The Brixton at Horseshoe Bay

In the surveyor’s words

From the most serious findings on record at The Brixton at Horseshoe Bay, in the surveyor’s own words.

• Immediate jeopardy, patternF686Mar 26, 2025

  Based 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 03/10/25. - 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. […]

• No harm, potential for more than minimal, patternF550Jun 26, 2025

  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. […]

• No harm, potential for more than minimal, patternF880Jun 26, 2025

  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. […]

• No harm, potential for more than minimal, patternF677May 16, 2024

  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]. […]

• No harm, potential for more than minimal, patternF759Mar 28, 2023

  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. […]