Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Las Alturas Nursing & Transitional Care Brownsvill during CMS and state inspections, most recent first.
Surveyors found that a medication cart on the 200 hall was left unlocked and unattended, with resident medications accessible inside. An LVN responsible for the cart acknowledged that it should have been locked whenever she walked away and that residents’ medications were stored in the cart. The DON reported that multiple staff, including the DON and ADON, were responsible for ensuring medication carts were locked and confirmed the expectation that carts be secured when unattended, noting that a resident or visitor could obtain medications and be harmed if the cart was left unlocked.
A nurse administered an IV antibiotic to a resident without verifying that the medication bag was labeled with the correct resident's name, as required by facility policy. The error was discovered after the medication had infused for a short time, when a family member noticed the discrepancy. The resident had multiple complex medical conditions and severe cognitive impairment, and the incident occurred despite clear physician orders and established medication administration procedures.
Two residents with dementia and mobility impairments were found unable to reach their call lights, which were observed on the floor during a survey. Both residents confirmed they could not access the devices, and staff interviews acknowledged the expectation that call lights be within reach. Facility policy requires call lights to be accessible, but this was not followed in these cases.
The facility did not coordinate assessments with the PASRR program or refer residents for necessary services, resulting in a deficiency related to regulatory compliance.
A resident with a diagnosis of PTSD and moderate cognitive impairment did not have PTSD addressed in their care plan, despite facility policy requiring all identified needs to be included. Staff interviews revealed a lack of awareness about the need to care plan for PTSD, resulting in the omission of measurable objectives and interventions for this condition.
A resident with a gastrostomy tube and severe cognitive impairment did not have a label on her enteral feeding bottle, as required by facility policy and physician orders. Nursing staff and the DON confirmed that proper labeling is necessary to ensure the correct feeding and rate are administered, but this was not done in this case.
A resident with pulmonary fibrosis and muscle weakness, who required oxygen therapy, did not receive oxygen at the physician-ordered setting of 2 LPM via nasal cannula. Instead, the oxygen concentrator was set at 1.5 LPM, as confirmed by the assigned LVN and DON, both of whom acknowledged the requirement to follow physician orders and check oxygen settings each shift.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not honored by the facility.
Two residents were discharged—one to a hospital and one to home—without the required notification being sent to the state LTC Ombudsman. Record reviews and staff interviews confirmed that the facility did not provide discharge notices as mandated by policy, and staff were unaware of this requirement.
A resident with severe cognitive impairment and a history of wandering eloped from the facility after a visitor, unaware of the resident's status, opened the door and allowed the resident to exit. The resident was last seen by an LVN, redirected to a common area, but left unsupervised when the staff member became occupied. The secured unit was not open at the time, and the resident was later found by police and returned without injury.
Two residents did not have baseline care plans completed or accurately documented within 48 hours of admission. One resident's care plan was delayed by several days, and another's care plan failed to note the presence of a PICC line. Staff interviews revealed confusion about responsibilities for care plan completion, and the facility's policy lacked specific guidance on baseline care plans.
A resident with severe cognitive impairment did not have their PRN acetaminophen administration documented in the eMAR, despite it being given for pain after a skin tear. The facility's policy did not require PRN medications to be signed off in the eMAR, leading to a deficiency in pharmaceutical services.
Unattended, Unlocked Medication Cart on 200 Hall
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of drugs and biologicals when the 200 hall medication cart was observed unlocked and unattended. On 3/3/2026 at 3:40 p.m., the 200 hall nurse’s medication cart, containing medications for residents on that hallway, was found in the hallway without the responsible LVN present and without the cart being secured by a lock. When the surveyor called the LVN’s attention to the unlocked cart, the LVN returned and locked it. In an interview at that time, the LVN acknowledged responsibility for the cart, stated that she was expected to lock it whenever she walked away, and confirmed that residents’ medications were stored inside and could be accessed if the cart was left unlocked. In a separate interview at 4:00 p.m., the DON stated that multiple staff, including the DON and ADON, were responsible for ensuring medication carts were locked, and confirmed the expectation that staff lock the cart when walking away, noting that a resident or visitor could grab medication from an unlocked cart and be harmed.
