Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Fox Hollow Post Acute during CMS and state inspections, most recent first.
A resident with ESRD on dialysis and a confirmed UTI/E. coli infection did not receive ordered antibiotics as documented. After labs and a urine culture were obtained, the NP ordered Blujepa, then later changed the order to Invanz IV, but the MAR showed no documentation that either antibiotic was administered. Nursing notes also lacked documentation of medication delivery status or follow-up with the pharmacy or provider. The resident later became lethargic and hypotensive at dialysis, was sent to the hospital with septic shock, and later expired.
A resident with ESRD and dialysis had a UTI/E. coli infection identified in the care plan, but ordered antibiotics were not documented as administered. After weakness prompted lab work and a urine culture, the NP ordered Blujepa, then the infection preventionist discontinued it due to renal failure and ordered Invanz IV. The chart lacked documentation that either antibiotic was obtained or given, and the resident later became lethargic and hypotensive at dialysis, was sent to the hospital with septic shock, and later expired.
A disposable razor was found left on top of a linen cart in the 600 hallway, rather than being secured or disposed of in a sharps container. A CNA reported she had not noticed the razor and believed it was left by the previous shift, and both the CNA and an LVN acknowledged that the razor should have been placed in a sharps container to prevent resident injury. The DON stated that razors are supposed to be kept locked in the supply room for CNAs, consistent with facility policy that emphasizes maintaining an environment free from accident hazards and prioritizing resident safety and supervision.
Kitchen sanitation and food labeling deficiencies: Surveyors observed a juice machine spout with a green substance around the rim, refrigerated tomatoes and oranges that were not labeled or dated, and a case of coffee creamers in the pantry that was also not labeled or dated. The DM stated staff were responsible for cleaning the machine and that she was responsible for checking kitchen cleanliness, while the Administrator stated he did not know why the machine was not cleaned and that labels had fallen off due to the refrigerator being cold. Facility policy required equipment to be kept clean and food to be dated for proper rotation.
Two residents with severe cognitive impairment had their call lights left out of reach while lying in bed. One resident’s call light was dangling near the floor, and the other’s was tucked between the mattress and bedrail; the second resident said he did not know where the button was or how he would call for the nurse. Staff, including CNA, LVN, ADON, DON, and the Administrator, stated call lights were supposed to be within reach and that everyone was responsible for ensuring this.
Failure to Care Plan Resident’s Refusal to Wear Shoes or Non-Skid Socks: A resident with muscle weakness, lack of coordination, unsteadiness on feet, and moderate cognitive impairment was observed in the dining room without shoes or non-skid socks. Staff stated the resident refused to wear them and that nurses were aware of the refusal, but the care plan had no goals, interventions, or tasks addressing the behavior. The DON stated the refusal should have been care planned and that the MDS nurse and all nurses were responsible for updating the care plan.
A resident with an indwelling Foley catheter and severely impaired cognition had the catheter drainage bag observed on the floor beside the bed. Staff stated the bag should not touch the floor, noting it could pick up bacteria and contribute to UTI risk. The resident’s care plan and order summary included Foley catheter care and keeping the bag and tubing below bladder level and off the floor.
Oxygen therapy was not managed as ordered for two residents. One resident with pneumonia, CHF, asthma, and dementia was receiving O2 via NC at 2 LPM without a physician order in the chart, and staff confirmed the order was missing. Another resident with cerebral infarction, CHF, CKD, HTN, and DM2 had an order for continuous O2 at 3 LPM, but the concentrator was observed set at 2 LPM until the ADON adjusted it. Staff stated the setting had not been checked as expected.
Medication administration errors exceeded the allowed rate when staff failed to follow ordered parameters for one resident’s Amiodarone and Metoprolol by not checking pulse before administration, and another resident’s Novolin R insulin was not given because the sliding scale order was entered incorrectly and omitted a blood sugar range. The MA, LVN, ADON, and DON all acknowledged the errors during observation and interview, and the residents had diagnoses including cardiac conditions and diabetes with hyperglycemia.
An LVN left the 400 hall med cart unlocked and unattended while getting supplies and entering a resident’s room, and the ADON and DON confirmed carts must be locked whenever staff step away. In a separate observation, Melatonin 5 mg in the 100 hallway med cart did not have an open date on the bottle, and the LVN and DON stated OTC meds should be labeled with the opened date.
A CNA provided direct care to residents for several months with an expired certification due to lapses in the facility's verification and reminder processes. Leadership and HR were unaware of the expired status until a review was conducted, and the CNA continued to work without a valid certification, contrary to facility policy.
