management staff stated the left oven door spring had been broken for about two to three weeks to about a month. Staff reported using a cardboard square and towels to help keep the door closed, and the Maintenance Supervisor and DM both acknowledged they knew about the broken oven door. The DM stated the facility had ordered a spring, but no invoice could be found, and the ADM stated the oven was expected to be operational and functional. Record review showed the facility’s Maintenance Service policy required maintenance of equipment in a safe and operable manner at all times.
Loose Handrail in Hall C
Penalty
Summary
The facility failed to ensure the hallway in C Hall between Rooms C3 and C4 had a handrail that was firmly attached to the wall. During an observation on 04/13/26 at 10:12 AM, the handrail in that hallway was noted to be loose and wobbly, rather than securely secured. The deficiency was identified for 1 of 6 hallways reviewed, specifically Hall C. During an interview on 04/14/26 at 1:35 PM, the Maintenance Supervisor stated he did not know about the handrail in C Hall or the water damage on the ceiling tiles, and said that if it was not written in the Maintenance logbook, then he did not know about it. The Maintenance Work Order Log from 3/16/26 to present contained no work orders related to the handrail between Rooms C3 and C4. The facility policy titled Maintenance Service states that maintenance service shall be provided to all areas of the building, grounds, and equipment, and that the maintenance department is responsible for maintaining the building in a safe and operable manner at all times.
Failure to Accurately Document Medication Administration in Resident Records
Penalty
Summary
The facility failed to ensure that medical records were maintained in accordance with accepted professional standards and practices, specifically regarding the accurate documentation of medication administration for eight residents. On a specific evening, a Certified Medication Aide (CMA) documented in the Medication Administration Records (MARs) that several residents had received their prescribed evening medications. However, unopened unit-dose medication packages labeled for these residents were later discovered in the medication cart, indicating that the medications had not been administered as documented. Interviews with staff revealed that the CMA responsible for the medication pass stated she had asked the residents if they would take their medications before opening the packages and, upon their refusal, did not administer the medications. She admitted to documenting the medications as given and later forgetting to update the MARs to reflect the refusals. The facility's policy required immediate documentation after medication administration, including reasons for any refusals, but this protocol was not followed. The ADON and other staff confirmed that the MARs inaccurately reflected that medications were administered when, in fact, they were not. The residents involved had significant medical histories, including dementia, mental health disorders, and other chronic conditions, and were prescribed various medications for these diagnoses. The failure to accurately document medication administration and refusals was identified through observation, record review, and staff interviews. The incident was discovered when another CMA found the unopened medications and reported the discrepancy, leading to an internal review and confirmation that the MARs did not accurately represent the care provided.
Unattended Unlocked Medication Cart Found in Hallway
Penalty
Summary
A deficiency was identified when a treatment cart containing medications, creams, and medical supplies was found unlocked and unsupervised in the hallway near the nurse's station. The cart was accessible to residents, and no staff were present to monitor it. Upon inspection with the charge nurse on duty, it was confirmed that prescription medications and other supplies were stored in the cart. The charge nurse acknowledged responsibility for the cart and stated she had been trained to keep it locked when unsupervised but was unsure why it was left unlocked at the time of observation. Interviews with facility leadership, including the ADON and ADM, confirmed that the facility's policy requires treatment carts to be locked at all times when unattended. Both leaders stated that staff are trained on this policy through in-services and that random checks are conducted to monitor compliance. Review of the facility's medication storage policy further supported the requirement for all drugs and biologicals to be stored in locked compartments when not in use, and that medication carts should not be left unattended while unlocked.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to provide information to residents and their representatives regarding their rights related to filing grievances or concerns. This deficiency was identified for 12 out of 21 confidential residents. These residents reported during a Resident Council meeting that they did not have access to the grievance form, were unaware of the option to file grievances anonymously, and had not been informed about the grievance procedure during council meetings. Additionally, they had not seen any postings of the grievance procedure in prominent locations within the facility. Upon reviewing the facility's grievance policy, it was noted that the policy required a copy of the grievance/complaint procedure to be posted on the resident bulletin board. However, observations revealed that the facility did not include instructions regarding the grievance procedure in any of the prominent postings. Furthermore, grievance forms were not readily available, and there was no provision for submitting grievances anonymously. An interview with the Administrator (ADM) revealed that he was the grievance officer responsible for reviewing grievances and assigning them to department heads. The ADM stated that grievance forms were kept at the nurses' station and in his office, but residents would need to know to ask for them. The ADM also mentioned that there was no procedure for residents to submit grievances anonymously. The ADM was unaware that the grievance procedure was not being discussed in Resident Council meetings, indicating a lack of communication and training regarding the grievance process.