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 Brownwood Nursing And Rehabilitation during CMS and state inspections, most recent first.
A facility failed to ensure safe smoking practices for three residents. One resident who required a fire-resistant smoking apron was repeatedly observed smoking without it, while two other residents were allowed to smoke without a completed safe smoking assessment in the record. Staff stated aprons were available, but they were not being offered to residents who needed them, and the DON/ADMN acknowledged that without an assessment there was no way to know what precautions were needed.
Staff failed to follow EBP for residents with indwelling devices and failed to ensure EBP signage and PPE were available at some rooms. An LPN administered IV meds through a central line and meds/nutrition through a G-tube using gloves but no gown, despite EBP orders and care plans. Two other residents with EBP orders had no EBP sign outside the room, and one room had no gowns available at the entrance or inside.
Nonfunctioning Hot Water in Resident Room Sink: A resident room sink had no working hot water for several days, and one resident stated she believed it had never worked. Two residents in the room had significant cognitive and ADL support needs, including assistance with hygiene and handwashing. Staff knew the hot water was not working, the sink had been avoided, and the Maintenance Director later found the valve under the sink had been turned off after a leak repair and had not been turned back on.
Failure to Reorder Glaucoma Eye Drops: A resident with glaucoma and severe cognitive impairment missed ordered Latanoprost eye drops because an LVN did not reorder the medication before the supply ran out. The MAR showed doses were not given on consecutive days, the med was not available in the emergency kit, and the POA reported concern that the resident was not receiving his glaucoma drops as ordered.
A resident receiving IV ampicillin for osteomyelitis had an unused ampicillin bag left on his bedside table while a nurse administered the reconstituted dose. The LVN was unsure why the medication was in the room and left it there, and a later observation showed it still unattended. The DON and RCN stated meds should be stored in the med room or on the med cart, and the facility policy required medications and biologicals to be stored securely and accessible only to authorized personnel.
Failure to Post Resident Census on Daily Nurse Staffing: The facility posted daily nurse staffing information in the hallway, but the resident census was shown as zero on the posting. The ADON used a new computer-generated report and was unaware the census was not included, while the DON and ADMN stated they did not know the census was required on the posting and that the facility did not have a policy for nurse staff posting.
Surveyors found that the facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for five residents. For residents with conditions including HTN, CAD, seizure disorder, dementia, COPD, DM2, renal insufficiency, CVA history, anticoagulant and antiplatelet use, diuretic therapy, Foley catheter use, impaired vision, hearing deficits, and depression, care plan goals were written in vague terms such as remaining free from complications, adverse reactions, or discomfort "through the review date" without quantifiable criteria. During interviews, MDS coordinators, the DON, and the Administrator acknowledged that the care plan goals were not measurable and that this was a pattern in the facility’s care planning practices.
The facility's kitchen failed to meet food safety standards, with improperly sealed and labeled food items in refrigerators and freezers, and unsanitary conditions such as unclean utensil holders and stove spill slats. The Dietary Manager and Administrator acknowledged lapses in following cleaning protocols, which could lead to foodborne illnesses among residents.
A facility failed to post an 'Oxygen in Use' sign on a resident's door, who required oxygen for COPD and shortness of breath. The absence of the sign, contrary to facility policy, was acknowledged by the DON as an oversight, potentially risking staff and visitor awareness during emergencies.
A medication cart was found unattended and unlocked at a nursing station, with a resident nearby, posing a risk of unauthorized access to medications. RN A admitted to being distracted and forgetting to lock the cart, which contained various medications. The DON confirmed that carts should always be locked when not in use, as per facility policy.
Failure to Ensure Safe Smoking Supervision and Protective Devices
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that residents who smoked received adequate supervision and assistance devices. Surveyors identified deficiencies involving three residents who smoked: one resident was observed smoking without the required smoking apron, and two residents were allowed to smoke without a completed safe smoking assessment in the record. Resident #13 had diagnoses including schizoaffective disorder, bipolar disorder, and anxiety, and her MDS showed a BIMS of 15. Her care plan and safe smoking assessment stated that she required a fire-resistant smoking apron while smoking. However, during multiple observations, she was seen smoking without an apron. During interview, she stated she never wore an apron and did not know she was supposed to wear one. Resident #1 had diagnoses including COPD, bipolar disorder, and dementia, with a BIMS of 12. His care plan directed staff to perform a smoking assessment according to facility policy, but no safe smoking assessment was found in the record. Resident #25 had diagnoses including respiratory failure, tracheostomy, and dementia, with a BIMS of 09. His care plan also directed staff to perform a smoking assessment according to facility policy, but no safe smoking assessment was found in the record. During observation, both residents were seen smoking, and staff reported that aprons were available but were not being offered to residents who required them.
