Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Care Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to have a signed hospice agreement in place before hospice services were provided to one resident, and it also failed to document communication with hospice about another resident’s repeated refusals of glaucoma eye drops. The resident receiving the eye drops had Alzheimer’s disease, severe cognitive impairment, and a terminal prognosis, and the MAR showed multiple missed doses over several months with no documented hospice notification. Staff stated they documented refusals on the MAR but did not call hospice each time or document conversations with the hospice nurse.
Call lights were not consistently kept within reach for two residents. One resident with Alzheimer’s disease, glaucoma, severe cognitive impairment, and dependence for bed mobility had his call light wrapped around a wall device and out of reach while in bed. Another resident with dementia and chronic pain had her call light hanging on her bed and out of reach while sitting in a recliner, and she said she could not reach it without using her back scratcher. Staff, including a CNA, LVN, DON, and ADMN, acknowledged the call lights were not always accessible.
The facility allowed three SNAs to provide direct resident care for more than four months without completing a training and competency evaluation program or obtaining CNA certification, contrary to NATCEP requirements and the facility’s own SNA job description limiting the role to 120 days. Employee file reviews showed one SNA had an expired CNA certification and two had no CNA certification, yet all continued working in direct care beyond the permitted timeframe. In interviews, the RNC and ADMN acknowledged that SNAs should be certified within four months of hire and attributed the failure to lack of a specific facility policy and inadequate monitoring and tracking of SNA education and certification by a previous DON from a sister facility.
The facility failed to maintain safe hot water temperatures in four resident rooms on the middle hall, with temperatures ranging from 114 to 117 degrees Fahrenheit. Despite the elevated temperatures, no residents reported burns or injuries. The issue arose after the Maintenance Supervisor adjusted the water heater's thermostat due to cold weather and forgot to revert it when temperatures warmed. The facility's policy requires weekly checks to ensure water temperatures remain between 100 and 110 degrees Fahrenheit.
The facility failed to label and date an opened vial of Tuberculin in one of the medication rooms, as observed during an inspection. The vial, which should be discarded 30 days after opening, lacked an open date, making it difficult to determine its expiration. The DON and Administrator acknowledged the oversight, noting that the night shift was responsible for checking and disposing of expired medications.
A resident actively involved in her diabetic care requested her Lantus Insulin be held at night if her sliding scale insulin was also held. LVN A complied but failed to document the rationale in the progress notes, leading to incomplete medical records. The Regional Compliance Nurse confirmed the facility's documentation policy was not followed, and the Medical Director emphasized the need for accurate records.
A CNA in an LTC facility failed to change gloves during incontinent care for a resident with Parkinson's and muscle weakness, leading to potential cross-contamination. Despite facility policies emphasizing hand hygiene and glove changes, the CNA applied barrier cream to both the rectal and scrotum areas without changing gloves. Staff interviews revealed differing opinions on the risk of cross-contamination, highlighting a lapse in infection control practices.
A resident with a history of heart failure and hypertension was transferred to the hospital due to elevated blood pressure, but the facility failed to notify the physician immediately. Despite the resident's request and family member's insistence, the nurse on duty did not contact the physician, which was against the facility's policy. The physician was informed six days later, potentially delaying treatment.
Missing Hospice Contract and Failure to Communicate Medication Refusals
Penalty
Summary
The facility failed to have a written hospice agreement signed by authorized representatives of both the hospice and the LTC facility before hospice care was furnished to a resident receiving hospice services. For one resident admitted with heart disease and receiving hospice care, the facility could not locate a hospice contract in its contract binder. The administrator stated he was unable to find a contract with the resident’s hospice provider and was waiting for the hospice company to send one, and he stated the contract should have been in place before the resident was admitted on hospice services. The facility also failed to communicate and document communication with the hospice provider regarding another resident’s care needs. That resident had Alzheimer’s disease, severe cognitive impairment with a BIMS score of 00, behavioral symptoms, and a terminal prognosis with hospice services in place. The resident had orders for glaucoma eye drops, but the MAR showed multiple refusals and missed doses across February, March, April, and May. The record review found no documentation that the hospice provider was notified of these refusals, and progress notes also showed no evidence of communication with hospice about the eye drop refusals. During observation, a nurse attempted to administer the eye drops and the resident refused by closing his eyes and pushing the nurse away. In interviews, the nurse stated she documented the refusals on the MAR but did not call hospice each time and did not document conversations with the hospice nurse. Another nurse stated she would let hospice know if the hospice nurse happened to be in the building but did not call every time the resident refused. The resident’s representative stated she was aware the eye drops were not being given and was concerned about the resident’s vision and behavior, and she was unsure whether the facility was notifying hospice after the refusals.
