Brownwood Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for of 3 residents 18 (Resident #13, Resident #1, and Resident #25) reviewed for accidents. 1. The facility failed to ensure Resident #13 wore a smoking apron when smoking as per her safe smoking assessment. 2. The facility failed to ensure Resident #1 had a safe smoking assessment completed prior to allowing him to smoke.3. The facility failed to ensure Resident#25 had a safe smoking assessment completed prior to allowing him to smoke. These failures could place residents at risk of injury and serious bodily harm.Findings include: 1. Record review of Resident #13's electronic face sheet, accessed on 04/15/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses that included: Schizoaffective Disorder, Bipolar Disorder, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews, the facility failed to 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 for 1 of 5 (LVN D) staff and 2 of 18 (Resident #22 and Resident #64) reviewed for infection control procedures.The facility failed to ensure LVN D followed EBP while managing Resident #68's central line (a long, flexible catheter inserted into a large vein near the heart to deliver medications, fluids, or monitor blood flow over an extended period) on 4/13/26. The facility failed to ensure LVN D followed EBP while managing a Resident #58's G-tube (medical device inserted through the abdomen directly into the stomach) on 04/14/2026.The facility failed to ensure staff were notified of EBP for Resident #22 and Resident #64.The facility failed to have a PPE readily accessible to staff outside or inside of Resident #22's and Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 64 resident rooms (room [ROOM NUMBER]) reviewed for environmental concerns.The facility failed to have hot water functioning in room [ROOM NUMBER]'s sink on 04/13/2026, 04/14/2026, and 04/15/2026.This failure could place residents and staff at risk of being uncomfortable and for infections from living in an environment that does not function.Findings included:Resident #9Record review of Resident #9's electronic face sheet, dated 04/15/2026, reflected an [AGE] year-old female admitted on [DATE] with diagnosis including Alzheimer's disease (a type of dementia with problems including memory, thinking, and reasoning that interfere with daily life) and dementia (loss of memory, thinking, and reasoning skills). Record review of Resident #9's quarterly MDS assessment, dated 02/11/2026, reflected that she had a BIMS score of 06…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs for 1 of 5 residents (Resident #29) reviewed for pharmaceutical services, in that: LVN D failed to reorder Latanoprost Ophthalmic Emulsion (0.005 % (Latanoprost) Resident #29 before his supply was depleted. This failure could place residents at risk for a decline in health and of not receiving the intended therapeutic benefit of the medications. The findings included:Record review of Resident #29's face sheet not dated, revealed a [AGE] year-old male initially admitted on [DATE] with the diagnosis of Glaucoma ( a condition in which the optic nerve becomes damaged by high fluid pressure in the eye leading to irreversible vision loss or blindness if untreated). Record review of Resident #29's admission MDS dated [DATE] revealed Section-C Cognitive Patterns Resident #29 had a BIMS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments and permitted only authorized personnel to have access to the keys for 1 of 18 (Resident # 68) residents reviewed for storage of drugs and biologicals. The facility failed to ensure Resident #68's medication was locked when unattended by authorized personnel. This failure could place residents at risk of having access to unauthorized medications, leading to possible harm or drug diversions. Findings included: Resident #68Record review of Resident #68's electronic face sheet, dated 04/15/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis including osteomyelitis of the left ankle (infection of the bone). Record review of Resident #68's admission MDS assessment, dated 04/02/2026, reflected a BIMS score of 12 indicating moderate cognitive impairment. Further review reflected he was taking high-risk medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) residents reviewed for comprehensive person-centered care plans.1. The facility failed to develop a care plan based on assessed needs with measurable objectives in the areas of Hypertension, adverse medication effects, altered cardiac problems, and Intravertebral disc disorder/Stenosis for Resident #1.2. The facility failed to develop a care plan based on assessed needs with measured objectives in the areas of Anticoagulant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that:. 1. Foods were not sealed and/or labeled properly in the facilities refrigerators (#1 and #2) and freezers (#2 and #3). 2. Ready to use clean utensils and napkins were placed and stored in uncleaned utensil holder. 3. Ready to use clean dishes, placed on and stored on top of uncleaned trays. 4. Cooking stove spill slats uncleaned with food particles and grease buildup. These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. Findings included: During an observation on 02/11/2025 beginning at 8:00 AM the facility kitchen revealed: Pantry 2 bags of opened tortillas in a sealed bag undated or labeled. 