Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 The Brixton At Horseshoe Bay during CMS and state inspections, most recent first.
A resident admitted with a stage IV pressure ulcer did not receive wound care as ordered, including the absence of a wound vac and missed dressing changes. The wound care specialist was not notified until eight days after admission, and the resident's wound worsened, leading to hospitalization with infection and osteomyelitis. Staff interviews confirmed lapses in communication and adherence to physician orders.
Three residents with cognitive impairments and physical limitations did not receive necessary nail care, resulting in long, jagged fingernails that posed risks of scratches and infection. Despite the facility's policy requiring routine nail care, staff interviews revealed a lack of clear responsibility and follow-through, leading to deficiencies in resident care.
A facility failed to accurately complete an MDS assessment for a resident, leading to a deficiency. The resident, with multiple medical conditions, was discharged home, but the MDS inaccurately recorded the discharge as to a hospital. The MDS Coordinator admitted the error, and the ADM confirmed the expectation of accuracy in assessments, which could affect payments and care plans.
Failure to Provide Ordered Wound Care and Timely Specialist Notification
Penalty
Summary
A facility failed to provide necessary treatment and services consistent with professional standards of practice to promote wound healing and prevent new pressure ulcers for a resident admitted with a stage IV pressure ulcer. Upon admission, the resident had multiple diagnoses including type II diabetes, venous insufficiency, and peripheral vascular disease, and was at risk for pressure injuries. The hospital discharge orders specified the use of a wound vac and detailed wound care instructions, but the facility did not have the wound vac available as ordered upon admission. The facility did not notify their wound care specialists of the resident's sacral wound until eight days after admission. During this period, the resident's wound care was not managed according to the prescribed orders, with several missed dressing changes documented. Progress notes and assessments indicated that the wound vac had not arrived, and daily wound care was not consistently provided. The resident's wound worsened, with increased drainage and size, and ultimately the resident was hospitalized with lethargy, altered mental status, fever, a worsening sacral decubitus ulcer, and was diagnosed with sacral osteomyelitis. Interviews with facility staff revealed a lack of communication and follow-through regarding wound care orders and specialist notification. The DON, ADON, and wound care company staff confirmed that the wound vac was delayed, dressing changes were missed, and the wound care specialist was not promptly informed of the resident's condition. Facility policy required treatments to be provided in accordance with physician orders, but this was not followed, resulting in the identification of an Immediate Jeopardy situation.
Removal Plan
- Wound care order discharged from Skin and Wound TAR for 3x weekly wet-to-dry dressing for Resident #1. This was completed by ADON.
- Administrator and/or designee reviewed all resident charts to evaluate which residents could have been affected by this deficient practice. Five current residents identified with pressure ulcers that could be affected. After review, none of the five current residents were identified to be affected by the same deficient practice.
- Skin assessments commenced for all facility residents. This was assigned to the ADON and/or designee.
- An audit was conducted to ensure all treatments, supplies, and equipment are available for ordered wound treatments. This was assigned to the ADON and/or designee.
- A medical records review was completed for all residents to ensure the most recent weekly skin assessments were completed. This was assigned to the DON.
- A care plan audit was conducted to ensure that treatment recommendations/orders were listed within the care plan and that the care plan was being followed. This was assigned to the MDS Nurse.
- Administrator (RN) and [NAME] President of Operations reviewed and updated facility policies and procedures related to skin care, wound care, and pressure injury prevention as needed. This was assigned to the Administrator and [NAME] President of Operations. Administrator and [NAME] President of Operations discussed with an independent nurse consultant (also an RN) on how to properly in-service the facility nurses.
- An audit of all pressure relieving devices and support surfaces was commenced to ensure proper use. This was assigned to the ADON and/or designee.
- Administrator (RN) provided education to all licensed nurses regarding facility policies and procedures related to skin/wound care, pressure injury prevention, and appropriate wound treatment measures. This training includes ensuring residents have the necessary pressure relieving devices and support surfaces, and their proper use. This was assigned to the Administrator.
- Administrator (RN) provided education to all licensed nurses regarding the importance of providing treatment to all residents in accordance with physician orders and care plans, appropriately documenting in the facility EHR, and properly entering treatment orders in the EHR and the resident's TAR. This was assigned to the Administrator.
- Administrator (RN) provided education to all licensed nurses regarding the importance and requirement of weekly skin assessments for all residents. This was assigned to the Administrator.
