Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brownsville Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with advanced dementia continued to receive Depakote despite repeated requests from the resident's representative to discontinue the medication. The DON did not stop the medication immediately, citing the need to consult with the PCP, and conflicting accounts emerged regarding communication with medical providers. Facility staff interviews revealed inconsistent understanding and lack of policy on handling requests to stop medications, resulting in the resident's right to refuse treatment not being upheld.
A resident with Alzheimer's disease and dementia was started on Depakote for mood disorder, but the care plan was not updated to reflect this new intervention as required by facility policy. Staff interviews and documentation confirmed that the care plan was not revised after the medication was initiated, despite procedures mandating such updates for psychoactive medications.
A resident with Alzheimer's Disease and dementia did not receive care in accordance with professional standards when the facility failed to consult the physician before discontinuing Depakote at the request of the resident's representative. The DON was unable to reach the physician's office over the weekend and did not document any follow-up, and the resident's representative was not updated about the resident's status or change in condition.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Multiple residents with infections or indwelling devices did not receive proper infection control precautions, including lapses in contact isolation and Enhanced Barrier Precautions. Staff were observed not wearing required PPE, not following hand hygiene protocols, and misunderstanding when to apply gowns and gloves, despite facility policies referencing CDC guidelines.
Two residents with severe cognitive impairment were found to have an unlabeled bottle containing a strong chemical substance left hanging on the handrail in their shared bathroom. Staff were unaware of the bottle's origin, and it was not labeled or secured as required. Both residents required a structured, secure environment due to dementia and cognitive deficits, and the facility lacked a specific policy on chemical labeling or storage in resident areas.
A deficiency was cited when a resident was not provided with enough food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
A resident with multiple chronic conditions was observed receiving oxygen at 3 LPM via nasal cannula, contrary to the physician's order for 2 LPM. The resident was unaware of the correct setting, and the assigned LVN confirmed the discrepancy, stating she had previously set it correctly and was unsure who changed it. The DON indicated that nurses are responsible for checking oxygen settings per shift and following orders, but the facility lacked a specific policy for oxygen administration.
A medication cart on the 400 Hall was found unlocked and unattended while the assigned Med-Aide was off the unit. Staff interviews confirmed knowledge of the requirement to keep medication carts locked when not in use, and facility policy mandates that carts remain secured at all times when unattended.
A resident with severe cognitive impairment and dysphagia was served a mechanically altered meal instead of the physician-ordered pureed diet and nectar thickened liquids. Staff failed to identify the error before serving, despite clear dietary orders and care plan documentation. The facility's tray-checking procedures and staff oversight were insufficient, resulting in the resident receiving an inappropriate meal and experiencing coughing during the meal.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not report alleged abuse, neglect, and resident-to-resident altercations to the State Survey Agency within required timeframes. For example, a resident's serious injury from a fall was not reported until after a second x-ray confirmed the fracture, and multiple altercations and unwitnessed injuries involving two residents were not reported as required. Staff interviews revealed inconsistent understanding of reporting protocols, and the facility's policy for immediate reporting was not consistently followed.
The facility did not properly safeguard resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors. This lapse involved inadequate protection and management of confidential information and documentation.
Two residents were administered psychoactive medications, including antipsychotics and anxiolytics, without obtaining proper informed consent from their representatives as required by policy. In both cases, medications were given before consent forms were signed or completed, and in one instance, a consent form was missing entirely. Staff interviews confirmed that the required process for obtaining and documenting consent was not consistently followed.
A resident with severe cognitive impairment and multiple diagnoses was administered Haldol for agitation without a documented psychiatric evaluation, despite facility policy and staff statements requiring such an assessment prior to antipsychotic use. Progress notes and interviews confirmed the absence of the required evaluation before the medication was given.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions. Review of documentation showed incomplete planning and insufficient detail to ensure comprehensive care.
The facility did not complete the care plan within 7 days of the comprehensive assessment and failed to ensure it was prepared, reviewed, and revised by a team of health professionals as required.
A resident did not receive sufficient food and fluids to maintain their health, as required. The report identifies a failure to meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
A resident with severe cognitive impairment and no documented behavioral symptoms was administered Haldol without a valid physician's order or documented indication for use. The medication was given based on a verbal order from a nurse practitioner, but the order was not entered into the MAR and lacked required details. Staff interviews confirmed that the order was incomplete and not properly verified before administration, contrary to facility policy.
A resident with severe cognitive impairment and no documented behavioral symptoms was administered Haldol without an approved psychiatric diagnosis or informed consent, despite pharmacy consultant recommendations. Staff interviews and record reviews confirmed that required evaluations and documentation were not completed prior to the administration of the antipsychotic, in violation of facility policy.
A resident with dementia and no documented behavioral symptoms was administered Haldol, an antipsychotic, without a clear clinical indication or proper documentation. The order for the medication was inconsistently recorded, and staff interviews revealed confusion about its origin and lack of required behavioral assessments or psychiatric evaluation. Facility policy requiring informed consent and documentation prior to psychotropic use was not followed.
A resident with diabetes and multiple wounds was readmitted without physician orders for blood glucose monitoring or wound care. The LPN did not request clarification or initiate orders for these needs, resulting in the resident going several days without blood sugar checks or wound treatment. The resident experienced a hypoglycemic episode requiring hospital transfer, and wound care was delayed until several days after admission. Staff interviews revealed a lack of communication and unclear policies regarding diabetic and wound care procedures.