Failure to Follow EBP for Residents With Indwelling Devices
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficiency involved staff not following enhanced barrier precautions (EBP) for residents with indwelling devices and not ensuring EBP notifications and PPE were available as required. Resident #68 was admitted with osteomyelitis of the left ankle and had a BIMS score of 12, indicating moderate cognitive impairment. His record reflected EBP orders and a care plan requiring gloves and gown for high-contact activities, including central line care. During an observation, an LVN entered the room to administer IV medication through the resident’s central line. The LVN performed hand hygiene, gathered supplies, returned to the room, donned gloves, and administered the medication, but did not wear a gown while flushing the central line, wiping the IV port with alcohol, or connecting and infusing the IV medication. There were no PPE items on the door or inside the room at the time of the observation. Resident #58 had a G-tube and orders and care plan for EBP. During an observation, the LVN administered medication and a nutritional supplement through the G-tube after flushing it with water. The LVN wore gloves but did not wear a gown during the medication and nutrition administration. The LVN stated she should have worn the gown and said she had been trained on EBP. Resident #58 also had redness around the G-tube site and was receiving an oral antibiotic for skin infection around the tube. Resident #22 and Resident #64 also had EBP orders and care plans, but staff were not notified of EBP as expected. Resident #22’s room entrance had no EBP sign and no gowns were present at the entrance or in the room during observation. Resident #64’s room also had no EBP sign outside the door during observation, although PPE was present in the room. The infection preventionist stated he was responsible for placing EBP signs and that central lines, urinary catheters, and G-tubes were appropriate for EBP. The DON stated she expected staff to follow EBP policy, to have EBP signs outside resident rooms, and to wear gowns when administering medication through a G-tube or IV.
Nonfunctioning Hot Water in Resident Room Sink
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in 1 of 64 resident rooms reviewed because the hot water in room [ROOM NUMBER]'s sink was not working on 04/13/2026, 04/14/2026, and 04/15/2026. The deficiency was identified during observations, interviews, and record review, and the report states that the lack of functioning hot water could place residents and staff at risk of being uncomfortable and for infections from living in an environment that does not function. Resident #9 was an [AGE]-year-old female admitted with diagnoses including Alzheimer's disease and dementia. Her quarterly MDS dated 02/11/2026 showed a BIMS score of 06, indicating severe cognitive impairment, and she required partial assistance with toileting hygiene and substantial assistance with personal hygiene, including washing hands. Resident #26 was an [AGE]-year-old female admitted and readmitted with dementia. Her quarterly MDS dated 03/02/2026 showed she was unable to complete the BIMS interview and was dependent on staff for toileting hygiene and personal hygiene, including washing hands. During observation, Resident #9 stated she believed the hot water had never worked and said she would like hot water to work in the sink. Room [ROOM NUMBER]'s sink was observed to have no working hot water throughout the observation period. RN A stated she knew the hot water did not work and that staff had been told not to use the sink because of repeated reports to maintenance. RN B, the infection preventionist, stated resident rooms should have hot water and that staff used other sinks, hand sanitizer, and wipes. The Maintenance Director later verified the hot water did not work, turned a knob under the sink, and the hot water then worked; he stated he did not know why the knob had been off. The Corporate Liaison stated she had turned off the hot water valve when repairing a leak and had forgotten to turn it back on, and the ADMN stated she had no knowledge of the issue until questions were raised.
Failure to Reorder Glaucoma Eye Drops
Penalty
Summary
Pharmaceutical services failed to meet the needs of Resident #29 when LVN D did not reorder Latanoprost Ophthalmic Emulsion 0.005% before the resident’s supply was depleted. Resident #29 was an elderly male admitted with glaucoma and had severe cognitive impairment on the MDS. His care plan identified impaired visual function related to glaucoma and included monitoring for eye problems and use of glasses. The physician ordered Latanoprost eye drops, 1 drop in both eyes daily, to be given 30 minutes after Dorzolamide. The MAR showed the resident’s Latanoprost had not been administered on 04/13/2026 or 04/14/2026, and it was scheduled for 5:00 p.m. on 04/14/2026. LVN D documented that she ordered the eye drops on 04/13/2026, but pharmacy did not deliver them that night and the resident remained without the medication the next day. During interview and observation, LVN D stated the resident was out of Latanoprost, the emergency med kit did not have the drops in house, and she had not yet documented notifying the family member that the resident was out of the medication. The POA stated he was concerned the resident was not receiving his glaucoma eye drops as ordered. The DON stated nurses were expected to order medication before it ran out and to make the family and physician aware immediately if ordered medication could not be obtained.
