The Brixton At Horseshoe Bay

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 5 of 15 residents (Resident #12, Resident #20, Resident #42, Resident #44, and Resident #51) reviewed for rights. 1. The facility failed to ensure CNA G and CNA H knocked on Resident #12, Resident #44, and Resident #51's doors when going into the residents' rooms. 2. The facility failed to ensure Resident #20 and Resident #44 were served their lunch trays at the same time as other residents at the same table on 06/24/2025. The deficient practice could place residents at risk of poor self-esteem and feeling like their privacy was being invaded or the facility was not their home. Findings included: Resident #12 Review of Resident #12's Face Sheet dated 06/26/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #12's…

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 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 for 4 (CNA A, CNA B, CNA F, and CNA G) of 5 staff reviewed for infection control. 1. The facility failed to ensure CNA B, CNA F, and CNA G conducted hand hygiene between residents during lunch tray pass. 2. The facility failed to ensure CNA A sanitized her hands with a glove change when performing Foley catheter care. These failures could place residents at risk of transmission of disease and infection. Findings include: Observation on 06/24/25 at 11:47 AM of the 200-hall lunch tray pass revealed CNA B brought a lunch tray into Resident #5's room, and hand hygiene was conducted. CNA B then passed a lunch tray to Resident #30, and no hand hygiene conducted. She then passed a lunch tray to Resident #12, and no hand hygiene conducted. CNA B passed a lunch tray to Resident #51, positioning…

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 ensure that based on the comprehensive assessment of a resident, that residents receive treatment and care in accordance with the residents' choices, and professional standards for 1 (Resident #8) of 25 residents assessed for quality of care. The facility failed to monitor and treat consistently Resident #8's neuropathy. This failure could lead to increased pain, depression, and a lower quality of life. Findings include: Resident #8 Record review of Resident #8's face sheet on 06/24/2025 dated 06/24/2025 revealed an [AGE] year old woman admitted to the facility on [DATE] with relevant diagnoses of galactosemia (an inherited genetic deficiency that causes the inability to metabolize a specific type of carbohydrate at a cellular level), chronic kidney disease (failing kidneys), type two diabetes (the inability to digest the carbohydrates consumed), Crohn's disease (an inflammatory disease causing lesions on the small intestine), and dementia (progressive…

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 each resident with a diet that meets their daily nutritional needs and special dietary needs for 1 (Resident #8) of 10 residents reviewed for appropriate diets. The facility failed to provide a therapeutic diet for Resident #8 with a diagnosis of galactosemia. This could lead to a toxic buildup of chemicals in the blood that could cause confusion, agitation, and a decreased quality of life. Findings Include: Resident #8 Record review of Resident #8's face sheet dated 06/24/2025 revealed an [AGE] year old woman admitted to the facility on [DATE] with relevant diagnoses of galactosemia (an inherited genetic deficiency that causes the inability to metabolize a specific type of carbohydrate found in dairy that causes toxic by product build up in the blood), chronic kidney disease (failing kidneys), type two diabetes (the inability to absorb the carbohydrates consumed), Crohn's disease (an inflammatory disease causing lesions on the…

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 the facility failed to ensure a resident who is unable to carry out activities of daily living receives grooming and personal care for 3 of 20 residents (#70, #52, and #32) reviewed for ADL care. The facility failed to ensure Residents #70, #52, and #32 were provided assistance with nail care. These failures could place residents at risk of scratches, infection, and loss of self-esteem. Findings included: Record review of the undated Face Sheet for Resident #70 reflected he was an [AGE] year-old male admitted to the facility on [DATE]. Record review of the Medical Diagnosis Sheet for Resident #70 dated 04/09/2024 reflected he had an unspecified fracture of left femur (broken thighbone), subsequent encounter for closed fracture with routine healing. Record review of the Comprehensive MDS for Resident #70 dated 04/16/2024 reflected he had a BIMS score of 3 indicating severe cognitive impairment. His functional abilities and goals reflected he required…

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 have an assessment that accurately reflected the status for 1 of 3 Residents (Resident #74) reviewed for assessment accuracy in that: Resident #74's discharge MDS dated [DATE] reflected she was discharged to Short Term General Hospital (acute hospital) when she was discharged home. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records. Findings include: Record review of Resident #74's face sheet dated 05/15/2024 revealed a [AGE] year-old female admitted on [DATE] with a diagnosis of cellulitis of groin (bacterial infection involving the inner layers of the skin), herpes virus vulvovaginitis (viral infection caused by herpes simplex virus causing inflammation of the female genitalia), chronic viral Hepatitis C (viral infection that causes inflammation of liver), hypothyroidism-unspecified (condition where the thyroid gland does not produce enough hormones), Schizoaffective disorder-bipolar…

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 medication error rates are not 5 percent or greater during observation of one CMA administering medication to for three of five residents (#11, #27, #20). There were five errors in 25 opportunities for errors, resulting in a 24 percent medication error rate, in that:. Resident #11's 06:00 - 10:00 a.m. medication Amlodipine 10 mg was administered against the doctors' orders to hold if blood pressure parameters are below 120 systolic. Resident 11's 09:00 a.m. Lidocaine patch was not removed per doctors' orders by CMA A. Resident #27's 06-10 a.m. medication Pepcid 20 mg was ordered but not given. Resident #20's 06:00-10:00 a.m. medication Pantoprazole 40 mg, Montelukast 10 mg, and Depakote 250 mg were not given within one hour before or after scheduled medication time, This failure could affect residents who receive medication and could result in residents not receiving the highest possible therapeutic outcome for the medication regimen. Also, adverse effects such as uncontrolled pain, effects of low blood…

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 observations, record review and interviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 52 of 52 residents reviewed for food sanitation/storage. The facility did not store six boxes of fruits in a dry storage area. The facility did not store chemicals away from food in the kitchen This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 3/26/23 at 8:13 am, underneath one of the three food preparation tables, there was a bucket filled with white-colored fluid sitting between two boxes of bananas and a box of white onions. On the left side of the bucket, the box of white onions was open. On the right side of the bucket, the two boxes of bananas were stacked on top of each other. The top box of bananas was open. During an interview on 3/26/23 at 8:20 am, [NAME] A said the white-colored fluid in the bucket was a mixture of cleaning solution and water. [NAME] A said the bucket filled with the mixture was temporarily sitting underneath the food…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent development and transmission of communicable disease and infections for 2 of 3 residents (Resident #31 and Resident #204) reviewed for infection control The facility failed to -ensure CNA G performed hand hygiene before assisting Resident #31 with meals. -ensure LVN M change gloves and perform hand hygiene during wound care for Resident #31 and Resident #204. This deficient practice could place the residents at risk for transmission and/or spread of infection. Finding included: Review of Resident #31's face sheet dated 03/28/23 reflected admitted to the facility on [DATE] with diagnosis diagnoses of DM (a condition which results in too much sugar in the blood), HTN (high blood pressure), and general muscle weakness. Review of Resident #31's annual MDS dated [DATE] reflected a BIMS of 11,…

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.