A resident was readmitted with multiple wounds and diabetes but did not receive timely wound care or blood sugar monitoring due to incomplete assessment, lack of communication with the NP, and failure to obtain necessary orders. The resident went five days without wound care and blood sugar checks, resulting in an episode of hypoglycemia that required hospital transfer. Staff did not follow facility policy or professional standards in documenting and reporting the resident's condition.
Three residents with complex medical needs, including diabetes and wounds, had incomplete documentation in their medical records. Nursing staff failed to sign off on physician-ordered treatments and medications, such as wound care and insulin administration, on the TAR and MAR. Staff interviews revealed that treatments were often provided but not documented due to forgetfulness or misunderstanding of documentation requirements, despite prior training and facility policy mandating accurate and timely recordkeeping.
The facility failed to develop comprehensive care plans for four residents, omitting critical details such as wound care, diet, and medication needs. A resident's care plan did not include necessary wound care instructions, while two others lacked information on diet and medication requirements despite having specific physician orders. Staff interviews confirmed these omissions, highlighting oversight and staffing issues in care plan management.
The facility failed to obtain and input orders for crushed medications for two residents, despite their dietary needs indicating a requirement for such orders. Staff relied on residents' diets to determine the need for crushed medications, leading to inconsistencies in administration. The Director of Nursing acknowledged the oversight and the necessity of having formal orders in place to prevent potential risks.
A LTC facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for four residents. A resident was found with medications left on their bedside table, and several medications were not signed off on the MAR for three other residents. Staff interviews revealed procedural lapses and personal issues contributing to these errors, highlighting deficiencies in medication handling and documentation.
The facility failed to ensure call lights were within reach for two residents with mobility impairments, risking their ability to call for assistance. Observations revealed call lights on the floor, and staff interviews confirmed the importance of accessibility, which was not maintained as per facility policy.
A facility failed to document a resident's advance directives, resulting in the absence of a code status in their records. The resident, with moderate cognitive impairment and multiple medical conditions, was defaulted to full code status due to missing DNR paperwork. Interviews with staff revealed inconsistencies in handling advance directives, with the admission nurse admitting to possibly forgetting to enter the code status.
A facility failed to complete a baseline care plan within 48 hours of a resident's admission, specifically omitting the advance directive section. The resident, with moderately impaired cognition and multiple medical conditions, had no documented code status, leading to potential misalignment with their end-of-life wishes. Staff interviews revealed confusion over responsibilities for entering and managing code status information, contributing to the deficiency.
A facility failed to update a comprehensive care plan for a resident with Alzheimer's disease, who was at high risk of elopement and placed in a secured unit. The care plan did not reflect this placement, despite the resident's severely impaired cognition. Interviews with staff revealed the omission was an oversight, with no negative outcomes reported.
A resident with severe cognitive impairment and an indwelling urinary catheter was found with catheter tubing touching the floor, contrary to care plan instructions. Interviews with staff revealed a lack of adherence to proper catheter care protocols, posing an infection control issue.
Two residents in the facility did not receive oxygen therapy according to physician orders. One resident with acute respiratory failure and other conditions received oxygen at 3.5 Lpm instead of the ordered 2 Lpm. Another resident with metabolic encephalopathy and hypoxia had oxygen set at 2.5 Lpm instead of 3.0 Lpm. Observations revealed that the oxygen machines were not set correctly, despite the facility's policy requiring adherence to physician orders and professional standards.
Two residents with histories of falls were not accurately coded in the MDS, potentially risking improper care. One resident with dementia and Parkinson's disease had an unwitnessed fall not recorded in the MDS. Another resident with Alzheimer's disease had two falls, including a witnessed fall with a minor injury, which were also not coded. The MDS Nurse and DON acknowledged these oversights, indicating a lapse in the assessment process.
Failure to Honor Resident's Right to Refuse Medication
Penalty
Summary
The facility failed to honor a resident's right to refuse or discontinue treatment, specifically regarding the administration of Depakote, an antipsychotic medication. The resident in question was a male with Alzheimer's disease and unspecified dementia, who was unable to communicate effectively and required significant assistance with daily activities. Despite the resident's representative (RP) explicitly requesting that Depakote be discontinued, the medication continued to be administered. The RP stated that she had not given consent for Depakote and had communicated her wishes to stop the medication during a care plan meeting attended by family members and facility staff. However, documentation of this request was not reflected in the care plan notes, and the medication was not discontinued following the RP's request. When the RP contacted the Director of Nursing (DON) to reiterate her request to stop Depakote, the DON informed her that verbal consent had previously been obtained and that the medication would not be discontinued until the primary care provider (PCP) could be consulted. The DON attempted to contact the PCP's office, but it was closed for the weekend. The DON then claimed to have spoken with a nurse practitioner (NP), who allegedly advised against discontinuing the medication until the PCP could be reached. However, subsequent interviews revealed that the NP was out of town and did not speak with the DON, and no discontinuation order was given. The RP made further attempts to communicate with the DON but did not receive a response. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Administrator, and other nurses, revealed a lack of clear policy or consistent practice regarding honoring a resident or RP's request to stop a medication. Some staff believed the medication should be placed on hold and the physician notified, while others deferred to the physician's decision even if the RP requested discontinuation. The facility's policy on resident rights emphasized the right to refuse treatment, but there was no specific policy addressing the process for discontinuing medications at the request of a resident or their representative.