Medication Left Unsecured in Resident Room
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and accessible only to authorized personnel when an unused bag of ampicillin was left unattended in Resident #68’s room. Resident #68 was a male admitted with osteomyelitis of the left ankle, and his MDS assessment reflected a BIMS score of 12, indicating moderate cognitive impairment. His physician orders included ampicillin sodium injection solution 2 gm to be infused intravenously six times daily until 4/30/2026. During an observation, an LVN entered the resident’s room to administer IV ampicillin, hung the reconstituted medication on the IV pole, and began the infusion. A second ampicillin bag that had not been reconstituted was observed sitting on the resident’s bedside table. The LVN stated she was unsure why the medication was in the room and left it there. A later observation showed the unused ampicillin bag still on the bedside table. The LVN, DON, and RCN all stated medications should not be left in residents’ rooms and should be stored in the medication room or on the medication cart; the facility policy also stated medications and biologicals are to be stored securely and accessible only to authorized personnel.
Failure to Post Resident Census on Daily Nurse Staffing
Penalty
Summary
The facility failed to post daily nurse staffing information that included the resident census for 3 reviewed days, 04/13/2026, 04/14/2026, and 04/15/2026. During observations on each of those days at 9:10 a.m., the daily nurse staffing posting was located in the front hallway across from the ADON's and DON's office, and the resident census was listed as zero. During interviews on 04/15/2026, the ADMN stated the ADON hung up the daily nurse staffing and said she was unaware that a census needed to be posted. The ADON stated she posted the staffing using a new computer program that generated the report, but she did not know the updated system did not include the census. The DON stated she did not know the census should be included on the posting, and the ADMN stated the facility did not have a policy for nurse staff posting and had been using the new system for about a year without realizing the census was not populating on the posted report.
Non-measurable care plan goals for multiple residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for all five residents reviewed. The facility’s own policy required comprehensive care plans with measurable objectives and timeframes to address each resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. However, record review showed that multiple care plan goals were written in vague terms that could not be evaluated, quantified, or verified, such as residents remaining free of complications or adverse effects "through the review date" without specific, measurable criteria. For one male resident with metabolic encephalopathy, essential hypertension, coronary artery disease, and cervical intervertebral disc stenosis, the care plan objectives for hypertension, adverse medication effects, altered cardiac problems, and intervertebral disc disorder/stenosis were not measurable. The goals stated that the resident would remain free of complications related to hypertension, free from adverse medication effects, free from signs and symptoms of cardiac complications, and free from pain or at an acceptable level of discomfort through the next review date, but did not include measurable parameters or timeframes that would allow staff to evaluate progress. Similar issues were found for another male resident with dementia, atrial fibrillation, bradycardia, anxiety disorder, seizure disorder, hypertension, and COPD, whose care plan goals for anticoagulant therapy, seizure disorder, hypertension, diuretic therapy, impaired visual function, hearing deficit, and use of antidepressant and anti-anxiety medications were all written in non-measurable terms such as remaining free from discomfort, adverse reactions, or complications. A third male resident with acute kidney failure, unspecified dementia, vertebral fracture, hypertension, renal insufficiency, and glaucoma had care plan goals for hypertension, hypothyroidism, history of CVA, antiplatelet medication, advanced stage Alzheimer’s dementia, and impaired visual function that were similarly non-measurable. These goals included remaining free of complications related to hypertension/hyperlipidemia, being free from signs and symptoms of hypothyroidism, being free from complications related to a history of CVA, being free from discomfort or adverse reactions related to antiplatelet use, having needs anticipated and met with dignity maintained, and having no indications of acute eye problems, all without specific measurable criteria. A female resident with COPD, cognitive communication deficit, depression, hypertension, mild cognitive impairment, and chronic obstructive pulmonary disease had care plan goals for anticoagulant therapy, hypertension, diuretic therapy, impaired thought processes, and impaired vision that also lacked measurable objectives, using general statements about being free from complications or maintaining current function. Another female resident with a displaced glenoid cavity fracture, type 2 diabetes, mild cognitive impairment, atrial fibrillation, hypertension, and diabetes mellitus had care plan goals for diabetes mellitus type 2, edema, adverse medication effects, hypertension, impaired visual function, hearing deficit, urinary retention