Call lights not kept within reach of two residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach. Resident #10 had diagnoses including Alzheimer’s disease and glaucoma, a BIMS score of 00 indicating severe cognitive impairment, used a wheelchair, had impaired range of motion to both lower extremities, and was dependent on staff for bed mobility and transfers. His care plan identified him as a fall risk and included the intervention to keep his call light within reach and encourage him to use it for assistance as needed. During observations, he was lying in bed with the call light wrapped around a square device on the wall and out of his reach. Resident #26 had diagnoses including dementia and chronic pain, a BIMS score of 13 indicating intact cognition, used a wheelchair, and needed moderate assistance with bed mobility and transfers. Her care plan also identified her as a fall risk and included the intervention to keep her call light within reach and encourage her to use it for assistance as needed. During one observation, her call light was in reach while she sat on the side of her bed eating breakfast, but during a later observation she was sitting in a recliner with the call light hanging on the middle of her bed and out of reach. She stated she needed assistance to get up and could not reach the call light without using her back scratcher. Staff interviews confirmed the call lights were not consistently kept within reach. A CNA stated Resident #10’s call light was wrapped around the wall device because the night shift had started doing it and she continued the practice, and she acknowledged he could not reach it when lying in bed. The resident’s representative stated she did not want the call light in his reach and would wrap it around the wall square when she was at the facility. For Resident #26, a CNA stated she could not reach the call light from the recliner and speculated it may not have been moved after care. The LVN stated she was responsible for making sure call lights were in reach and did not know why Resident #26’s was not, and the DON and ADMN both stated residents were expected to have access to their call lights.
Student Nurse Aides Used Beyond 4-Month Limit Without CNA Certification
Penalty
Summary
The deficiency involves the facility’s use of student nurse aides (SNAs) as nurse aides for more than four months without ensuring they had completed a required training and competency evaluation program or obtained CNA certification. Record review of SNA A’s employee file showed a hire date with no evidence of current nurse aide certification; an employability status check showed SNA A previously held a CNA certification that had expired. Record review of SNA B’s and SNA C’s employee files also showed hire dates with no evidence of CNA certification, and employability status checks indicated they had no CNA certification. Despite this, these individuals were used to provide direct resident care beyond the four‑month limit allowed for student nurse aides. During interviews, the RNC stated her expectation was that newly hired NAs would be enrolled in classes within 30 days and be certifiable at 60 days, and acknowledged there was no facility policy on NAs other than following NATCEP requirements. She stated SNAs should have been certified as CNAs no more than four months after hire and attributed the failure to the previous DON from a sister facility who had been responsible for monitoring SNA education and certification time frames. The ADMN similarly stated SNAs should have been certified within four months of hire, confirmed that the sister facility’s DON had not kept up with monitoring and tracking certification, and acknowledged that these SNAs had continued performing direct care with residents after the four‑month period. The ADMN stated the DON had been responsible for monitoring nurse aides and that there was potential harm for residents if staff were not properly trained to recognize out‑of‑range signs and symptoms. Facility documentation from the NATCEP Program Specialist and the facility’s own SNA job description confirmed that individuals could not be used as nurse aides for more than four months without completing training and testing, and that the SNA role was limited to 120 days in which certification must be obtained.
Hot Water Temperature Exceeds Safe Limits in Resident Rooms
Penalty
Summary
The facility failed to maintain the hot water temperatures within the safe range of 100 to 110 degrees Fahrenheit in four out of ten resident rooms on the middle hall. During observations and interviews, it was found that the water temperatures in these rooms ranged from 114 to 117 degrees Fahrenheit. This was confirmed by the Maintenance Supervisor, who acknowledged that the temperatures were too high and attributed the issue to a recent adjustment made to the water heater's thermostat due to cold weather. The residents involved in this deficiency included individuals with varying cognitive abilities and medical conditions such as dementia, muscle wasting, and atrophy. Despite the elevated water temperatures, none of the residents reported having been burned or injured. The Maintenance Supervisor and the Administrator were both aware of the situation, and it was noted that the water heater serving the middle hall was not well insulated, which contributed to the temperature fluctuations. The facility's Weekly Water Temperature Log showed that prior to the incident, the temperatures had been within the acceptable range. However, the adjustment made to the water heater's thermostat was not reverted when the weather warmed, leading to the elevated temperatures. The facility's policy on hot water systems requires weekly checks to ensure temperatures remain between 100 and 110 degrees Fahrenheit, but this oversight resulted in a temporary lapse in compliance.