Failure to Revise Care Plan After Initiation of Psychoactive Medication
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident following the initiation of Depakote, an antiseizure medication prescribed for mood disorder. The resident, an elderly male with Alzheimer's disease and unspecified dementia, was admitted with significant cognitive and functional impairments, including being always incontinent, requiring maximal assistance with activities of daily living, and having unclear speech. Despite a new order for Depakote being initiated and later discontinued and re-initiated, there was no evidence that the resident's care plan was updated to reflect this change in medication as required by facility policy. Interviews with facility staff confirmed that the standard practice was for the nurse receiving the medication order to update the care plan, and that psychoactive medications should be care planned upon initiation. Documentation showed that while the medication and its purpose were discussed in a care plan meeting with the resident's representative and family, the actual care plan was not revised to address the new intervention. Facility policies required care plan updates upon status changes and initiation of psychoactive medications, but these procedures were not followed in this instance.
Failure to Consult Physician for Medication Discontinuation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not consult with the resident's physician regarding the discontinuation of Depakote at the request of the resident's representative. The resident, who had diagnoses including Alzheimer's Disease and unspecified dementia, was dependent on staff for most activities of daily living and was unable to communicate effectively. The medication administration record showed that Depakote was administered as ordered until the day the resident refused a dose and later became unresponsive. Documentation revealed that the Director of Nursing attempted to contact the primary care provider's office for discontinuation orders but was unable to reach them as the office was closed for the weekend. There was no follow-up note indicating that further action was taken to obtain the necessary physician orders for discontinuation. The resident's representative reported not being updated by the facility and only learned of the resident's unresponsiveness and subsequent death after calling to follow up. The facility's charge nurse job description included the responsibility to communicate with the resident's point of contact regarding status updates or changes in condition, which was not documented as having occurred in this case.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Implement and Enforce Infection Control Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices for three residents. For one resident with ESBL and MRSA infections, staff did not enforce proper contact precautions. The resident was observed repeatedly leaving and entering his room while on contact isolation, and was allowed to share a room with another resident not on precautions, despite available single rooms. Facility leadership and infection control personnel acknowledged the lack of a specific contact isolation policy and relied on CDC guidelines, but did not consistently implement them. Another resident with MRSA in the urine and a history of multiple infections was not properly protected by staff adherence to contact isolation protocols. A CNA was observed in the resident's room without wearing any PPE, touching surfaces and the resident's belongings, and failing to perform hand hygiene after contact. The CNA admitted to not knowing the specific reason for isolation and not wearing PPE because he believed he was not in direct contact with the resident. Interviews with other staff revealed inconsistent understanding of isolation procedures and hand hygiene requirements. A third resident, who required Enhanced Barrier Precautions (EBP) due to a cholecystectomy drain, did not receive appropriate infection control measures during blood sugar checks and insulin administration. The nurse wore gloves but failed to don a gown as required by EBP protocols, despite signage and facility policy. Interviews with the nurse and DON confirmed a misunderstanding of when gowns were required under EBP, and that training had been provided but was not effectively implemented. Facility policies referenced CDC guidelines and EBP requirements, but staff actions did not consistently align with these standards.
Unlabeled Chemical Left in Shared Bathroom of Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that the environment remained free of accident hazards for two residents with severe cognitive impairment who shared a bathroom. During an observation, an unlabeled bottle containing a clear liquid with a strong chemical odor was found hanging on the handrail in the shared bathroom. Staff interviews revealed that no one knew the origin of the bottle, and it was unclear whether it belonged to the residents, housekeeping, or a family member. The bottle was not labeled, and staff acknowledged that chemicals should not be left in resident areas, especially in unlabeled containers. Record reviews indicated that both residents required a structured environment in a secure unit due to diagnoses of Alzheimer's disease, unspecified dementia, and cognitive communication deficits, with severely impaired cognition as evidenced by low BIMS scores. The facility's Safety Data Sheet for a disinfectant/detergent cleaner described the chemical as causing severe skin and eye burns and being harmful if swallowed or in contact with skin, with instructions to store it locked up. The facility did not have a specific policy on labeling chemicals or keeping them out of resident rooms, contributing to the deficiency.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide sufficient food and fluids to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is necessary to support the resident's overall well-being. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Administer Oxygen at Physician-Ordered Setting
Penalty
Summary
A resident with multiple diagnoses, including abnormal lung findings, dementia, congestive heart failure, chronic kidney disease, muscle wasting, type 2 diabetes, dysphagia, and hypertension, was admitted with a physician order for oxygen therapy at 2 liters per minute (LPM) via nasal cannula. The resident's care plan included interventions to address the risk for altered respiratory status, specifying that oxygen should be administered as ordered. During an observation, the oxygen concentrator was found set at 3 LPM instead of the ordered 2 LPM. The resident was in bed with the head of the bed slightly elevated and showed no signs of respiratory distress at the time of observation. The resident was unaware of the correct oxygen setting and did not recall the nurse checking the oxygen machine, although he stated the nurse had been in his room earlier. The assigned nurse confirmed the oxygen was set at 3 LPM and acknowledged the physician's order was for 2 LPM. She reported having checked the setting earlier in her shift and was unsure who may have changed it, noting the resident had received a nebulizer treatment that morning. The DON stated that nurses are responsible for checking oxygen settings once per shift and following physician orders, but also revealed that the facility did not have a specific Oxygen Administration Policy. Facility policy on medication administration required medications to be given as ordered.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medication cart assigned to the 400 Hall Med-Aide was observed to be unlocked and unattended. The Med-Aide responsible for the cart was not present on the unit at the time of the observation. This was confirmed through interviews with the Med-Aide, who acknowledged awareness of the requirement to lock the medication cart when not in use, and with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), both of whom stated that medication carts should always be locked when unattended to prevent unauthorized access. A review of the facility's policy on medication administration and cart security, dated 10/01/19, indicated that medication carts are to be locked at all times when not in use and should not be left unlocked or unattended in resident care areas. The failure to secure the medication cart as per policy was directly observed and confirmed by staff interviews and policy review.