Failure to Ensure Accurate Labeling and Administration of IV Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate labeling and administration of intravenous medication for a resident. On the specified date, a nurse administered an IV antibiotic, Meropenem, to a resident without verifying that the medication bag was correctly labeled with the resident's name. The nurse noticed only the medication name and dosage, but did not check the label for the resident's name, and was alerted to the issue by a family member who pointed out that the name on the medication bag was different. The medication had already been infused for less than five minutes before the error was discovered. The resident involved had multiple diagnoses, including atrial fibrillation, coronary artery disease, hypertension, wound infection, diabetes mellitus, and non-Alzheimer's dementia, and was assessed as having severe cognitive impairment. The physician's order for Meropenem IV was clearly documented, specifying the dosage and duration for treatment of a sacral wound infection. Despite these orders, the medication administration process was not followed as required, specifically the verification of the resident's identity prior to administration. The facility's medication administration policy required staff to verify the medication label against the medication sheet for accuracy, including the resident's name, drug, frequency, duration, strength, and route. However, this procedure was not followed in this instance, resulting in the administration of medication from a bag not labeled with the correct resident's name. The incident was reported by both the nurse and the family member, and documentation confirmed that the error was due to failure to adhere to established medication administration protocols.
Failure to Ensure Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had their call light devices within reach while in bed, as required by facility policy. During observations, both residents were found with their call lights on the floor and unable to access them. Interviews with the residents confirmed they could not reach the call lights. Both residents had medical histories including dementia, muscle weakness, and difficulty walking, with one resident having a moderate cognitive impairment and a history of falls. Both residents used wheelchairs and required assistance with personal care. Staff interviews revealed that LVNs were aware that call lights should be within reach and stated that they routinely check to ensure this. However, during the survey, the call lights were not accessible to the residents. The facility's policy specifies that call lights should be placed within easy reach of residents and that specific types of call lights should be added to the care plan based on residents' abilities and limitations. Despite these guidelines, the deficiency was observed and confirmed by staff.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Include PTSD in Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan that addressed all of a resident's identified needs, specifically omitting the diagnosis of post-traumatic stress disorder (PTSD) for one resident. Record review showed that the resident had a diagnosis of PTSD, moderate cognitive impairment, and required assistance with personal care. Despite this, the care plan initiated for the resident did not include PTSD as a problem or risk, nor did it outline measurable objectives or interventions related to this diagnosis. Interviews with staff revealed a lack of awareness regarding the resident's PTSD diagnosis and uncertainty about whether it should be included in the care plan. The facility's policy requires that care plans be comprehensive and include measurable objectives to address all medical, nursing, mental, and psychosocial needs identified in the assessment. However, both the MDS coordinator and the DON indicated they were unaware of the need to care plan for PTSD, and the care plan did not reflect this diagnosis. This omission resulted in the failure to communicate the resident's PTSD needs to the care team, as required by facility policy.
Failure to Label Enteral Feeding Bottle for Resident with G-Tube
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a gastrostomy tube had proper labeling and instructions on the supplemental feeding bottle. During observation, it was noted that the resident's enteral feeding bottle was not labeled, and there was no label found nearby. The resident in question was a female with severe cognitive impairment, as indicated by a BIMS score of 1, and had a care plan in place to prevent complications related to tube feeding. Physician orders specified the type and rate of enteral nutrition to be administered. Interviews with nursing staff and the Director of Nursing confirmed that feeding bottles are required to be labeled with the resident's name, feeding type, rate, and the time and date the feeding was initiated. Staff acknowledged that without proper labeling, it would not be possible to verify the correct feeding or rate, and this could result in the resident not receiving the prescribed nutrition. The facility's policy also required accurate and safe administration of medications and feedings via enteral tubes, but this was not followed in this instance.
Failure to Administer Oxygen at Physician-Ordered Setting
Penalty
Summary
A deficiency occurred when a resident with pulmonary fibrosis and muscle weakness, who required oxygen therapy for shortness of breath, did not receive oxygen at the physician-ordered setting. The resident's care plan and physician order specified oxygen at 2 liters per minute via nasal cannula. However, during an observation, the oxygen concentrator was set at 1.5 liters per minute. The resident was in bed with the head of the bed slightly elevated and showed no signs of respiratory distress at the time of observation. The nurse assigned to the resident confirmed the oxygen setting was incorrect and stated it should have been at 2 liters per minute as ordered. She reported checking the settings at the beginning of her shift but was unsure who might have changed it. The nurse also stated that she typically checks the oxygen once a day and as needed. The DON indicated that nurses are responsible for checking oxygen settings once per shift and are expected to follow physician orders. Facility policy requires that oxygen therapy be administered as ordered by a physician, with the method and amount determined by the resident's condition and reflected in the physician order.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulation. Specific actions or omissions by facility staff that led to this deficiency are not detailed in the report, nor are there descriptions of the circumstances or medical history of the resident(s) involved.