A resident who was fully dependent for transfers suffered a fractured toe when her foot struck the mast of a mechanical lift during a transfer by two CNAs who failed to protect her feet and did not immediately report the incident, despite the resident expressing pain. The facility lacked a policy on mechanical lift use and did not ensure staff consistently reported changes in resident condition, contributing to the injury.
A facility failed to provide a resident and their representative with written notice of the bed-hold policy when the resident was transferred to a hospital. The resident, with multiple health conditions, was readmitted to the facility without documentation of a bed-hold notice. Interviews revealed confusion over responsibility for issuing these notices, contrary to the facility's policy requiring notice both in advance and at the time of transfer.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen administration. A resident with severe cognitive impairment and respiratory conditions received oxygen at an incorrect rate, while another resident with heart failure and respiratory failure also received oxygen at an incorrect rate. Additionally, a resident with morbid obesity and muscle weakness was receiving oxygen therapy without appropriate orders, highlighting a significant oversight in the facility's respiratory care management.
A facility failed to maintain proper infection control practices, as evidenced by an LVN entering a resident's room on contact precautions without PPE and an AD handling food without changing gloves after touching a resident's wheelchair. Despite regular in-service training, these incidents highlight lapses in adherence to infection control protocols.
A resident with multiple health conditions was admitted to an LTC facility without physician orders for necessary oxygen therapy. Despite receiving oxygen since admission, the facility's records did not initially reflect this need, and staff confirmed the absence of timely orders. The facility's policies require physician orders for oxygen, which were not obtained, placing the resident at risk.
The facility failed to develop comprehensive care plans for two residents, one requiring oxygen therapy and another with Alzheimer's disease. The care plans did not reflect the residents' needs due to missing documentation and communication issues among staff, leading to inadequate care planning.
The facility failed to store and prepare food according to professional standards, as raw beef was improperly stored next to lettuce in the refrigerator, and raw meat was thawed in a 3-compartment sink. Staff interviews confirmed that these practices did not comply with the facility's policies and the FDA Food Code, posing a risk of cross-contamination.
A facility failed to accurately document a resident's falls in the Discharge MDS assessment. The resident, with severe cognitive impairment and multiple health issues, experienced falls that were noted in the care plan but not reflected in the MDS. Interviews with staff confirmed the oversight, which could lead to improper care due to inaccurate records.
A resident reported her wallet missing, but the facility failed to complete the grievance form and follow up on the issue. The resident was not informed about the investigation, except that a police report was made. The Administrator admitted to not filling out the form, and the DON explained that grievances were documented in binders and discussed in meetings, but the responsibility for completion varied.
A resident with pneumonia and severely impaired cognition was prescribed continuous oxygen therapy, but the facility failed to include this in the care plan. Despite the resident using oxygen, it was not documented in the care plan or marked in the MDS assessment. Interviews with staff revealed a lack of coordination in updating the care plan, leading to the deficiency.
A resident with severe cognitive impairment and multiple medical conditions was found with a urinary catheter bag touching the floor, contrary to facility policy. Staff interviews revealed inconsistencies in catheter care practices, posing a risk for cross-contamination and urinary tract infections.
A resident was discharged from a facility without the required 30-day notice due to financial issues and non-compliance with Medicaid application processes. The resident's family member was informed of the discharge only a few days prior, and the facility staff believed the discharge was mutually agreed upon. However, the facility's policy did not explicitly require a 30-day notice, leading to the deficiency.
The facility failed to re-admit a resident after hospitalization, despite a pending appeal against a discharge notice. The resident had a history of aggressive behavior and medication refusal, and the facility cited these issues as reasons for not allowing his return, violating their written policy.
Failure to Administer Ordered Antibiotics for Confirmed UTI
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease and dialysis needs received treatment and care in accordance with provider orders and the resident’s care plan for a confirmed urinary tract infection. The resident had a comprehensive care plan that included antibiotic therapy for UTI/E. coli, and nursing notes documented complaints of generalized weakness, provider notification, and orders for lab work including a CBC, CMP, ammonia level, urinalysis, and urine culture. After the urine culture results were reported to the NP, an order was given for Blujepa 750 mg twice daily for 5 days and a consult with the infection preventionist. The record showed no documentation that Blujepa was administered, no documentation of the medication’s delivery or acquisition status, and no documentation of follow-up communication with the pharmacy or provider regarding the delay. Later, the NP discontinued Blujepa and ordered Invanz 500 mg IV nightly for 10 days, but the MAR also showed no documentation that Invanz was administered. Before the resident received the ordered antibiotic treatment, she became lethargic and hypotensive while at dialysis and was sent to the hospital by EMS. The resident was admitted with septic shock, NSTEMI, and thrombocytopenia, and later expired from cardiac arrest. During interviews, the NP stated he waited for culture results because the resident had no symptoms, the pharmacy stated the Blujepa order had been received but typically took 3 to 4 days to arrive, and nursing staff stated they did not document follow-up on the medication status or estimated arrival time.