Failure to Provide Prescribed Pureed Diet to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered pureed diet and nectar thickened liquids was served a mechanically altered meal instead of the prescribed pureed texture. The resident, who had a history of stroke, muscle wasting, dysphagia, non-traumatic brain dysfunction, Alzheimer’s, aphasia, and severe cognitive impairment, was observed coughing after consuming the incorrect food texture. Her meal ticket clearly indicated the need for a pureed diet, but her plate contained chopped carrots, mashed potatoes, and cut-up chicken, which did not meet her dietary requirements. Nursing staff, including an RN and the ADON, acknowledged that the resident received the wrong food texture and that the error was not identified before the meal was served. The RN admitted to overlooking the pureed texture requirement on the tray card and stated that she should have returned the tray to the kitchen immediately. The process for checking trays involved both kitchen staff and nurses, but the system failed to prevent the delivery of the incorrect meal. The RN also mentioned that the resident had been refusing her pureed diet, was edentulous, and did not want to wear dentures, but these factors were not adequately addressed in the care plan or during meal service. The facility’s kitchen policy required that Nutrition & Foodservice staff check each resident’s tray card to ensure the correct diet and portion sizes, and that nurses verify trays before serving. However, interviews revealed that trays were sometimes mixed up, and the required in-services and oversight by the Registered Dietitian were lacking at the time of the survey. The absence of proper checks and adherence to dietary orders led to the resident receiving an inappropriate meal, as documented by both staff interviews and direct observation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Alleged Abuse, Neglect, and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, or mistreatment to the State Survey Agency as required by regulation. Specifically, the facility did not report within the mandated two-hour timeframe when a resident sustained a serious bodily injury, nor did it report multiple resident-to-resident altercations and unwitnessed injuries within the required period. For example, one resident experienced a fall resulting in an acute distal fibular diametaphyseal fracture, but the incident was not reported to the state until after a second x-ray confirmed the injury, despite the initial x-ray already indicating a fracture. Additionally, the facility did not report two separate resident-to-resident altercations involving physical contact and aggression. In one instance, two residents engaged in a physical altercation where one struck the other, causing the second resident to stumble and then push back. These incidents were documented in progress notes and care plans, but there was no evidence that they were reported to the State Survey Agency as required. Furthermore, the facility failed to report several unwitnessed injuries and falls, including bruising, skin tears, and bumps to the head, for another resident who had a history of behavioral disturbances and unexplained injuries. Interviews with staff, including LVNs, the DON, and the Administrator, revealed inconsistent understanding and application of reporting requirements. Staff often waited for confirmation from a nurse practitioner or physician before reporting injuries, even when initial evidence suggested a serious injury had occurred. The facility's own policy required immediate reporting of all alleged violations, including those involving resident-to-resident altercations and injuries of unknown origin, but these procedures were not consistently followed.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices, which revealed lapses in the protection and management of confidential resident information and medical documentation. Specific details regarding the nature of the records or the residents affected were not provided in the report. The deficiency centers on the facility's failure to adhere to established protocols for handling and securing medical records, resulting in noncompliance with regulatory requirements for resident privacy and record maintenance.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided consent prior to the administration of psychoactive medications, as required by both facility policy and state regulations. In one instance, a resident with severe cognitive impairment and a history of dementia and traumatic brain injury was prescribed and administered Haldol, an antipsychotic medication, for agitation without obtaining prior consent from the resident's representative. Documentation showed that the medication was administered before the consent form was signed, and the care plan was updated to reflect antipsychotic use only after the medication had already been given. Interviews with staff confirmed that consent should have been obtained before administration, but this process was not followed in this case. In another case, a resident with Alzheimer's disease and unspecified dementia was prescribed multiple psychoactive medications, including Zyprexa, Buspirone, Lorazepam, and Risperidone. Review of medical records revealed that these medications were administered before the required informed consent forms were signed and dated by the resident's guardian or responsible party. In some instances, consent forms were missing entirely or were not properly completed. Staff interviews confirmed that the process for obtaining and documenting consent was not consistently followed, and the DON acknowledged that medications had been administered prior to receiving the necessary consents. Facility policy requires that residents and their representatives be informed of the risks, benefits, and alternatives to psychoactive medications before initiation or dose increases, and that consent be documented in advance. However, record reviews and staff interviews demonstrated that these procedures were not adhered to for the residents in question. The lack of proper consent and documentation could affect the residents' right to self-determination and informed participation in their care.