Failure to Notify LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to provide required discharge notifications to the Office of the State Long-Term Care (LTC) Ombudsman for two residents who were discharged, one to a hospital and one to home with family. Record reviews showed that neither resident's electronic medical record contained evidence that the Ombudsman was notified prior to their discharge, as required by facility policy. Both residents had intact cognition as indicated by their BIMS scores, and their medical histories included conditions such as acute respiratory failure, COPD, hypertension, diabetes, and dementia. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the Ombudsman of resident discharges. The Social Services Director stated she was unaware of the need to notify the Ombudsman and had not done so for any discharges during her tenure. The state LTC Ombudsman representative confirmed that no discharge notices had been received from the facility in the past year. The facility's policy specifies that a copy of the discharge notice must be sent to the Ombudsman, but this was not followed in these cases.
Elopement Due to Inadequate Supervision and Visitor Error
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of wandering was not adequately supervised, resulting in the resident eloping from the facility. The resident, who had diagnoses including unspecified dementia, hypertension, insomnia, mood disorder, and hyperlipidemia, was independently ambulatory with a walker and had a wander guard in place. Surveillance footage showed the resident left the facility at 7:00 p.m. and was found by police approximately 0.5 miles away after a civilian reported the individual. The resident was returned to the facility without injury. Prior to the elopement, the resident was last seen by an LVN in front of the nurse's station around 6:30-6:40 p.m. The LVN redirected the resident to the common area but then became occupied with other tasks, during which time the resident left the area. The facility's secured unit was not open at the time of the incident. The elopement was facilitated when a visitor, unaware that the individual was a resident, opened the door for the resident and allowed them to exit the building. The facility's policies required immediate search and assessment if a resident could not be located or if alarms sounded, and staff were responsible for maintaining resident safety at all times. However, the combination of insufficient supervision, lack of secured unit access, and a visitor inadvertently assisting the resident in leaving led to the resident's unsupervised exit from the facility.
Failure to Timely Complete and Accurately Document Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans that included necessary instructions for effective and person-centered care within 48 hours of admission for two residents. For one resident, the baseline care plan was not completed within the required 48-hour timeframe, with the care plan being initiated four days after admission. Interviews with staff revealed confusion regarding responsibility for completing the baseline care plan, with LVNs believing RNs were responsible and the MDS Coordinator indicating that the initial admission assessment should trigger the baseline care plan. The delay in completing the care plan meant that important risks, such as fall risk, were not documented in a timely manner. For another resident, the baseline care plan failed to include the presence of a PICC line upon admission. Although the resident was admitted with a PICC line to the upper right arm, the baseline care plan incorrectly indicated that the resident did not have a PICC or central line. This omission was attributed to the admitting nurse not marking the correct section, and the MDS Coordinator did not revise the care plan to correct the error. Staff interviews confirmed that the presence of a PICC line should have been documented in the baseline care plan to ensure appropriate interventions were triggered. The facility's care plan policy required that care plans be initiated upon admission and developed within 48-72 hours, serving as a guide for care needs and preferences. However, the policy did not specifically address baseline care plans, and staff interviews indicated a lack of clarity regarding the process and responsibilities for completing these plans. The deficiencies identified could result in missed or inadequate care for residents, particularly those with complex medical needs or at risk for adverse events.
Failure to Document PRN Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident. Specifically, on November 1, 2024, a Licensed Vocational Nurse (LVN) did not sign off on the administration of PRN acetaminophen for a resident who had sustained a skin tear after a transfer. The resident, who had severe cognitive impairment and was at risk for experiencing discomfort or pain, had a physician's order for acetaminophen to be given as needed for pain. However, the electronic Medication Administration Record (eMAR) did not reflect the administration of the medication from November 1 to November 4, 2024, despite progress notes indicating it was given. Interviews with the LVN, Assistant Director of Nursing (ADON), and Director of Nursing (DON) revealed that the medication was administered but not documented in the eMAR. The facility's Medication Administration policy did not explicitly require PRN medications to be signed off in the eMAR, as long as they were documented in the resident's electronic medical record. The DON and Administrator confirmed that there was no negative outcome for the resident due to the lack of documentation in the eMAR, as the medication was charted elsewhere.
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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 Brownsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alta Vista Rehabilitation And Healthcare | 1.4 mi | ★★★★★ | 16 | 0 |
| Fox Hollow Post Acute | 1.9 mi | ★★★★★ | 12 | 3 |
| Mesa Hills Post Acute | 2.7 mi | ★★★★★ | 6 | 0 |
| Ebony Lake Nursing And Rehabilitation Center | 2.9 mi | ★★★★★ | 14 | 0 |
| Spanish Meadows | 3.3 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.