related to an indwelling Foley catheter, and use of antidepressant medication that were not measurable. These goals included having no complications related to diabetes, fluid balance improving or not worsening, remaining free from adverse medication effects, remaining free of complications related to hypertension, having no indications of acute eye problems, maintaining the highest level of communication, remaining free from catheter-related trauma, and being free from discomfort or adverse reactions related to antidepressant use, again without quantifiable criteria. During interviews, both MDS coordinators acknowledged that the goals in the care plans were not measurable, with one stating she knew the goals were not measurable and that she and the other coordinator were working to develop measurable goals. The DON stated the IDT was responsible for creating measurable outcomes and agreed the outcomes needed to be measurable, and the Administrator also agreed the goals were not measurable and described the issue as a pattern.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was noted that various food items in the facility's refrigerators and freezers were not properly sealed or labeled. Specifically, opened bags of tortillas, bread, and cereal were found without dates, and several items in the freezers, such as egg patties, egg rolls, sandwiches, cookies, and beef patties, were unsealed and exposed to air. This lack of proper labeling and sealing could lead to cross-contamination and foodborne illnesses among residents. Additionally, the facility's kitchen was found to have cleanliness issues. Clean utensils and napkins were stored in unclean holders, and clean dishes were placed on unclean trays. The cooking stove had spill slats that were not cleaned, with visible food particles and grease buildup. These unsanitary conditions were confirmed through interviews with the Dietary Manager (DM) and the Administrator (ADMN), who acknowledged that the staff had not followed the established cleaning schedules and protocols. The facility's policies, dated 2012, require that all food products be labeled and dated, and that kitchen equipment be cleaned and sanitized regularly. However, the DM admitted that staff had signed off on cleaning tasks without actually performing them, and the ADMN confirmed that these lapses could lead to residents consuming expired or contaminated food, potentially causing illness or allergic reactions. The failure to monitor and enforce these protocols was attributed to inadequate oversight by the DM and ADMN.
Failure to Post Oxygen Use Sign for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen administration, as evidenced by the absence of an 'Oxygen in Use' sign on the door of a resident's room. The resident, a female with a diagnosis of Chronic Obstructive Pulmonary Disease and shortness of breath, was admitted to the facility with physician orders to use oxygen at 2-3 liters per minute via nasal cannula. During an observation, it was noted that there was no sign indicating oxygen use or a no smoking warning on the resident's door, which is a requirement according to the facility's policy on oxygen administration. The Director of Nursing (DON) acknowledged that the expectation was for such signs to be posted to inform staff and others of the oxygen use, especially during emergencies. The DON stated that management staff, including the Assistant Director of Nursing (ADON) and herself, were responsible for ensuring these signs were in place during their daily rounds. The failure to post the sign was attributed to oversight, which could potentially place residents at risk of respiratory infection due to the lack of awareness among staff and visitors about the oxygen use in the resident's room.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in permanently affixed compartments, as evidenced by an incident involving medication cart #1. During an observation, the medication cart was found unattended at the nursing station with its drawers facing out and unlocked, allowing them to be opened easily. A resident was standing within arm's reach of the cart, posing a risk of unauthorized access to medications. RN A, who was responsible for the cart, admitted to being distracted by a request from therapy and forgot to lock the cart. Interviews with RN A and the Director of Nursing (DON) confirmed that the medication cart should not be left unlocked and unattended. RN A acknowledged the potential harm if a resident accessed medications not prescribed for them, which could lead to adverse reactions. The DON reiterated that medication carts must always be locked when not in use to prevent unauthorized access and potential harm. The facility's policy mandates that medication carts be locked when not in use or under direct supervision, and the failure to adhere to this policy was attributed to RN A being in a hurry and forgetting to secure the cart.
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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.
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Nursing homes near Brownwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Ridge Manor | 0.2 mi | ★★★★★ | 5 | 0 |
| Pecan Bayou Nursing And Rehabilitation | 0.3 mi | ★★★★★ | 6 | 0 |
| Songbird Lodge | 0.4 mi | ★★★★★ | 15 | 0 |
| Cross Country Healthcare Center | 1.9 mi | ★★★★★ | 1 | 0 |
| Care Nursing & Rehabilitation | 6.7 mi | ★★★★★ | 3 | 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.