Inspection visit
Inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the
facility were labeled with currently accepted professional principles, and included the appropriate accessory
and cautionary instructions, and the expiration date when applicable for and 1 of 2 medication carts (Hall A
& B nurse medication cart) reviewed for medication storage. The facility failed to ensure the nurses cart #1
for the A& B Hall did not contain insulin, and nebulizer treatment vials that were opened and not labeled
with the open date. This failure could place residents at risk of adverse medication reactions.Findings
included: Observation on [DATE] at 11:30 AM revealed the nurse's medication cart #1 for the A&B Hall had
the following opened medications with no open date labeled: 1. 2 insulin glargine pens2. 2 boxes
Ipratropium Bromide and albuterol sulfate inhalation nebulizer solution Interview on [DATE] at 11:31 AM
with RN C, she said once insulin and nebulizers were opened, they need to be dated with open dates. She
said it was the responsibility for all nurses to check carts for labelling and dating, every shift, but she did not
check the whole cart that morning. She stated insulins were good for 28 days and inhalers were also good
for 30 days. She stated the risk of not having an opening date was they would not be able to know when
they expired, and they would not be effective. Interview on [DATE] at 1:36 PM with the DON revealed she
said inhalers and insulin, when opened should be dated. She stated it was the responsibility of nursing
management to check and audit the carts after the nurses. The DON said the nurses were responsible for
dating the medication when opened. She stated insulin was good for 28 days, and the inhalers and
nebulizer should be dated once the box was opened. Record review of the Medication Storage policy, dated
1/2021, reflected the following: 1. It is the policy of this facility to ensure all medications housed on our
premises will be stored, dated, and labeled according to the manufacture's recommendations and sufficient
to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Record review of Lantus SoloStar Step-by-Step Guide | Lantus(R) (insulin glargine injection) 100 Units/mL
accessed [DATE] reflected the following:HOW TO STORE YOUR OPENED LANTUS (insulin glargine)
SOLOSTAR PENAfter its first use, don't refrigerate the Lantus SoloStar pen. Keep it at room temperature
only (below 86 F).After 28 days, throw your opened Lantus pen away-even if it still has insulin in it.Keep
Lantus away from direct heat and light. Record review of Did You Know? Nebulizer Storage
Recommendations - HealthDirect accessed [DATE] reflected the following:Ipratropium Bromide/Albuterol
Sulfate:Store in protectivefoil pouch at all times.Once removed from foil pouch, the vials should be used
within oneweek.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
676034
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676034
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brady West Rehab & Nursing
2201 Menard Hwy
Brady, TX 76825
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve
food under sanitary conditions for 1 of 1 main kitchen in that: [NAME] B took the dinner rolls with her hands
to place them on the residents plates when plating the lunch meal. These failures could place residents
who ate food from the kitchen at risk of foodborne illness. Findings includedDuring an observation and
interview on 09/03/2025 at 11:20 AM revealed [NAME] B was seen plating the meals for lunch time.
[NAME] B was touching the meal tickets, using a suction grabber device to grab the hot plates and then
using the serving ladles to place the food on the plates. [NAME] B was then seen taking a dinner rolls with
her bare hands and placing them on the meal plates. The Culinary Manger was present in the kitchen at the
time of the food being served. The Surveyor asked the Culinary Manager if it was okay for [NAME] B to be
taking the rolls with her bare hands and placing them on the plate. The Culinary Manager said no and went
and provided [NAME] B with a pair of tongs and asked her to use the tongs instead of her bare hands to
place the dinner rolls on the plate. During an interview on 09/03/2025 at 2:28 PM the Manager said that
[NAME] B should not have touched the dinner rolls with her bare hands as that could possibly contaminate
the rolls. The Culinary Manager said the cook had been working at the facility for about 10 years and she
knew that she was not supposed to touch the rolls but instead use something else to serve the rolls. The
Culinary Manager said she believed that [NAME] B had gotten nervous and forgotten to use something like
tongs to serve the rolls. During an interview on 09/04/2025 at 2:02 PM the Administrator was made aware
of the observation of [NAME] B using her hands to grab the dinner rolls and placing them on the resident's
meal plate. The Administrator said the cook should have used another method for placing the rolls on the
plate as that could lead to the spread of infections. Record review of the facility's undated document title
Infection control overview and policy indicated in part: Hand hygiene continues to be the primary means of
preventing the transmission of infection. The following is a list of some situations that require hand hygiene:
When coming on duty, before and after eating or handling food (hand washing with soap and water),
consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of
infections. In addition to proper hand hygiene, it is important for staff to use appropriate personal protective
equipment (PPE) as a barrier to exposure to any body fluids whether known to be infected or not. For
example, in situations identified as appropriate gloves and other equipment such as gowns and masks are
to be sued as necessary to the control the spread of infections. Wearing intact disposable gloves in good
condition and that are changed after each use helps reduce the spread of microorganisms.