Failure to Complete Required Evaluation Before Antipsychotic Administration
Penalty
Summary
The facility failed to ensure that a resident received an accurate assessment prior to the administration of an antipsychotic medication. Record review showed that the resident, who had diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a traumatic subdural hemorrhage, was not evaluated before being given Haldol Decanoate for aggressive behavior. The resident's admission MDS indicated severe cognitive impairment with no behavioral symptoms or indicators of psychosis, and there was no documentation of an evaluation prior to the initiation of the antipsychotic. Progress notes confirmed that the antipsychotic was ordered and administered without a prior psychiatric evaluation, and the care plan was updated to reflect the use of Haldol for agitation. Interviews with facility staff, including a physician assistant, LVN, and the DON, confirmed that an evaluation should have been completed before administering the medication, and that no such evaluation was documented. The facility's policy also required an evaluation and documentation prior to the use of psychotropic medications, which was not followed in this case.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all assessed needs or include clear, measurable goals and interventions.
Failure to Timely Develop and Review Care Plan by Interdisciplinary Team
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the required timeline and interdisciplinary team involvement were not met.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Ensure Proper Physician Order and Documentation for Antipsychotic Administration
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident, specifically regarding the administration of Haldol (an antipsychotic medication). A review of the resident's records showed that there was no physician's order for Haldol Decanoate, nor was there an indication for its use documented on the order. Despite this, progress notes indicated that a nurse practitioner had given a verbal order for Haldol for aggressive behavior, and a nurse documented administering the medication. However, the medication administration record (MAR) did not contain an order for Haldol, and the order lacked the required indication for use. The resident involved had a history of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a traumatic subdural hemorrhage. The admission Minimum Data Set (MDS) indicated severe cognitive impairment, with no behavioral symptoms or indicators of psychosis, and the resident was not previously receiving an antipsychotic. The care plan was later updated to reflect the use of antipsychotic medication for agitation, but this was after the medication had already been administered without a proper order. Interviews with facility staff revealed that the medical director was not aware of the Haldol order and would not have prescribed it. Nursing staff acknowledged that all necessary checks, including consent, diagnosis, and documentation, were required before administering antipsychotics, and the Director of Nursing confirmed that the order was incomplete and not properly verified before administration. The facility's medication administration policy required verification of orders and documentation on the MAR, which was not followed in this instance.
Failure to Act on Pharmacist Recommendations for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that drug regimen irregularities reported by the consultant pharmacist were acted upon for a resident whose medications were reviewed. Specifically, recommendations from the pharmacy consultant regarding the use of Haldol, an antipsychotic medication, were not followed. The consultant pharmacist had recommended that an approved psychiatric diagnosis be documented to support the continued use of Haldol and that an informed consent form be obtained and placed in the resident's medical record. However, the medical record did not contain the required consent for Haldol until several months after the medication was ordered, and there was no documentation of a psychiatric evaluation to justify its use during that period. The resident involved had a history of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a traumatic subdural hemorrhage. The resident was admitted and re-admitted to the facility, and the Minimum Data Set (MDS) indicated severe cognitive impairment with no behavioral symptoms or indicators of psychosis. Despite this, Haldol was ordered and administered without the necessary supporting documentation, including a psychiatric evaluation and informed consent, as required by facility policy and regulatory guidelines. Interviews with facility staff, including the physician assistant, licensed vocational nurses, and the director of nursing, confirmed that the required evaluation and consent were not obtained prior to the administration of Haldol. Staff acknowledged that the proper procedures were not followed, and the documentation in the medical record was incomplete regarding the rationale for the use of the antipsychotic medication. Facility policies reviewed also emphasized the need for appropriate diagnosis, consent, and documentation when administering psychotropic medications, which were not adhered to in this case.
Unnecessary Antipsychotic Administration Without Indication or Documentation
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, specifically regarding the administration of Haldol (an antipsychotic) without an adequate indication for use. The resident in question had diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a history of traumatic subdural hemorrhage. Despite the absence of documented behavioral symptoms or psychosis, a new order for Haldol Decanoate 50mg IM monthly was initiated for 'aggression behavior,' but there was no supporting documentation of such behaviors in the resident’s records. Review of the resident’s medical records revealed inconsistencies and lack of clarity regarding the Haldol order. The medication was administered on at least two occasions, but the order was not consistently present on the Medication Administration Record (MAR), and there was no documented indication for use from the time the order was written through several months afterward. Interviews with facility staff, including the prescribing provider and the DON, revealed confusion about the origin of the order, with the primary physician denying knowledge of or responsibility for the prescription. Staff also confirmed that the required behavioral assessments and psychiatric evaluations were not completed prior to administration, and that the resident did not exhibit behaviors warranting antipsychotic use. Additionally, the facility’s policy required informed consent and documentation of risks, benefits, and alternatives prior to initiating psychotropic medications, especially those with black box warnings. While a consent form was eventually signed by the resident’s representative, this occurred months after the initial administration of the medication. The lack of proper documentation, absence of a clear clinical indication, and failure to follow facility policy led to the administration of an unnecessary antipsychotic medication to a resident.