Missed Antibiotic Therapy for Resident With UTI
Penalty
Summary
The facility failed to ensure a resident was free of significant medication errors related to antibiotic therapy for a urinary tract infection. The resident had end stage renal disease and received dialysis while living at the facility. Her care plan identified antibiotic therapy for a UTI/E. coli infection, with interventions to administer antibiotics as ordered and to monitor and document side effects and effectiveness every shift. After the resident complained of generalized weakness, nursing staff contacted the NP, who ordered lab work and later a urinalysis with culture. When the urinalysis results were reported, no new orders were given at that time. After the urine culture results were reported, the NP ordered Blujepa 750 mg twice daily for 5 days and a consult with the infection preventionist. The medication administration record showed no documentation that Blujepa was administered, and the chart contained no documentation about whether the medication had been delivered or acquired, or any follow-up communication with the pharmacy or provider regarding the delay. Later, the infection preventionist discontinued Blujepa because it was contraindicated for residents with renal failure and ordered Invanz 500 mg IV nightly for 10 days. The medication administration record also showed no documentation that Invanz was administered. Nursing notes reflected that the resident became lethargic and hypotensive while at dialysis and was sent to the hospital by EMS. The resident was admitted with septic shock, NSTEMI, and thrombocytopenia, and the hospital record reflected that she later expired from cardiac arrest.
Unsecured Disposable Razor Left on Hallway Linen Cart
Penalty
Summary
Surveyors identified a deficiency when a disposable razor was found left on top of the 600 hallway linen cart, rather than being secured or disposed of properly. During an evening observation, the surveyor saw the razor on the cart, and a CNA on duty acknowledged she had not noticed it and stated it had been left there by the previous shift. The CNA further stated the razor should have been disposed of in a sharps container because any resident could grab it and get hurt. An LVN also confirmed that the razor should not have been on top of the linen cart and should have been disposed of in a sharps container. The DON later stated that razors are supposed to be kept under lock and key in the supply room for CNAs and acknowledged that any resident could grab the razor and cause harm. Facility policy on Safety and Supervision of Residents, revised July 2017, states that the facility strives to make the environment as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. This deficiency reflects the facility’s failure to ensure the resident environment remained as free of accident hazards as possible by allowing a disposable razor to be left unsecured on a linen cart in a resident hallway, contrary to staff statements and written policy regarding safe handling and storage of razors.
Kitchen sanitation and food labeling deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. During observation of the juice machine on 01/20/26 at 8:27 AM, one of the spouts had a green substance around the entire rim. During observation of the walk-in refrigerator on 01/20/26 at 8:31 AM, a plastic container of tomatoes and a plastic container of oranges were found not labeled or dated to show when they were received. During observation of the walk-in pantry on 01/20/26 at 8:40 AM, a case of five coffee creamer bottles was also found not labeled or dated to show when it was received. In an interview on 01/20/26 at 8:47 AM, the DM stated that all staff were responsible for cleaning the juice machine and that equipment used after breakfast was cleaned every morning. The DM stated she was responsible for checking that the kitchen and equipment were clean but had forgotten to look at the juice machine spout. The DM also stated she had a system for labeling food items, with the morning shift labeling refrigerated foods and the afternoon shift labeling dry foods, and that she or the cook oversaw that all food items were labeled properly. In an interview on 01/22/26 at 9:32 AM, the Administrator stated he did not know why the juice machine was not cleaned and stated that labels fell off the plastic containers in the refrigerator because the refrigerator was cold. The Administrator also stated he did not know why the coffee creamers were not labeled. Record review showed the Sanitation policy required utensils, counters, shelves, and equipment to be kept clean, and the Refrigerators and Freezers policy required all food to be appropriately dated for proper rotation by expiration dates, with received dates marked on cases and individual items removed from cases for storage.
