Above 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 Las Brisas Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
Food storage and labeling practices were not followed in the kitchen. Surveyors found expired canned and packaged foods, unlabeled rice cereal removed from original containers, a jar with no expiration date, and a dented can in dry storage. The DM said kitchen staff were responsible for unloading deliveries and labeling food with the received date and open date, while a Kitchen Aide said staff labeled food with the date received.
Failure to perform hand hygiene during meal service: An LVN served breakfast trays to four residents, touched a resident and dining room surfaces, unwrapped utensils, and removed drink tops without washing hands or using hand sanitizer between residents. The DON stated staff are trained to wash hands before tray service and use sanitizer between each tray, and the LVN said she skipped hand hygiene because she was trying to serve the meals before they got cold.
The facility's main kitchen failed to meet food safety standards, with issues such as dirty ice machine filters, improperly labeled and stored food items, and pest presence. Dietary staff did not adhere to hand hygiene protocols, increasing the risk of cross-contamination. The dietary manager was unable to clarify the dating system for food items and was observed not washing hands or changing gloves, potentially compromising resident safety.
The facility failed to maintain an effective infection control program, as observed when an LVN and an MA did not disinfect blood pressure cuffs between uses on four residents. This oversight occurred despite the residents' various medical conditions requiring regular monitoring. Interviews revealed a lack of awareness and training among staff, highlighting the need for improved infection control practices.
The facility failed to maintain an effective pest control program, resulting in a fruit fly infestation in various areas, including dining rooms, hallways, and resident rooms. Observations and interviews revealed that the issue persisted despite reports to maintenance staff, with no specific pest control measures targeting fruit flies. The administrator was unaware of the problem, and pest control records did not reflect any action taken against fruit flies.
A facility experienced a 6% medication error rate during a medication pass, involving two residents. One resident missed doses of Cranberry tablets due to unavailability, while another was left to self-apply Solonpas patches without supervision. The errors were attributed to a failure to adhere to medication administration protocols, as acknowledged by the MA and DON.
The facility failed to secure controlled drugs in a locked compartment, as observed in the medication room where an unlocked lockbox contained eight syringes of Ativan Benadryl cream. The ADON and DON, responsible for monitoring the lockboxes, could not specify the frequency of checks. This oversight contradicts the facility's policy requiring controlled medications to be stored in locked, permanently-affixed compartments.
Food Storage and Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen reviewed for food safety. During observation of the dry storage area, surveyors found 2 cans of jellied cranberry sauce expired 11/29/2025 with a written received date of 12/01/2024, 2 squeezable plastic dijon mustards expired 07/09/2024 with a written received date of 04/2025, 2 large bags of rice cereal removed from their original containers with no item description and no expiration or best-by date, 1 package of yellow corn tortillas expired 04/21/2025 with a written received date of 06/29/2025, and 1 jar of coleslaw dressing with no expiration date and a written received date of 01/05/2026. Surveyors also observed 1 can of dark red kidney beans with a dent on the bottom front seam. During interview, the Dietary Manager stated that all kitchen staff were responsible for unloading deliveries and placing labels on food, and that the label should include the received date and the date the item was opened. He said staff would immediately throw away expired food and that dented cans were placed in his office. When asked how staff determined an expiration date when an item had no expiration date, he said he did not know. A Kitchen Aide stated that all kitchen staff were responsible for unloading the delivery truck and placing labels on food, and that the label should include the date the food was received. The facility's Food Storage Policy stated that new food items removed from their original containers should be labeled and dated, and that badly dented cans should be identified during inspection. The U.S. FDA Food Code 2022 was also reviewed regarding food receiving and storage practices.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation in the main dining room, LVN A entered the dining room, did not use hand sanitizer, took four trays from the kitchen, placed them on a cart, and served all four trays without hand hygiene. LVN A served a breakfast tray to Resident #67, touched the dining room table, touched the resident’s hand and shoulder, and prepared the meal tray for the resident to eat breakfast, all while not wearing gloves and without washing hands or using hand sanitizer available in the hallway. LVN A was also observed serving and setting up breakfast trays for Resident #84, Resident #22, and Resident #65, unwrapping utensils and removing drink tops for each resident without completing hand hygiene before moving to the next resident. Resident #22 was moderately cognitively impaired and required assistance with activities of daily living; Resident #65 was severely cognitively impaired and required one staff member for assistance; Resident #67 was moderately cognitively impaired and required one staff member for assistance; and Resident #84 was severely cognitively impaired and required assistance with activities of daily living. In interview, LVN A stated she did not complete hand hygiene after direct contact with residents and said she was supposed to use hand sanitizer between serving each tray, but did not do so because she was trying to get the breakfast trays served before the food got cold. The DON stated all staff must complete hand hygiene after contact with residents and are trained to wash hands with soap and water prior to tray service and use hand sanitizer between each tray.