Failure to Obtain Admission Orders for Blood Sugar Checks and Wound Care
Penalty
Summary
A deficiency occurred when a resident with a history of type 2 diabetes mellitus, chronic heart failure, and multiple skin impairments was readmitted to the facility without physician orders for immediate care, specifically for blood sugar checks and wound care. Upon readmission, the resident did not have orders in place for blood glucose monitoring, despite being prescribed oral diabetic medications. The lack of blood sugar checks persisted for five days, during which the resident experienced a hypoglycemic episode with a blood sugar reading of 50, requiring transfer to the hospital. Interviews with facility staff revealed that the admitting nurse did not request or clarify orders for blood sugar checks, relying solely on the hospital medication list, and was unaware of the facility's policy or standard practice for diabetic care. Additionally, the resident was admitted with multiple skin impairments, including wounds to the left foot, left heel, sacrum, and penis, but did not receive wound care orders until four days after admission. The admitting nurse documented the presence of skin impairments but did not communicate these findings to the nurse practitioner or request treatment orders. The initial nursing evaluation indicated skin issues, but no detailed assessment or wound care plan was initiated until several days later. Staff interviews confirmed that the nurse did not follow the expected process of notifying the physician about new or existing wounds upon admission. The facility lacked a clear policy for diabetic procedures or wound care at the time of the incident, and staff training on these topics was inconsistent. The failure to obtain and implement physician orders for both blood sugar monitoring and wound care at the time of admission resulted in the resident not receiving necessary care for identified health needs. This deficiency was identified as Immediate Jeopardy due to the potential for significant harm.
Failure to Provide Timely Wound Care and Blood Sugar Monitoring
Penalty
Summary
A deficiency occurred when a resident was readmitted to the facility with multiple skin impairments, including a diabetic wound to the left heel and dorsum of the foot, moisture-associated skin damage (MASD) to the sacrum, and an abrasion to the penis. Upon readmission, the admitting nurse identified skin impairments but did not document their location or measurements on the required forms and failed to communicate these findings to the nurse practitioner (NP) or request wound care orders. As a result, the resident did not have any wound care orders in place for five days following readmission, and no wound care was provided during this period. The facility's policy required notification of the physician for any new treatment needs or changes in condition, but this was not followed. Additionally, the same resident, who had a history of type 2 diabetes mellitus and was on oral diabetic medications, was readmitted without orders for blood sugar checks. The admitting nurse verified the medication list with the NP but did not request or clarify the need for blood sugar monitoring, despite the resident's diagnosis and previous history of fluctuating blood sugars. For five days, no blood sugar checks were performed, and the resident subsequently experienced an episode of hypoglycemia, with a blood sugar reading of 50, which led to a hospital transfer. The lack of blood sugar monitoring was not addressed until after the incident occurred. Interviews with facility staff, including the admitting nurse, ADON, NP, and DON, revealed a lack of communication and understanding regarding the need to obtain and clarify orders for wound care and blood sugar checks upon admission. Documentation was incomplete, and staff did not follow facility policy or professional standards of practice in assessing, documenting, and reporting the resident's condition. The facility did not have a specific policy for diabetic procedures or blood sugar checks, and staff training on these procedures was lacking at the time of the incident.
Incomplete Documentation of Treatments and Medications
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for three residents. For one resident with a history of diabetes, COPD, and pressure injuries, the Treatment Administration Record (TAR) for March was found to have multiple unsigned sections for physician-ordered treatments, including wound care and use of a pressure-reducing mattress. Nursing staff interviewed confirmed they had provided the treatments but did not sign off on the TAR, citing reasons such as forgetting due to being busy or not understanding the significance of blank entries. Staff acknowledged that they had received training on documentation requirements but did not consistently follow facility policy. Another resident with diagnoses including diabetes, heart failure, and skin integrity issues had incomplete documentation on both the TAR and Medication Administration Record (MAR). Several physician-ordered treatments for wounds and pressure reduction were not signed off on the TAR for various shifts, and a blood sugar check and insulin administration were not documented on the MAR. Nursing staff responsible for these omissions stated they either forgot to document, did not see the order, or were unsure of the policy. In one instance, a nurse failed to document a resident's refusal of a blood sugar check and insulin, which should have been coded appropriately on the MAR. A third resident, also with diabetes and severe cognitive impairment, had incomplete documentation on the MAR for sliding scale insulin orders. The MAR lacked signatures and blood glucose documentation for scheduled times, and staff could not recall the specifics of care provided on those dates. Interviews with nursing and administrative staff confirmed that the required documentation was missing and that staff had not followed the facility's documentation policy, despite recent training. The facility's policy requires all assessments, observations, and services to be accurately and timely documented in the resident's medical record, which was not adhered to in these cases.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for four residents, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #1's care plan did not include his wound or the physician-ordered wound care, despite having a surgical incision on his right plantar foot that required daily treatment. This omission was confirmed during a review of Resident #1's care plan, which lacked any mention of his wound care needs. For Resident #2, the care plan did not address her diet or the need for crushed medications, even though she had a diagnosis of dysphagia and a modified barium swallow study recommended a pureed diet and crushed medications to mitigate choking risks. Similarly, Resident #3's care plan failed to include his diet and the need for crushed medications, despite having physician orders for a pureed diet and a history of orders for crushed medications. Resident #4's care plan also lacked details about her diet and the need for crushed medications, although her medical records indicated these requirements. Interviews with facility staff, including MDS C and the DON, revealed that the care plans were not updated to reflect these critical needs due to oversight and staffing issues. MDS C and the DON acknowledged the importance of including such information in care plans to ensure appropriate interventions and goals for residents. However, the care plans for these residents were incomplete, potentially impacting their care and safety.