- Education provided by Administrator was performed at shift change to ensure the education could be provided to the maximum number of nurses face-to-face. Nurses not currently working will be called by phone to be provided said education. All nurses will be provided education prior to their next scheduled shift. This was assigned to the Administrator.
- [NAME] President of Operations provided education to administrative and admissions staff regarding the ability to admit residents to the facility if and only if the physician orders can be followed appropriately and all required equipment will be at facility for the treatment of the admitted resident.
- In-services provided in regards to skin/wound care, pressure injury prevention, and appropriate wound treatment measures added to the onboarding program for nurses so that training is provided prior to administering skin and wound management. This was assigned to [NAME] President of Operations.
- All participants in training required to sign the sign-in sheet to confirm and acknowledge understanding of the material presented.
- DON and/or designee to complete daily treatment record and nursing documentation audits to ensure accurate and complete documentation of skin related treatments and preventative measures. To be conducted daily for 2 weeks, then 3x weekly for an additional 2 weeks. If issues noted, they are to be addressed promptly. Results to be presented in monthly QAPI.
- DON and/or designee to audit weekly skin assessments to ensure completion in accordance with facility policies and procedures. All skin assessments to be reviewed for the next 2 weeks for all residents. If issues noted, they are to be addressed promptly. Results to be presented in monthly QAPI.
- DON and/or designee to review and validate all changes to treatment orders. To be conducted as changes occur. If issues noted, they are to be addressed promptly. Results to be presented in monthly QAPI.
- Administrator and/or designee to conduct daily audit on admitting residents to ensure proper notification of specialist / physician. To be conducted daily for 2 weeks, then random audits for an additional 2 weeks. If issues noted, they are to be addressed promptly. Results to be presented in monthly QAPI.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate grooming and personal care assistance to three residents who were unable to perform activities of daily living independently. Specifically, the facility did not ensure that the residents received necessary nail care, which included trimming and filing of fingernails. This deficiency was observed in three residents, each with varying degrees of cognitive impairment and physical limitations, who had long, jagged fingernails that posed a risk of scratches, infection, and loss of self-esteem. Resident #70, a male with severe cognitive impairment and a history of a femur fracture, was observed with fingernails extending 3/4 inch past the fingertips. Despite expressing a need for assistance with nail care, his nails remained untrimmed over multiple days. Similarly, Resident #52, a female with moderate cognitive impairment and diabetes, had long, jagged nails with debris underneath. The staff acknowledged the need for nail care but failed to provide it, citing that licensed nurses were responsible for diabetic residents' nail care. Resident #32, a female with severe cognitive impairment, also had long, jagged nails with debris, and reported not receiving nail care for an extended period. Interviews with staff, including CNAs, LVNs, and the ADON, revealed a lack of clear responsibility and follow-through regarding nail care. Staff members noted the potential for infection and skin tears due to the condition of the residents' nails. The facility's policy required routine nail care on shower days and as needed, but this was not consistently implemented, leading to the observed deficiencies in resident care.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to provide an accurate assessment for a resident, identified as Resident #74, which led to a deficiency in the accuracy of the Minimum Data Set (MDS) assessment. The resident, a female with multiple diagnoses including cellulitis, herpes virus vulvovaginitis, chronic viral Hepatitis C, hypothyroidism, schizoaffective disorder, and depression, was discharged home. However, the discharge MDS inaccurately recorded her discharge status as being sent to a Short-Term General Hospital. This error was identified during a review of the resident's records, which included a face sheet and a Transfer/Discharge Report that correctly indicated the resident was discharged home. The MDS Coordinator, responsible for completing the MDS assessments, acknowledged the mistake during an interview, stating that she had incorrectly marked the discharge status. The Administrator (ADM) confirmed that the MDS Coordinator was responsible for the assessments and that he signed off on them, expecting them to be accurate. The ADM also noted that an incorrect MDS assessment could potentially affect payments and care plans. The facility's policy, last revised in November 2023, requires comprehensive and accurate assessments, with interdisciplinary responsibility for completion and attestation of accuracy by the RN coordinator.
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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 Horseshoe Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Granite Mesa Health Center | 5.4 mi | ★★★★★ | 9 | 0 |
| Avir At Kingsland | 11.2 mi | ★★★★★ | 18 | 0 |
| Avir At Burnet | 16.2 mi | ★★★★★ | 5 | 0 |
| Avir At Johnson City | 19.1 mi | ★★★★★ | 10 | 0 |
| Bertram Nursing And Rehabilitation | 22.1 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.