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain food safety standards in its main kitchen, as observed during a survey. Ice machines #1 and #2 were found with dirty filters and vents, which were not free from dust and dirt. Additionally, food items in the refrigerator, freezer, and dry storage room were not labeled or stored according to professional standards. Items were found without proper labeling, including missing item descriptions, preparation dates, and discard dates. Some food items were past their 'best buy' or expiration dates, and there was evidence of pest presence, such as fruit flies, around food items. The facility also failed to ensure proper hand hygiene among dietary staff. Observations revealed that staff did not wash their hands or change gloves after touching other surfaces while handling food or upon re-entering the kitchen. This lack of adherence to hand hygiene protocols could lead to cross-contamination and increase the risk of food-borne illnesses among residents. Furthermore, the facility's dietary manager was unable to provide clear information regarding the dating system used for food items, leading to confusion about when items were received, opened, or should be discarded. The manager also failed to demonstrate proper handwashing practices, as he was observed not washing his hands or changing gloves after returning to the kitchen from the dining room. These deficiencies in food safety practices and hand hygiene could potentially compromise the health and safety of the residents.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two staff members, LVN A and MA B, who did not disinfect blood pressure cuffs between resident uses. This oversight was observed during routine blood pressure checks for four residents. LVN A did not sanitize the blood pressure cuff before or after using it on two residents, while MA B also failed to clean the cuff between uses on two other residents. The residents involved in these observations had various medical conditions, including hypertension, diabetes, atrial fibrillation, and cognitive impairments. These residents required assistance with activities of daily living and had specific physician orders for regular blood pressure monitoring. The failure to disinfect the blood pressure cuffs between uses could potentially lead to cross-contamination and the spread of infections among residents. Interviews with the staff revealed a lack of awareness and training regarding the importance of disinfecting equipment between uses. LVN A admitted to forgetting to clean the cuff, while MA B was unaware of the requirement to do so. The Director of Nursing, who was also the infection control preventionist, acknowledged the need for staff to clean equipment after each use and indicated that staff training on infection control was necessary. The facility's policy on infection control emphasized the importance of cleaning and disinfecting resident-care equipment, but it was not consistently followed by the staff.
Ineffective Pest Control Program Leads to Fruit Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live fruit flies in various areas, including the nurse's station, dining rooms, service hallway, and resident rooms. Observations made on multiple occasions revealed swarms of fruit flies in these areas, with specific instances noted in the private dining room, service hallway, and kitchen. The presence of fruit flies was also reported by residents and staff, who expressed concerns about the ongoing issue and the lack of pest control measures. Interviews with staff and residents indicated that the problem had persisted for some time, with reports of fruit flies being made to the maintenance staff. However, there was no evidence of pest control interventions specifically targeting fruit flies, as the pest control records only documented preventative treatments for cockroaches and rodents. The facility's pest control policy required staff to report pest sightings immediately, but there was no indication that this process was effectively followed or that the pest control company was informed of the fruit fly issue. The administrator was unaware of the pest problem and did not know the process for reporting pest issues. The pest control log at the nurse's station did not contain any notations of fruit flies, and the facility's pest control visits did not verify the presence of fruit flies. This lack of awareness and action contributed to the continued presence of fruit flies, which could potentially lead to the spread of infection and decreased quality of life for residents.
Medication Administration Errors Lead to 6% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a six percent error rate during a medication pass observation. This deficiency involved two residents, where medication administration errors were identified. For Resident #13, the facility did not have the prescribed Cranberry tablets 500mg available for three days, leading to missed doses. The medication was intended for urine retention and was ordered to be administered twice daily. The absence of the medication was noted during a morning medication pass, and the medication aide (MA B) acknowledged the lack of availability and the potential harm of missing doses. For Resident #65, the error involved the improper administration of Solonpas patches, which were prescribed for pain management on the resident's knees. MA B provided the patches to the resident but did not observe their application, contrary to the physician's order and facility policy. The resident was left to apply the patches independently, which MA B justified by the resident's alertness and rehabilitation status. However, this practice was inconsistent with the facility's medication management policy, which requires staff to remain with residents during medication administration. Interviews with MA B and the Director of Nursing (DON) revealed a lack of adherence to established medication administration protocols. MA B admitted to not following the three rules of dispensing and leaving medications with residents, while the DON emphasized the importance of staff staying with residents during medication administration. The facility's policy mandates that medications should not be left in resident rooms and that unavailable medications should be promptly addressed. These lapses in protocol contributed to the identified medication errors.
Failure to Secure Controlled Medications in Locked Compartment
Penalty
Summary
The facility failed to provide a locked and permanently affixed compartment for the storage of controlled drugs in the medication room. During an observation, it was found that the lockbox in the medication room refrigerator, which contained eight syringes of Ativan Benadryl cream (a schedule IV controlled medication), was unlocked. This oversight was noted in the presence of the Assistant Director of Nursing (ADON), who acknowledged that the lockbox should always be locked and was unaware of why it was unlocked at the time of observation. Interviews with the ADON and the Director of Nursing (DON) revealed that both were responsible for monitoring the lockboxes to ensure proper storage of medications. However, neither could specify how often the lockboxes were checked or when they were last monitored. The facility's policy, revised in April 2024, mandates that all controlled medications must be maintained in separately locked, permanently-affixed compartments. The failure to secure the lockbox could potentially allow unauthorized access to the medications, posing a risk of drug diversion or misuse.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northgate Plaza | 1.5 mi | ★★★★★ | 16 | 0 |
| The Villages On Macarthur | 2.3 mi | ★★★★★ | 1 | 0 |
| Ashford Hall | 3.6 mi | ★★★★★ | 14 | 0 |
| Avante Rehabilitation Center | 4.5 mi | ★★★★★ | 1 | 0 |
| Avir At Irving | 4.6 mi | ★★★★★ | 10 | 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.