The Brixton at Horseshoe Bay

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #1) of five residents reviewed for pressure injuries. The facility failed to: - Have a wound vac available as ordered by the hospital upon Resident #1's admission on [DATE]. - Notify their wound care specialists of Resident #1's sacral wound until 03/18/25 (8 days after admission). - Follow treatment orders for Resident #1's sacral wound. She was sent to the ER on [DATE] and diagnosed with lethargy, altered mental status, fever, sacral decubitus ulcer, and sacral osteomyelitis (infection in bone). [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.