Call Lights Left Out of Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach while they were in bed. Resident #1 had diagnoses including hypertension, nontraumatic intracerebral hemorrhage, stroke, and speech and language deficits following stroke. His quarterly MDS showed severe cognitive impairment with a BIMS score of 03, dependence on two or more staff for bed mobility, eating, showering/bathing, and toileting, and frequent bowel and bladder incontinence. Resident #1’s care plan addressed cognitive impairment and included interventions to anticipate needs and meet them promptly. Resident #2 had diagnoses including Alzheimer’s disease, dementia, white matter disease, and heart disease. His Medicare 5-day MDS showed severe cognitive impairment with a BIMS score of 05, supervision or touching assistance needed for eating, dependence on two or more staff for showering/bathing, partial to moderate assistance with toileting, and occasional bowel incontinence with bladder continence not rated due to catheter. His care plan addressed impaired cognitive function and included interventions to ask yes/no questions, cue and reorient as needed, and monitor for changes in cognitive function. During observation, Resident #1 was lying in bed with the head of bed inclined and the call light was not within reach; it was at the head of the bed to the side dangling toward the floor. Resident #2 was also lying in bed with the head of bed inclined and his call light was not in reach; it was tucked between the mattress and the bedrail. Resident #2 stated he did not know where the button for the light was and did not know how he would call for the nurse if he needed anything. Staff interviews confirmed that the call lights were supposed to be within residents’ reach, that everyone was responsible for ensuring this, and that the facility’s policy required the call light to be within easy reach when a resident was in bed.
Failure to Care Plan Resident’s Refusal to Wear Shoes or Non-Skid Socks
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #72 that included measurable objectives and time frames to meet the resident’s medical, nursing, mental, and psychosocial needs. Resident #72 was a 66-year-old male with diagnoses including muscle weakness, unspecified lack of coordination, and unsteadiness on feet. His quarterly MDS assessment dated 11/30/25 showed moderate cognitive impairment, that he was able to make himself understood, usually able to understand others, and able to walk 10 feet, 50 feet, and 150 feet with supervision or touching assistance. Record review of the comprehensive care plan dated 12/1/25 showed no focus, goals, or interventions/tasks related to Resident #72’s behavioral issue of refusing to wear shoes or non-skid socks. During observation on 1/20/26 at 12:30 p.m., Resident #72 was in the dining room without shoes or non-skid socks. CNA J stated that Resident #72 refused to wear shoes or non-skid socks and that nurses were aware of the refusal. LVN K stated the refusal should have been reported to the DON and said she was sure the refusal was already care planned, but it was not. The DON stated that when a resident refused to wear shoes it should have been care planned and that the MDS nurse and all nurses were responsible for updating the care plan.
Foley Drainage Bag Left on Floor
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling Foley catheter when the catheter tubing and drainage bag were found touching the floor. Resident #116 was an [AGE]-year-old male admitted with obstructive and reflux uropathy, had severely impaired cognition with a BIMS score of 4, and was documented as having an indwelling catheter on the MDS. His care plan included keeping the catheter bag and tubing below bladder level and away from the entrance room door, and the physician order summary included Foley catheter care every shift and as needed. During observation, Resident #116’s catheter bag was noted laying on the floor on the right side of the bed. A CNA was informed and stated the Foley bag should not be touching the floor; after sanitizing hands and putting on gloves, she hung the bag on the bedframe. An LVN stated the bag should not touch the floor and that a negative outcome would be that the Foley would not drain well and could pick up bacteria from the floor. The DON also stated the bag should not be touching the floor because it could cause a urinary infection, and the facility policy stated the catheter tubing and drainage bag are to be kept off the floor.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who required oxygen therapy. Resident #132, an older female with diagnoses including pneumonia, congestive heart failure, moderate persistent asthma, and dementia, was observed lying in bed receiving oxygen via nasal cannula at 2 LPM even though there was no physician order for oxygen in the electronic chart. Her care plan identified her as at risk for respiratory complications due to shortness of breath and directed oxygen therapy as ordered. During interviews, the LVN confirmed that no physician oxygen order was in place for Resident #132 and stated that the resident required continuous oxygen via nasal cannula. The ADON covering the hall also confirmed the absence of an oxygen order and stated that the admitting nurse was responsible for entering the order right away. The DON stated that nurses were responsible for following physician orders and that oxygen could not be administered without a physician order. Resident #3, an older female with diagnoses including cerebral infarction, congestive heart failure, heart disease, chronic kidney disease, hypertension, and type 2 diabetes mellitus, had a physician order for oxygen at 3 LPM continuous via nasal cannula per concentrator. On observation, the oxygen concentrator was set at 2 LPM instead of the ordered 3 LPM. The nurse verified the incorrect setting and stated she had not yet checked the oxygen in the room, while the ADON stated the family tended to move the oxygen setting and that she had found it at 2 LPM and increased it to 3 LPM. The DON stated that every nurse entering the room should have checked the oxygen setting to ensure the correct rate.