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. In the walk-in refrigerator, several food items, including a Styrofoam cup covered with tin foil, a bag of shredded cheese, and a pie, were found without labels or dates. Additionally, personal items such as a jacket and a drink were improperly stored in the pantry alongside food items, which could lead to cross-contamination. These observations indicate a lack of compliance with the facility's policy that requires all refrigerated and frozen foods to be covered, labeled, and dated. Furthermore, the facility did not maintain proper food temperatures during service. A staff member, identified as [NAME] A, measured the temperature of pureed chicken on the steam table and found it to be 103.4 degrees Fahrenheit, which is below the required safe temperature of 135 degrees Fahrenheit. Despite acknowledging the need to reheat the food, the staff member proceeded to prepare and serve the meal without reheating it. Interviews with the Dietary Manager (DM) and the Administrator (ADM) confirmed that all staff had been trained on proper food storage and reheating procedures, yet these protocols were not followed, potentially exposing residents to foodborne illnesses.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A and LVN B. CNA A did not perform hand hygiene while assisting three residents with their meals. During a dining observation, CNA A was seen moving between residents, providing spoonfuls of food, and using napkins to clean residents' mouths without using alcohol-based hand sanitizer (ABHS) or washing hands with soap and water. This lack of hand hygiene was confirmed during an interview with CNA A, who admitted to not consistently using ABHS between assisting different residents. LVN B also failed to adhere to proper infection control practices during wound care for a resident. LVN B did not perform hand hygiene before donning clean gloves after removing soiled dressings from the resident's foot. This was observed during a wound care session, and LVN B acknowledged the lapse in hand hygiene during an interview, stating she had been trained on the importance of washing hands between glove changes but did not remember the last in-service training. The Director of Nursing (DON), who also serves as the infection preventionist, was unsure of the last hand hygiene training for the nursing staff, although it should occur quarterly. The facility's policies clearly outline the importance of hand hygiene before and after resident contact and between glove changes. However, the observed practices of CNA A and LVN B did not align with these policies, potentially placing residents at risk for infection and cross-contamination.
Facility Fails to Maintain Functional and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. Observations revealed that several hand sinks and toilets were not operational over a period of three days. Specifically, the hand sink in room D5 and the women's restroom near the nurse's station had standing water that continued to rise when the water was turned on. Additionally, the toilet in room A6 was full of feces and could not be flushed, and the toilet and hand sink in room A8 were also nonfunctional, with standing water observed in the sink basin. Interviews with the Maintenance Supervisor (MS) and housekeeping staff indicated a lack of communication and reporting regarding the plumbing issues. The MS was informed of the issues on February 10, 2025, and attempted to address them with a plunger. It was discovered that the plumbing lines were clogged on three of six hallways, and clothing items were found in the plumbing lines, which were believed to be the cause of the clogs. The MS stated that there was no prior report of the plumbing issues in the maintenance log, and emphasized the importance of immediate reporting of such concerns to prevent safety and sanitation risks. The Administrator (ADM) and housekeeping staff were unaware of the extent of the plumbing issues until the survey. The ADM stated that maintenance requests should be recorded in the maintenance log and addressed promptly. The facility's policy on maintenance service, revised in December 2009, outlines the responsibility of the maintenance department to keep the building in a safe and operable condition. However, the lack of timely reporting and resolution of the plumbing issues led to an environment that was nonfunctional, unsanitary, and potentially unsafe for residents and staff.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that a resident was treated with respect, dignity, and care, which compromised the resident's quality of life. The resident's room was not cleaned daily, lacked a window covering, and did not have a privacy curtain. These deficiencies were observed during a survey, where the resident's room was found in disarray with a strong smell of feces and urine, trash and clothing scattered on the floor, and no sheets on the mattress. The resident's call light was out of reach, and the window was uncovered, exposing the resident to the outside view. The resident, who had a history of mental health issues including schizoaffective disorder and was legally blind, often refused care and had a behavior of destroying items in her room. Despite these challenges, the facility did not document any refusal of care or destruction of property in the resident's care plan. Interviews with staff revealed that the resident frequently refused to allow staff to clean her room and had a history of pulling down blinds and privacy curtains. However, there was no documentation in the care plan to address these behaviors or to justify the absence of window coverings and privacy curtains. Interviews with various staff members, including the administrator, director of nursing, and hospice staff, highlighted a lack of communication and follow-up on the resident's refusals of care. The facility's policy required staff to document refusals and attempt to provide care later, but this was not consistently done. The absence of window coverings and privacy curtains was acknowledged as a privacy concern, yet no effective solution was implemented to ensure the resident's dignity and privacy were maintained.