Failure to Obtain Orders for Crushed Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, specifically in obtaining and inputting orders for crushed medications. Resident #3, a male with multiple diagnoses including metabolic encephalopathy and acute respiratory failure, was on a mechanically altered diet but did not have an active order for crushed medications. Although there was a previous order allowing for medications to be crushed as needed, it was discontinued, and no new order was in place until after surveyor intervention. Similarly, Resident #4, a female with dysphagia and other conditions, also lacked an order for crushed medications despite recommendations from a modified barium swallow study indicating a choking risk. Interviews with staff revealed a reliance on residents' diets to determine the need for crushed medications, rather than ensuring proper orders were in place. Medication aides and the Assistant Director of Nursing (ADON) acknowledged the absence of orders for crushed medications for both residents, despite the facility's policy requiring such orders. The staff admitted to using nursing judgment based on diet rather than formal orders, which led to inconsistencies in medication administration. The Director of Nursing (DON) confirmed that orders for crushed medications were necessary according to facility policy and acknowledged the oversight in not having these orders in place for Residents #3 and #4. The DON stated that the facility had been relying on diet information to guide medication administration, which had not resulted in any negative effects, but recognized the importance of having formal orders to prevent potential risks such as choking or aspiration.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for four residents. Resident #12 was found with four unidentified pills and two capsules in a medication cup on his overbed table, which he had not taken. The Medication Aide left Resident #12's medications on his bedside table and documented that the medications had been administered, despite the resident not taking them. Interviews revealed that the Med Aide did not follow the proper procedure of staying with the resident until the medication was taken, leading to a discrepancy in the medication administration record (MAR). For Residents #23, #35, and #63, there were instances where medications were not signed off on the MAR on specific dates. Resident #23 had five medications not signed off, Resident #35 had two, and Resident #63 had three. Interviews with staff indicated that personal issues and overwhelming situations, such as a high number of visitors, contributed to the failure to document medication administration properly. This lack of documentation could potentially lead to residents receiving double doses of medication, although no negative outcomes were reported. The facility's policy on medication administration requires that medications be administered by licensed nurses or authorized staff, with proper documentation on the MAR. The failure to adhere to these procedures, as evidenced by the missing signatures and improper medication handling, highlights a significant deficiency in the facility's pharmaceutical services. The DON acknowledged the oversight in reviewing daily reports that would have flagged the missing signatures, indicating a lapse in the facility's internal monitoring processes.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had the right to reside and receive services with reasonable accommodation of their needs and preferences, specifically regarding the accessibility of call lights. Two residents, both with significant mobility impairments and at risk for falls, were found to have their call lights out of reach. Resident #90, who has muscle weakness and hemiparesis following a stroke, was observed with her call light on the floor next to her bed. Similarly, Resident #98, who has muscle weakness and a history of falls, had her call light on the floor behind a nightstand. Both residents require assistance with personal care and rely on the call light system to request help. Interviews with staff, including a nursing assistant and the Assistant Director of Nursing (ADON), confirmed that call lights should be within reach of residents at all times to ensure they can call for assistance when needed. The staff acknowledged the importance of this practice and admitted that the call lights were not properly secured in these instances. The facility's policy on call light accessibility emphasizes the need for staff to ensure call lights are within reach and secure, yet this was not adhered to, leading to the deficiency.
Failure to Document Resident's Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's right to formulate advance directives was honored, as evidenced by the absence of the resident's code status in the facility's records. The resident, who had a moderately impaired cognitive status with a BIMS score of 10, was admitted with several medical conditions, including Nontraumatic Acute Subdural Hemorrhage, Type 2 Diabetes Mellitus, Hemiplegia, and Essential Primary Hypertension. Despite these conditions, the facility did not have an active physician's order for the resident's code status, which is crucial for honoring the resident's end-of-life wishes. Interviews with facility staff revealed a lack of clarity and consistency in handling advance directives. LVN A and the DON both indicated that without the DNR paperwork, residents were defaulted to full code status, potentially leading to unwanted resuscitative measures. The Social Services staff mentioned discussing advance directives during admission but acknowledged a delay in completing the documentation. The admission nurse, LVN H, admitted to possibly forgetting to enter the code status, highlighting a gap in the facility's process for ensuring residents' advance directives are accurately recorded and respected.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, which included necessary instructions for effective and person-centered care. Specifically, the advance directive section of the baseline care plan was not completed for the resident, who had a moderately impaired cognition with a BIMS score of 10. The resident's medical conditions included Nontraumatic Acute Subdural Hemorrhage, Type 2 Diabetes Mellitus without Complications, Hemiplegia, and Essential Primary Hypertension. The absence of advance directive information in the resident's electronic face sheet and physician order summary report meant there was no active physician's order for code status, leaving the resident's end-of-life wishes unaddressed. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for entering and managing code status information. An LVN was unable to find the code status in the resident's electronic chart and stated that without the necessary documentation, the resident would be considered full code by default. The MDS coordinator indicated that nurses open the initial baseline care plan, while social services are responsible for completing the code status. However, the social services staff member believed she had five days to complete the advance directives, contrary to the facility's policy requiring completion within 48 hours. This miscommunication and misunderstanding of responsibilities contributed to the deficiency in the resident's baseline care plan.