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with 3 errors identified during 27 medication administration opportunities for an 11.11% error rate. Two residents were involved in the findings: one resident with diagnoses including hypertension, atrial fibrillation, peripheral vascular disease, and other circulatory disorders, and another resident with type 2 diabetes mellitus with hyperglycemia, chronic kidney disease, and muscle wasting and atrophy. Both residents were assessed as cognitively intact with BIMS scores of 13. For the resident receiving Amiodarone and Metoprolol, the medication administration observation showed the MA checked blood pressure but did not check the pulse before preparing and administering the medications. The MA documented the medications first, then returned to check the pulse only after the computer system prompted for it when documenting Amiodarone. The MA stated she was supposed to check the pulse before giving the medications and acknowledged she did not do so because she got nervous. The ADON and DON both stated that pulse and blood pressure were to be checked before administering these medications because both had hold parameters for pulse less than 60. For the resident receiving Novolin R insulin, the medication was not administered during the observed pass because the sliding scale order had been entered incorrectly into the computer system. The LVN entered a blood sugar of 233, but the system did not prompt for insulin because the 200-249 range had been omitted from the order entry. The LVN stated she had entered the order on the date it was received and later corrected it after reviewing the order with the surveyor. The ADON and DON stated the order should have been reviewed and caught, and the DON stated it was her responsibility to have caught the error.
Unlocked Medication Cart and Missing Open Date on OTC Medication
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled in accordance with accepted professional principles. During an observation, the 400 hall nurse’s medication cart was left unlocked and unattended by an LVN while she got supplies from the cart and walked into a resident’s room, and then left it unlocked again when she returned to the cart before administering G-tube medication. The LVN stated she was responsible for the cart and had forgotten to lock it because she was nervous during the observation. The ADON stated it was the nurse’s responsibility to keep the medication cart locked every time they stepped away, and the DON stated the carts should be locked immediately before walking away from them. The facility also failed to ensure an OTC medication in the 100 hallway medication cart had an opened date written on the bottle. During observation, Melatonin 5 mg in the cart did not have an open date. The LVN stated OTC medications should have an open date written on them and that it was important to know how long the bottle had been opened. The DON stated the bottle was still within the expiration date but would be disposed of because the facility did not know when it had been opened.
Failure to Ensure Nurse Aide Maintained Active Certification
Penalty
Summary
The facility failed to ensure that a nurse aide (CNA A) maintained a current and active certification while employed and providing direct care to residents. Record reviews showed that CNA A's nurse aide certification had expired, and she continued to work for approximately four months, accumulating around 700 hours of resident care with an expired certification. The Texas Nurse Aide Public Registry confirmed the expired status, which rendered CNA A not employable as a nurse aide in a licensed nursing facility in Texas during that period. Interviews with facility leadership, including the Administrator, DON, and HR, revealed a lack of consistent and timely verification of staff certification statuses. The Administrator and DON were unaware of the expired certification until it was identified during a review, and both stated that staff were responsible for renewing their certifications, with HR acting as a backup. HR confirmed that certifications were checked upon hire and then yearly, but no reminders or regular reports were sent to staff or leadership regarding upcoming expirations. The facility's policy required staff to present recertifications prior to expiration and maintain current certification, but this was not followed in CNA A's case. CNA A stated she was unaware her certification had expired and had relied on previous reminders from the facility, but acknowledged it was ultimately her responsibility to ensure her certification was active. She continued to provide care to residents during the period her certification was expired. The deficiency was identified when personnel files were reviewed, and it was confirmed that CNA A had been working without a valid certification, contrary to facility policy and regulatory requirements.