Failure to Provide Accessible Call Light System for Resident
Penalty
Summary
The facility failed to ensure that Resident #2 had a working communication system within reach, which would allow her to call for assistance when needed. Observations revealed that the call light cord and button were consistently wrapped and tied up against the wall, out of the resident's reach. This was noted during multiple observations over several days, despite the resident's care plan indicating that the call light should be within reach to prevent falls and ensure safety. Resident #2, who is legally blind and has a severely impaired cognitive status, was observed in her room with the call light out of reach on numerous occasions. Interviews with staff, including CNAs and RNs, confirmed that the call light was supposed to be within the resident's reach. However, it was noted that the resident had a history of pulling the call light cord out of the wall, which may have contributed to the staff's decision to keep it out of reach. Despite the resident's history of destructive behavior and the potential risk of self-harm, the facility's policy required that residents have access to a call system to request assistance. The failure to provide Resident #2 with a reachable call light system compromised her ability to call for help, which could have led to negative outcomes, such as falls or other emergencies, going unaddressed.
Failure to Maintain a Safe and Clean Environment for a Resident
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, leading to a deficiency in housekeeping and maintenance services. The resident's room was observed to be in a state of disarray, with a strong smell of feces and urine, clothing, trash, and pullups scattered on the floor, and no window coverings or privacy curtains. The room lacked basic furnishings such as a dresser, and the toilet was clogged with feces. These conditions were observed during a state survey, and interviews with staff revealed that the resident often refused to allow staff to clean her room and had a history of destroying property. The resident involved had a complex medical history, including cognitive impairments, schizoaffective disorder, and legal blindness, which contributed to her behaviors of refusing care and destroying her room. Despite these challenges, the facility staff were expected to maintain a clean and safe environment. However, the report indicates that there was a lack of consistent documentation of the resident's refusals and behaviors, and staff did not always follow up to ensure the room was cleaned when the resident was not present. Interviews with various staff members, including housekeeping, CNAs, and nursing staff, highlighted a lack of communication and coordination in addressing the resident's needs. Housekeeping staff were aware of the resident's behaviors but did not consistently clean the room multiple times a day as needed. Nursing staff were expected to document refusals and ensure the room was cleaned, but this was not consistently done. The facility's management acknowledged the issues but had not implemented effective strategies to address the resident's behaviors and maintain a sanitary environment.
Inaccurate PASRR Level I Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I assessment. This deficiency was identified for one of the six residents reviewed for PASRR screening, specifically for Resident #16. The resident did not have an accurate and updated PASRR Level I assessment reflecting a diagnosis of mental illness, which could place residents at risk for not receiving necessary care and services. Resident #16, a male with multiple diagnoses including Type 2 Diabetes, Generalized Anxiety Disorder, Major Depressive Disorder, and Intermittent Explosive Disorder, was admitted to the facility without an accurate PASRR Level I assessment. The resident's care plan and physician's orders indicated active diagnoses of mental illness, yet the PASRR Level I form dated April 23, 2015, incorrectly stated that the resident did not have a mental illness. This discrepancy was not addressed, and no additional PASRR screenings were provided by the facility for Resident #16. Interviews with facility staff, including the Vice President of Operations (VPO) and the Administrator (ADM), revealed a lack of awareness and oversight regarding the accuracy of Resident #16's PASRR Level I screening. Both acknowledged the importance of having an accurate PASRR Level I to ensure residents have access to necessary services, yet they could not specify the potential negative outcomes of an inaccurate assessment. The facility's policy on admission criteria requires all new admissions to be screened for mental disorders, but this was not effectively implemented for Resident #16.