1 bag of opened loaf of bread with no opened date. 2 bags of cereal in clear plastic bags with no received date. Refrigerator #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided respiratory care consistent with professional standards of practice for 1 of 25 residents (Resident #215) reviewed for oxygen administration. The facility failed to ensure an Oxygen in Use sign was posted on the outside of Resident #215's door. These deficient practices could place residents who received oxygen and treatments at risk of respiratory infection. The findings include: Record review of Resident # 215's face sheet dated 02/13/2025 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and shortness of breath. Record review of Resident #215's Entry MDS assessment dated [DATE] revealed: Section C (Cognitive Patterns) BIMS score had not been completed. Record review of Resident #215's Physician Orders revealed a start date of 02/07/2025 May use oxygen at 2-3 liters/minute via nasal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 3 medication carts reviewed for storage in that: The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion. The findings include: During an observation and interview on 02/13/2025 at 1:55 PM, the medication cart was unattended at the nursing station with the drawers facing out, the button that locks the cart was not pushed in and the drawers opened when they were pulled. There was a resident standing within arm's reach of the medication cart. RN A was seen coming down the hall at 2:00 pm. RN A stated she had gotten distracted because therapy had asked her to do something. During an interview on 02/13/2025 at 02:15 PM, RN A stated the medication cart should not be left unlocked and unattended at any time. RN A stated she got called away to give a resident in physical therapy a medication and just…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs for 6 (Resident # 1, Resident #33, Resident #37, Resident #44, Resident #46, and Resident #51) of 6 residents reviewed for care plans. The facility failed to specify measurable objectives that could be evaluated or quantified for Resident #1, Resident #33, Resident #37, Resident #44, Resident #46, and Resident #51. The facility failed to specify measurable objectives that could be evaluated or quantified with a timeframe to achieve for Resident #1, Resident #44, and Resident #46. These failures could place residents at risk for not receiving timely interventions or interventions not individualized to meet their specific physical, mental, and/or emotional needs. Findings included: Record review of Resident #1's electronic face sheet revealed a [AGE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 2 residents (Resident #44) reviewed for (DRR) Drug Regimen Review. The facility failed to timely follow up on Resident #44's medication regimen review which had pharmacy recommendations. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage. The findings included: Resident #44 Record review of Resident #44's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with medical diagnoses of dementia, kidney stones, high blood pressure, arthritis, knee pain, and anxiety. Record review of Resident #44's Quarterly MDS dated [DATE], Section C 0500 BIMS Score Summary revealed the resident scored 11 out of 15 indicating moderate cognitive impairment. Record review of Resident #44's physician orders on 01/25/2024 revealed mirtazapine oral tablet 30mg give 1 tabled by mouth at bedtime for insomnia. Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the menu was followed for 6 of 6 (Resident # 6, #4, #8, #42, #17 and #41) residents who received a pureed meal reviewed during the lunch meal. The facility failed to ensure Residents recieving a puree texture diet were provided the food according to the menu, incuding potato salad and a roll. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss. Findings included: Record review of Resident #6's Quarterly MDS dated [DATE] revealed: Section A- Identification Information Resident #6 was an [AGE] year old male admitted on [DATE]; Section C- Cognitive Patterns Resident #6 had a BIMS of 12 (moderate cognitive impairment); Section K- Swallowing/Nutritional Status Resident #6 had a mechanically altered diet. Record review of facility documents, titled, Resident Roster Diet Type dated 01/23/2024 revealed that Resident # 6, #4, #8, #42, #17 and #41 had texture type of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators and dry storage. The facility failed to ensure all food was not past expiration date. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 01/23/2024 between 9:55 AM and 10:25 AM of the kitchen revealed: Refrigerator #1 1. One open container of cottage cheese with an use by date of 01/06/2024. 2. One unopened container of cottage cheese with an use by date of 01/06/2024. 3. One plastic container with a seal contained canned mushrooms and was not labeled with a food item description or an use by date. 4. One plastic container with a seal contained canned black olives and was not labeled with a food item…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.