Failure to Protect Resident During Mechanical Lift Transfer Results in Injury
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent for transfers due to a history of cerebral infarction and spinal stenosis, was being transferred from bed to wheelchair using a mechanical lift by two CNAs. During the transfer, the resident's left foot struck the mast of the mechanical lift, resulting in an acute fracture of the third digit proximal phalanx. The CNAs failed to protect the resident's feet during the transfer, and did not immediately report the incident to the charge nurse, despite the resident expressing pain and showing signs of injury. The resident later reported severe pain to an Occupational Therapy Assistant (OTA) during therapy, who observed bruising and escalated the concern to the Director of Rehabilitation (DOR) and then to the LVN. The LVN assessed the resident, noted discoloration, and notified the nurse practitioner, who ordered x-rays confirming the fracture. Interviews revealed that both CNAs involved in the transfer did not consider the incident significant enough to report at the time, even though the resident had expressed discomfort and grunted when her foot was injured. Further review found that the facility did not have a policy on mechanical lift use, and staff had not consistently reported changes in resident condition as required. The lack of a mechanical lift policy and failure to ensure adequate supervision and protection during transfers contributed to the accident and subsequent injury. These failures placed residents at risk of injury due to inadequate hazard prevention and supervision.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to provide written notice to a resident and their representative regarding the duration of the bed-hold policy when the resident was transferred to a hospital. This deficiency was identified during a review of the resident's records and interviews with facility staff and the resident's representative. The resident, an elderly female with multiple diagnoses including muscle weakness, encephalopathy, type 2 diabetes, Alzheimer's disease, and seizures, was admitted to the hospital and later readmitted to the facility. However, there was no documentation of a bed-hold notice being provided at the time of the hospital transfer. Interviews with the Director of Nursing (DON) and the facility Administrator revealed a lack of clarity regarding the responsibility for issuing bed-hold notices. The DON indicated that nursing was not responsible for providing these notices, while the Administrator stated that the bed-hold form was included in the admission agreement and managed by the Business Office Manager, who was unavailable at the time. The facility's policy requires that residents and their representatives receive written notice of the bed-hold policy both in advance of any transfer and at the time of transfer, but this procedure was not followed in this case.
Deficiencies in Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen administration. Resident #260, a 75-year-old female with severe cognitive impairment and multiple respiratory conditions, was observed receiving oxygen at 2.5 LPM instead of the prescribed 2 LPM. The nurse responsible for Resident #260 claimed the concentrator's reading was accurate when checked at a slanted angle, but this was inconsistent with the prescribed rate. Despite the discrepancy, Resident #260 did not exhibit symptoms of respiratory distress at the time of observation. Similarly, Resident #261, an 82-year-old female with acute and chronic congestive heart failure and respiratory failure, was observed receiving oxygen at 1.5 LPM instead of the prescribed 2 LPM. The nurse assigned to Resident #261 also claimed the concentrator's reading was accurate when checked at a slanted angle. Although Resident #261 did not show signs of respiratory distress during the observation, the incorrect oxygen rate could potentially lead to complications. Resident #79, a 73-year-old female with morbid obesity and muscle weakness, was receiving oxygen therapy without appropriate orders. The resident had been on oxygen since admission, but there were no documented orders for continuous oxygen therapy until a PRN order was received later. Staff interviews revealed that the resident had been receiving oxygen intermittently, and there was confusion about the necessity of a physician's order for oxygen administration. The lack of proper documentation and verification of orders for Resident #79's oxygen therapy highlighted a significant oversight in the facility's respiratory care management.
Infection Control Lapses in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by two specific incidents involving staff members. In the first incident, a Licensed Vocational Nurse (LVN) entered the room of a resident on contact precautions without donning the required personal protective equipment (PPE), specifically a gown and gloves. This was despite clear signage indicating the need for such precautions. The LVN believed that PPE was only necessary when providing direct care, such as wound care, rather than upon entering the room. Interviews with other staff members, including Certified Nursing Assistants (CNAs) and the Director of Nursing (DON), revealed a general understanding of the need for PPE in such situations, although the LVN's actions suggested a lapse in adherence to these protocols. In the second incident, an Activity Director (AD) was observed handling food while wearing gloves, then touching a resident's wheelchair without changing gloves before resuming food handling. The AD acknowledged the need to change gloves and perform hand hygiene after touching potentially contaminated surfaces, yet failed to do so in practice. This incident highlights a gap between knowledge and execution of infection control practices, as confirmed by interviews with the AD and other staff members who reiterated the importance of hand hygiene and glove changes between tasks. The facility's policies on hand hygiene and transmission-based precautions were reviewed, indicating that staff are regularly in-serviced on these protocols. However, the observed deficiencies suggest that despite frequent training, there are inconsistencies in the application of infection control measures. The facility's leadership, including the DON and Administrator, acknowledged the importance of these protocols and the need for staff to adhere to them to prevent the spread of infections within the facility.