Failure to Provide Scheduled Activities
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, which affected the physical, mental, and psychosocial well-being of several residents. Observations and interviews revealed that scheduled activities often did not occur, and no alternative activities were offered when cancellations happened. This lack of engagement left residents feeling let down and bored, as they were not able to participate in activities that they looked forward to, such as meditation, poker tournaments, and bowling. Resident #20, a cognitively intact male with diabetes, heart failure, and anemia, expressed disappointment and boredom due to the lack of scheduled activities. He mentioned that the Activities Director (AD) was often unavailable to conduct activities because she was pulled away to perform other duties. Similarly, Resident #24, a cognitively intact female with heart failure, muscle weakness, and hypertension, noted that activities were frequently canceled, and the AD was busy with other tasks, such as shopping for residents and fundraising. Resident #59, who is severely cognitively impaired, also reported that activities did not occur as scheduled, leading to disappointment. The facility's activity calendar policy requires activities to be scheduled seven days a week, including holidays, and displayed in high-visibility areas. However, observations showed that activities like meditation and poker tournaments were not conducted as planned, and residents were left waiting without any communication from the AD. The AD admitted to being overwhelmed with various tasks and not announcing cancellations or arranging for other staff to cover activities. This failure to adhere to the activity schedule and provide alternative options when necessary resulted in a deficiency in meeting the residents' needs for engagement and social interaction.
Menu Deviations in Lunch Services
Penalty
Summary
The facility failed to adhere to the prescribed menus for two consecutive lunch services, which were observed on February 10 and February 11, 2025. On February 10, the lunch served included cilantro lime chicken, mashed potatoes, beans, fruit cocktail, and a beverage, deviating from the planned menu of cilantro lime chicken, rice pilaf, charro beans, tortilla chips, salsa, dessert empanada, and a beverage. On February 11, the lunch served was beef goulash, squash medley, mixed green salad, baked cookie, and a beverage, which matched the planned menu except for the absence of biscuits, which were supposed to be served with margarine and dressing of choice. The Dietary Manager (DM) explained that substitutions were made due to a shortage of rice pilaf and the residents' preferences, such as substituting mashed potatoes for rice pilaf and hot sauce for salsa. Additionally, tortilla chips were not served as residents reportedly did not like them, and biscuits were omitted due to space constraints on the steam table, with sliced bread offered as an alternative. The DM acknowledged that these deviations could potentially lead to residents not receiving the proper nutrition and calories, which could result in weight loss. The facility's policy requires that any deviations from the posted menus be recorded and archived, but it is unclear if this was done in these instances.
Failure to Maintain Safe Storage of Residents' Food Items
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of residents' food items in personal refrigerators located in Rooms D6, D8, and E9. During observations, it was noted that none of these refrigerators had a temperature log present to monitor daily temperatures. The refrigerators contained perishable food items such as mayonnaise, cheese, milk, and cereal, some of which had illegible expiration dates or were past their sell-by dates. Interviews with staff revealed that housekeeping staff were responsible for checking the temperatures and cleaning the residents' personal refrigerators daily. However, there was no log maintained to ensure these checks were performed, and staff were not aware of the required temperature for the refrigerators. The staff acknowledged the importance of these checks to prevent residents from consuming spoiled food, which could lead to illness. The facility's policy on refrigerator and freezer maintenance required monthly tracking sheets for temperature recording and daily checks by designated employees. However, these procedures were not followed for the residents' personal refrigerators. Additionally, the facility's policy for foods brought by family members did not address the storage of such foods in personal refrigerators, further contributing to the oversight in ensuring food safety.
Inadequate Supervision Leads to Resident Burn Injury
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistive devices for a resident while smoking, leading to a burn injury. The resident, who had a severe cognitive impairment and a history of tremors, was observed smoking without the necessary supervision and safety measures in place. Specifically, the staff member assigned to monitor the resident was found to be on a cell phone instead of providing direct supervision, and the resident was not using a cigarette extender or smoking apron as required by her care plan. The resident's care plan clearly indicated the need for supervision while smoking, as well as the use of a smoking apron and cigarette extender to prevent injury. However, on the day of the incident, these interventions were not implemented. The resident sustained a burn to her left middle finger, which required medical treatment. Interviews with staff revealed that the monitor tech responsible for supervision was not attentive and failed to follow the protective measures outlined in the resident's care plan. The incident was not witnessed, and there was confusion regarding the presence of the resident's family member during the smoking session. The family member denied being present when the burn occurred, while the resident claimed otherwise. The facility's failure to provide adequate supervision and implement the necessary safety interventions resulted in the resident's injury, highlighting a significant lapse in the facility's adherence to its safety and supervision policies.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, as evidenced by the actions of two monitoring techs (MT A and MT B) towards a resident. The incident involved MT A aggressively handling the resident by pulling and jerking his hand from a handrail and subsequently pushing him down in his room. MT B, who witnessed the incident, failed to intervene or report the abuse immediately, which is a violation of the facility's abuse prevention policy. The resident involved had a complex medical history, including cognitive communication deficit, mood disorder, bipolar disorder, depression, generalized anxiety disorder, Parkinsonism, and mild cognitive impairment. At the time of the incident, the resident was noted to be severely impaired and required assistance with various activities of daily living. Despite these needs, the resident was able to walk independently but was considered a fall risk. The incident occurred when the resident was standing in the hallway holding onto a handrail, and the monitoring techs redirected him to his room in an aggressive manner. Interviews and video evidence revealed that MT A and MT B did not follow the resident's care plan, which included non-forceful redirection and engagement in conversation if the resident displayed wandering or aggression. Instead, MT A used excessive force, and MT B did not report the incident until questioned about another matter. The facility's policies clearly state the need for immediate reporting of any signs of abuse or neglect, which was not adhered to in this case.
