Brownwood Nursing & Rehabilitation

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, and interviews, the facility failed to post nurse staffing information that included the resident census for 3 days (04/13/2026, 04/14/2026, and 04/15/2026) of 3 days reviewed for required postings. The facility failed to include the daily resident census 04/13/2026, 04/14/2026 and 04/15/2026 on the daily nurse staffing required posting. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.