Failure to Obtain Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #79, had physician orders for immediate care upon admission, specifically for oxygen therapy. Resident #79, a 73-year-old female with diagnoses including morbid obesity, muscle wasting, muscle weakness, and hypertension, was admitted to the facility and required continuous oxygen therapy. However, the care plan completed shortly after admission did not reflect the need for oxygen therapy, and there were no initial physician orders for oxygen documented in the resident's medical records. Despite the absence of documented orders, Resident #79 was observed receiving oxygen therapy, and staff interviews confirmed that the resident had been on oxygen since admission. The facility's staff, including a CNA and LVN, acknowledged that the resident had been using oxygen intermittently, and the LVN mentioned that the resident was initially taken off oxygen upon admission due to stable oxygen saturation levels. However, a new order for PRN oxygen was only received on a later date, after the resident exhibited symptoms of shortness of breath and edema. The facility's policies on oxygen administration and medication orders require a physician's order for oxygen therapy, which was not obtained in a timely manner for Resident #79. Interviews with the ADON and DON revealed that there were no standing orders for PRN oxygen, and the facility's protocol was not followed, as there were no progress notes indicating respiratory distress prior to the receipt of the PRN oxygen order. This oversight placed the resident at risk of not receiving appropriate physician-ordered care.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which led to deficiencies in their care. Resident #79, a 73-year-old female with multiple diagnoses including morbid obesity and hypertension, was not provided with a care plan that included her need for oxygen therapy. Despite being on oxygen since her admission, this requirement was not reflected in her care plan or MDS assessment. Interviews with staff revealed a lack of communication and documentation regarding the resident's oxygen therapy, which was not included in the care plan due to missing orders in the system. Resident #100, diagnosed with Alzheimer's disease, also did not have a comprehensive care plan addressing her condition or the medication memantine prescribed for her dementia. The care plan was not completed within the required timeframe, and staff interviews indicated a breakdown in the process of updating and communicating care plans. The MDS Nurse was unaware of the need for specific care due to the absence of orders in the chart, leading to an incomplete care plan. The facility's policy requires the development of a comprehensive, person-centered care plan within 21 days of admission, but this was not adhered to for the residents in question. The lack of proper care planning could result in inadequate care and services for the residents, as staff rely on these plans to understand and meet the residents' needs. The deficiency highlights issues in the facility's documentation and communication processes, which are crucial for ensuring residents receive appropriate care.
Improper Food Storage and Preparation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the storage and preparation of food. During an observation of the kitchen, it was noted that raw beef was improperly stored next to lettuce on a shelf inside the walk-in refrigerator. Additionally, raw meat was observed being thawed in a 3-compartment sink, which is not in line with safe food handling practices. Interviews with staff confirmed that the raw meat should have been stored on the bottom shelf to prevent cross-contamination, as per the facility's policy and the U.S. Food and Drug Administration Food Code. The facility's policy on food receiving and storage, revised in November 2022, clearly states that uncooked and raw animal products should be stored separately and below fruits and vegetables to prevent contamination from meat juices. The deficiency was further highlighted by the facility's policy on food preparation and service, which mandates compliance with safe food handling practices. The failure to follow these guidelines was acknowledged by the staff and the administrator, indicating a lapse in adherence to established protocols designed to protect residents from foodborne illnesses.
Failure to Accurately Document Resident Falls in Discharge MDS
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the status of a resident, specifically regarding falls. The resident, an 83-year-old female with Alzheimer's, dementia, muscle wasting, and osteoporosis, was discharged to home with family. Her Discharge MDS assessment did not reflect any falls, despite the care plan indicating that she had experienced falls on two occasions: once while self-transferring from the restroom to bed, resulting in a laceration below the chin, and another time with discoloration to the eyebrow, which the resident attributed to a fall in the restroom. Interviews with the MDS/LVN Coordinator and the DON confirmed that the falls should have been captured in the Discharge MDS assessment if they occurred within the look-back period. The facility's policy requires comprehensive assessments at designated intervals, and all persons completing any portion of the MDS must attest to the accuracy of the information. The failure to document the falls in the Discharge MDS could lead to improper care due to inaccurate records.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident who reported her wallet missing. The resident, who had no cognitive impairment and was able to communicate effectively, reported the missing wallet to the Administrator. However, the grievance form was incomplete, lacking details such as the person investigating, the Administrator's signature, and the resolution. The resident stated she was not informed about the investigation, except that a police report was made. Interviews with the Administrator and the Director of Nursing (DON) revealed that the grievance was resolved when it was discovered that the resident's son had the wallet. However, the Administrator admitted to not filling out the grievance form. The DON explained that grievances were documented in binders at each nurse's station and discussed in morning meetings, but the responsibility for completing the grievance depended on its nature. The facility's grievance policy indicated that grievances should be filed within a specific time frame, but the incomplete documentation suggested a lack of adherence to this policy.
Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically addressing the need for oxygen therapy. The resident, a male with a diagnosis of pneumonia and severely impaired cognition, was prescribed continuous oxygen therapy at 2 liters per minute via nasal cannula. Despite this prescription, the resident's care plan did not include oxygen therapy, and the quarterly MDS assessment did not mark oxygen use. This oversight was identified during a record review and observation, where the resident was seen using oxygen without it being documented in the care plan. Interviews with facility staff, including the ADON, MDS nurse, and DON, revealed a lack of coordination and responsibility in updating the care plan to include oxygen therapy. The MDS nurses were identified as responsible for updating care plans, but the omission was not caught during the facility's morning meetings or by the charge nurses who input physician orders. The facility's policy requires that a comprehensive care plan be developed within seven days of the resident's comprehensive assessment, but this was not adhered to, leading to the deficiency.
Inadequate Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling catheter, leading to a deficiency in preventing urinary tract infections. The resident, a male with severe cognitive impairment and multiple medical conditions including obstructive and reflux uropathy, was observed with his urinary catheter bag touching the floor. This situation was identified during an interview and observation, where the resident mentioned recent discomfort due to a blocked catheter. The facility's policy requires catheter tubing and drainage bags to be kept off the floor to prevent infection. Interviews with staff, including an LVN and the DON, revealed inconsistencies in catheter care practices. The LVN acknowledged the catheter bag should be hung and corrected the situation upon observation. The DON mentioned that while the catheter system is closed, contact with the floor could pose a risk if the system is open. Another LVN confirmed the risk of infection if the catheter bag touches the floor, emphasizing the importance of immediate correction. Despite these acknowledgments, the facility's failure to consistently adhere to its catheter care policy resulted in a potential risk for cross-contamination and urinary tract infections.
Failure to Provide 30-Day Discharge Notice
Penalty
Summary
The facility failed to provide a 30-day notice of discharge to a resident and their representative before the resident was discharged home. The resident, a male with multiple health conditions including a heart attack, diabetes, and heart disease, was discharged without the required notice. The resident's family member was informed of the discharge only a few days prior, and the discharge was executed due to financial reasons and non-compliance with the Medicaid application process. The resident's family member had been asked multiple times to provide bank statements necessary for the Medicaid application, but she refused, stating she did not intend for the resident to stay long-term. Despite the facility's attempts to obtain the necessary documentation, the family member did not comply, leading to a significant outstanding balance. The facility decided to discharge the resident due to the financial situation and the family's indication that they would take the resident home. Interviews with facility staff, including the Social Worker, BOM, and Administrator, revealed a lack of clarity and communication regarding the discharge process and the necessity of a 30-day notice. The staff believed that the discharge was mutually agreed upon due to the financial circumstances, but the required notice was not provided. The facility's policy did not explicitly include the requirement for a 30-day discharge notice, contributing to the oversight.
Failure to Re-Admit Resident After Hospitalization
Penalty
Summary
The facility failed to re-admit a resident after hospitalization, violating their written policy on permitting residents to return after hospitalization or therapeutic leave. The resident, a male with a history of hypertensive heart disease, vascular dementia, and major depressive disorder, was initially admitted to the facility in 2020. He exhibited physical and verbal behavioral symptoms, including aggression towards other residents and staff, and had a history of refusing medications. Despite these challenges, the facility had a care plan in place to manage his behaviors, including psychological assessments and various interventions to alleviate his anxiety and aggression. The resident was sent to the hospital after an incident where he hit a female resident in the face. The hospital cleared him for return, but the facility refused to re-admit him, citing his aggressive behavior and refusal to take medications as reasons. The facility had issued a 30-day discharge notice prior to the hospitalization, stating that they could not meet his needs and that he was a threat to the health and safety of other residents and staff. The resident's responsible party had appealed this discharge notice, and a hearing was scheduled, but the facility still refused to re-admit him after his hospital stay. Interviews with the Director of Nursing (DON), a Med Aide, and the hospital staff confirmed the resident's aggressive behavior and refusal to take medications. The facility's policy stated that residents should not be transferred or discharged while an appeal is pending unless their presence endangers the health or safety of others. Despite this policy, the facility did not allow the resident to return, citing multiple incidents of aggression and the inability to manage his care needs as justification for their decision.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 104 citations issued within 25 miles in the last 12 months — including the 2 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Mesa Hills Post Acute | 1.7 mi | ★★★★★ | 6 | 0 |
| Alta Vista Rehabilitation And Healthcare | 1.7 mi | ★★★★★ | 16 | 0 |
| Las Alturas Nursing & Transitional Care Brownsvill | 1.9 mi | ★★★★★ | 2 | 0 |
| Brownsville Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 4 | 0 |
| Ebony Lake Nursing And Rehabilitation Center | 2.7 mi | ★★★★★ | 14 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.