Failure to Implement Comprehensive Care Plan for Resident's Wound Care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple medical conditions, including high blood pressure, depression, type 2 diabetes, and bilateral above-the-knee amputations. The resident was cognitively intact, as indicated by a BIMS score of 14. Despite having physician orders for wound care, the care plan did not adequately address the treatment for the resident's left stump wound, which was a critical aspect of their care needs. During an observation, it was noted that the resident was sitting in a Geri chair with the left stump wound uncovered, contrary to physician orders that required the wound to be covered when the resident was out of bed. The wound was observed to have yellow crusting and some open areas, although there was no drainage. The LVN responsible for the resident's wound care was unsure why the bandage was not in place and acknowledged that the absence of a bandage could potentially worsen the wound condition. Interviews with the LVN and the DON revealed a lack of clarity and adherence to the physician's orders regarding the resident's wound care. The DON confirmed that the orders required the wound to be covered when the resident was out of bed but could not explain why this was not followed. The facility did not provide a policy for following physician orders or care plans, indicating a gap in ensuring compliance with prescribed care protocols.
Failure to Adhere to Wound Care Protocols
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in wound management. The resident, a cognitively intact female with a history of high blood pressure, depression, type 2 diabetes, heart attack, and bilateral leg amputations, was observed with an uncovered wound on the left stump while sitting in a Geri chair. The physician's orders required the wound to be covered when the resident was out of bed, but this was not adhered to, as evidenced by the observation of the wound being exposed with yellow crusting and some open areas. Interviews with the resident revealed that the staff frequently neglected to cover the wound, causing discomfort and concern for potential injury. The resident expressed a preference for the wound to be covered for comfort and safety, but had not communicated this to the staff, assuming they were aware of the proper care procedures. The LVN responsible for changing the wound dressings was unsure why the wound was uncovered and acknowledged that the bandage should be applied when the resident was out of bed. The Director of Nursing (DON) confirmed the physician's orders for the wound to be covered and recognized the potential negative outcomes of not following these orders, including adverse events. The facility's wound care policy outlined specific procedures for wound management, but these were not followed in this instance, leading to the deficiency in care for the resident's pressure ulcer.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed in the care of a resident. The resident, a cognitively intact female with multiple medical conditions including high blood pressure, diabetes, and pressure ulcers, was found to be using an oxygen humidification bottle that had not been changed since February, despite facility policy requiring weekly changes. This oversight was acknowledged by the LVN responsible for changing the bottles, who admitted uncertainty as to why the change had not occurred. Additionally, during incontinent care, two CNAs failed to adhere to proper hand hygiene and PPE protocols. They did not wash their hands before or during the care process, and they used the same gloves throughout the procedure, which included handling a mechanical lift and changing the resident's brief. The CNAs also neglected to use the appropriate PPE, such as gowns, despite the resident being on barrier precautions due to wounds. Furthermore, an LVN did not follow proper hand hygiene or PPE protocols during wound care for the same resident. The LVN did not wash hands or use hand sanitizer before gathering supplies or during the wound care process. The LVN also failed to wear a gown, which was required due to the resident's barrier precautions. These lapses in infection control practices were acknowledged by the staff involved, who cited being in a hurry or focused on other tasks as reasons for their non-compliance.
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What surveyors actually found near you
We read the 24 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brownfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brownfield Rehabilitation And Care Center | 0.8 mi | ★★★★★ | 10 | 0 |
| Lynwood Nursing And Rehabilitation | 16.3 mi | ★★★★★ | 14 | 1 |
| Levelland Nursing & Rehabilitation Center | 29.3 mi | ★★★★★ | 10 | 1 |
| Crown Point Health Suites | 30.1 mi | ★★★★★ | 7 | 0 |
| Hansford County Hospital District Dba Lakeridge Nu | 31.2 mi | ★★★★★ | 12 | 0 |
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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.