Failure to Label and Date Tuberculin Vial in Medication Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with professional principles in one of the two medication rooms inspected. During an observation and interview, it was found that the front medication room contained an opened and undated vial of Tuberculin (TB) medication in the refrigerator. The vial indicated that it should be discarded 30 days after being opened, but neither the vial nor the box had an open date written on it. The Director of Nursing (DON) acknowledged that staff were expected to date the vial upon opening, and the night shift was responsible for checking the refrigerator for expired medications and disposing of them. Without the date on the vial, it was difficult to determine when the solution would expire, potentially affecting its therapeutic effectiveness. The Administrator was informed of the issue and stated that the person who opened the vial forgot to date it. The Administrator also confirmed that the night shift was responsible for maintaining the medication room and removing undated medications. The facility's policy on medication storage, dated July 2012, indicated that multi-dose vials for injection should expire 30 days after the first puncture unless otherwise noted by the manufacturer. The lack of proper labeling and dating of the Tuberculin vial could lead to inaccurate readings due to the uncertainty of when it was opened.
Failure to Document Insulin Administration Decisions
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the administration of Lantus Insulin. The resident, a cognitively intact retired nurse, was actively involved in her diabetic management and requested that her Lantus be held at night if her sliding scale insulin was also held. LVN A, who had been working at the facility for three months, complied with the resident's request but failed to document the reason for withholding the insulin in the resident's progress notes. The resident's electronic Medication and Treatment Administration Record showed multiple instances where Lantus was held without signs of low blood sugar, but there was no documentation explaining the decision. During interviews, LVN A admitted to using nursing judgment and the resident's input to withhold the insulin but acknowledged the lack of detailed documentation as an error. The Regional Compliance Nurse confirmed that the facility's documentation policy was not followed, as there was no explanation in the progress notes for the withheld medication. The Medical Director stated that nurses should use their judgment in conjunction with the resident's request to determine care, and if there were any doubts, they should contact him. However, in this case, LVN A did not question the decision and did not document the rationale, leading to incomplete records. The facility's policy requires comprehensive and timely documentation, which was not met in this instance, as confirmed by the Regional Compliance Nurse.
Infection Control Breach During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to proper infection control protocols during incontinent care for a resident. The resident, who was admitted with diagnoses of Parkinson's disease and muscle weakness, was frequently incontinent of bowel. During an observation, CNA A was seen applying barrier cream to the resident's rectal area and then to the scrotum area without changing gloves, which could lead to cross-contamination. Interviews with staff revealed a lack of consensus on whether cross-contamination had occurred. CNA B confirmed witnessing the incident, while CNA A could not recall if she had cross-contaminated. The Director of Nursing (DON) expressed uncertainty about the potential for cross-contamination, suggesting that significant contact was necessary for contamination to occur. However, the Assistant Director of Nursing (ADON) acknowledged that CNA A should have changed gloves to prevent possible contamination, as the facility's policy requires changing gloves and performing hand hygiene between tasks. The facility's policies on infection control and perineal care emphasize the importance of hand hygiene and changing gloves to prevent the transmission of infections. Despite these policies, the incident with CNA A highlights a failure to adhere to established procedures, potentially placing residents at risk for infections. The facility's infection control program is designed to provide a safe and sanitary environment, but this incident indicates a lapse in following the necessary precautions to prevent the spread of infections.
Failure to Notify Physician of Resident's Hospital Transfer
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant need to alter treatment and a decision to discharge the resident to the hospital. This deficiency involved a resident who was transferred to the hospital due to elevated blood pressure. The resident, who had a history of congestive heart failure, Type II diabetes, anemia with chronic kidney disease, and hypertension, was admitted to the facility on 12/10/2024. On 12/25/2024, the resident's blood pressure was recorded at 186/112, and later at 199/80, prompting a request from the resident and her family member to be sent to the emergency room. Despite the elevated blood pressure readings and the subsequent transfer to the hospital, the facility did not notify the resident's physician of the change in condition or the transfer. Interviews with the facility's staff, including the Administrator and the Director of Nursing, revealed that the nurse on duty failed to contact the physician, which was against the facility's policy. The physician was only informed of the transfer six days later, on 12/31/2024. The lack of communication with the physician could have delayed medical treatment for the resident.
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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) |
|---|---|---|---|---|
| Cross Country Healthcare Center | 5.7 mi | ★★★★★ | 1 | 0 |
| Songbird Lodge | 6.4 mi | ★★★★★ | 15 | 0 |
| Pecan Bayou Nursing And Rehabilitation | 6.5 mi | ★★★★★ | 6 | 0 |
| Brownwood Nursing And Rehabilitation | 6.7 mi | ★★★★★ | 11 | 0 |
| Oak Ridge Manor | 6.8 mi | ★★★★★ | 5 | 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.