Failure to Update Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #63, who was at high risk of elopement. Despite being admitted to the secured unit due to this risk, the resident's care plan did not reflect this critical information. The care plan, dated 05/29/2024, was supposed to include measurable objectives and timeframes to meet the resident's needs, as identified in the comprehensive assessment. However, it lacked the necessary details about the resident's placement in the secured unit, which was a significant oversight given her diagnosis of Alzheimer's disease and severely impaired cognition. Interviews with the MDS-LVN and the DON revealed that the omission was an oversight, as the MDS-LVN admitted to forgetting to update the care plan to reflect the resident's housing in the secured unit. Both staff members acknowledged that the care plan should have included this information, although they noted that there were no negative outcomes for the resident due to this omission. The facility's policy mandates that care plans be comprehensive and person-centered, incorporating the resident's strengths, needs, and preferences, but this was not adhered to in this instance.
Inadequate Catheter Care Leads to Infection Control Issue
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling urinary catheter, which could lead to an increased risk of urinary tract infections. The resident, an elderly male with severe cognitive impairment and medical conditions including benign prostatic hyperplasia and acute kidney failure, was observed with his catheter tubing touching the floor. This observation was made despite the care plan specifying that the catheter bag and tubing should be positioned below the bladder level and away from the door entrance. Interviews with facility staff, including an LVN and the DON, revealed that the responsibility for catheter care was assigned to the floor nurse. The LVN acknowledged that the catheter tubing should not be on the floor and suggested using a sheath to prevent infection control issues. The DON confirmed that catheter tubing on the ground was an infection control issue and mentioned ongoing in-services for catheter care. However, the facility failed to provide the requested policies on catheter care or infection control before the survey exit.
Deficiency in Oxygen Administration for Residents
Penalty
Summary
The facility failed to provide respiratory care according to professional standards for two residents who required oxygen therapy. Resident #258, a female with acute respiratory failure, chronic pulmonary edema, pneumonia, and acute systolic heart failure, was observed to have her oxygen administered at 3.5 liters per minute (Lpm) instead of the physician-ordered 2 Lpm. This discrepancy was noted during an observation on June 24, 2024, when the Director of Nursing (DON) checked the oxygen machine and found it set incorrectly. The DON confirmed that the nurses are trained to set the ball meter to the middle of the ball and are responsible for checking the oxygen machine at the beginning and throughout their shifts. Similarly, Resident #260, a female with metabolic encephalopathy, acute respiratory failure with hypoxia, chronic pulmonary edema, and acute systolic heart failure, was found to have her oxygen set at 2.5 Lpm instead of the ordered 3.0 Lpm. This was observed on June 24, 2024, with the ball meter set to the top of the ball rather than the middle. An interview with LVN A revealed that nurses are responsible for setting the oxygen machines correctly and are trained to ensure the middle of the ball is level with the prescribed number. LVN A also mentioned that further training would likely occur following the survey. The facility's Medication Administration policy, dated October 24, 2022, states that medications, including oxygen, are to be administered by licensed nurses as ordered by the physician and in accordance with professional standards. The policy emphasizes the importance of reviewing the Medication Administration Record (MAR) to ensure correct administration. Despite these guidelines, the facility's failure to adhere to the prescribed oxygen levels for these residents represents a deficiency in providing safe and appropriate respiratory care.
Failure to Accurately Code Falls in MDS
Penalty
Summary
The facility failed to ensure accurate assessments for two residents regarding their fall incidents, which were not properly coded in the Minimum Data Set (MDS). Resident #1, who had a history of dementia, lack of coordination, Parkinson's disease, and unsteadiness, experienced an unwitnessed fall. Despite this, the fall was not recorded in the resident's annual MDS, which could lead to improper care and services. The MDS Nurse acknowledged the oversight, indicating that the fall should have been coded to ensure the resident received appropriate care. Similarly, Resident #2, diagnosed with Alzheimer's disease, had two falls that were not captured in the quarterly MDS. The resident had a witnessed fall resulting in a minor skin tear and another unwitnessed fall. Despite these incidents being documented in the care plan and interventions being implemented, the falls were not reflected in the MDS. The MDS Nurse admitted the error, suggesting it was an oversight, and the Director of Nursing (DON) confirmed that the falls were care planned but not coded in the MDS. The failure to accurately code these falls in the MDS could potentially place residents at risk of receiving incorrect care. The facility's interdisciplinary team, including the DON and MDS Nurse, is responsible for ensuring the accuracy of MDS assessments. However, the oversight in coding these falls indicates a lapse in the assessment process, which could impact the residents' physical, mental, and psychosocial well-being.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 118 citations issued within 25 miles in the last 12 months — including the 5 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 Brownsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fox Hollow Post Acute | 2.1 mi | ★★★★★ | 12 | 3 |
| Mesa Hills Post Acute | 2.4 mi | ★★★★★ | 6 | 0 |
| Alta Vista Rehabilitation And Healthcare | 3.4 mi | ★★★★★ | 16 | 0 |
| Ebony Lake Nursing And Rehabilitation Center | 3.6 mi | ★★★★★ | 14 | 0 |
| Las Alturas Nursing & Transitional Care Brownsvill | 4 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.