Event ID:
Facility ID:
676034
If continuation sheet
Page 2 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676034
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brady West Rehab & Nursing
2201 Menard Hwy
Brady, TX 76825
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain an infection prevention and control
program designed to provide a safe, sanitary and comfortable environment to help prevent the development
and transmission of communicable diseases and infections for 2 of 3 residents (Resident #5, and Resident
#1) and 4 of 4 (NA #A, MA #F, ADON, and Director of Rehab) staff members reviewed for infection control
in that;The facility failed to ensure NA A changed her gloves after they became contaminated during
incontinent care while assisting Resident #5.The facility failed to ensure LVN B performed hand hygiene
between glove changes while providing wound care for Resident #1.The facility failed to ensure NA #A,
ADON, and Director of Rehab were tested for Tuberculosis (TB), a potentially serious infectious bacterial
disease that mainly affects the lungs, upon hire.The facility failed to ensure MA #F and Director of Rehab
completed a Tuberculosis Health Risk Screen upon hire and yearly. These failures could place resident's
risk for cross contamination and the spread of infection. Finding included:
Residents Affected - Some
1. Record review of Resident #5's electronic admission record dated 09/04/2025 indicated he was admitted
to the facility on [DATE] with diagnoses of muscle weakness and dementia. He was [AGE] years of age.
Record review of Resident #5's quarterly MDS dated [DATE] indicated in part: BIMS = 6 indicating the
resident had severe impairment. Bladder and bowel: Urinary continence = Always incontinent. Bowel
continence = Always incontinent.
Record review of Resident #5's care plan dated 07/22/2025 indicated in part: Resident is incontinent of
bowel/bladder. The resident will be clean with minimal incontinence related
skin breakdown through next review date. Check frequently for wetness and soiling and change as needed.
During an observation on 09/02/2025 at 11:30 AM revealed CNA E and NA A performed incontinent care
on Resident #5. Both aides entered the resident's room and explained to the resident what they were going
to do then they went into the restroom and washed their hands. NA A put some gloves on and unfastened
the resident's brief, then took some wet wipes and wiped his peri area. Both staff then turned the resident
on his right side and NA A wiped Resident #5's rectal area. Resident #5 had a bowel movement, so NA A
wiped the bowel movement with some wet wipes. NA A's gloves were observed to come in contact with
some of the bowel movement. While still wearing the same gloves, NA A took the new brief and fastened it
on Resident #5. While still wearing the same gloves, NA A adjusted the resident's draw sheet and
repositioned the resident in bed.
During an interview on 09/04/2025 at 11:32 AM NA A said she should have changed her gloves after they
became contaminated. NA A said by not changing her gloves that could lead to cross contamination and
the spread of infections. NA A said she had gotten nervous and forgotten to change her gloves.
Record review of face sheet for Resident #1 revealed an [AGE] year-old male admitted to the facility
07/17/2025 with the following diagnoses: Type two diabetes mellitus (condition in which the body has
trouble controlling blood sugar), obesity, dependence on renal dialysis (a medical treatment that removes
waste products and excess fluid from the blood), hemiplegia following cerebral infarction (paralysis or
weakness on one side of the body caused by stroke), pressure ulcer of right heal
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676034
If continuation sheet
Page 3 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676034
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brady West Rehab & Nursing
2201 Menard Hwy
Brady, TX 76825
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
unstageable, non-pressure chronic ulcer of left lower leg.
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #1's current Physician's orders dated 8/29/2025 revealed an order for daily
wound care to right lower leg.
Residents Affected - Some
Record review of Resident #1's annual MDS dated [DATE] revealed BIMS of 15 indicating no cognitive
impairment. Section M - Skin Conditions revealed Resident #1 was at risk for developing pressure ulcers
and received pressure ulcer/injury care.
Record review of Resident #1's Comprehensive Care Plan, revised on 07/25/25 revealed the resident was
at risk for skin breakdown with approaches to follow skin care protocol and perform weekly skin
assessments.
On 9/03/25 at 4:41 PM, observed LVN B perform wound care to Resident #1's right heel. LVN B sanitized
her hands before putting on gloves and personal protective equipment prior to starting wound care. LVN B
removed the wound dressing to the right heel, then changed her gloves. LVN B put on new gloves and
performed care to Resident #1's right lower leg wound, per physician's orders. LVN B then changed gloves
and placed a dressing to the right lower leg wound, per physician's orders. LVN B did not perform hand
hygiene between glove changes. LVN B repositioned Resident #1 and exited the room. LVN B did not
sanitize her hands prior to leaving the room or upon exiting the room.
During an interview on 19/03/25 at 5:00PM with LVN B, she stated she did not sanitize her hands between
glove changes while performing wound care for Resident #1. LVN B stated she should have used hand
sanitizer or washed her hands between glove changes and after performing wound care. She stated her
failure to properly sanitize her hands during and after wound care was just an oversight. LVN B stated she
had been trained at the facility on proper hand hygiene. LVN B stated a potential negative outcome for
failure to properly sanitize hands during and after wound care would be infection and cross contamination.
During an interview on 09/04/2025 at 1:56 PM the DON said NA A should have changed her gloves to
prevent the spread of infections and to prevent cross contamination. The DON said the NA probably got
nervous and forgot her steps. The DON the staff probably needed more training and they would be doing
that.
During an interview on 09/04/2025 at 2:04 PM the Administrator was made aware of the observation of
incontinent care performed by NA A. The Administrator said the NA should have changed her gloves once
they became contaminated as that could lead to cross contamination.
During an interview on 9/04/25 at 2:27 PM with the DON, she stated she was not aware that staff failed to
observe proper hand hygiene during and after wound care. She stated the facility's policy for hand hygiene
during and after wound care was that hands were sanitized prior to beginning the procedure and with each
glove change, before putting on clean gloves. She stated hands should be washed prior to exiting the room
and after performing wound care. She stated her expectation of staff for proper hand hygiene during and
after wound care was that staff practice proper hygiene according to facility-provided education as well as
their nursing education. The DON stated a potential negative outcome for failure to observe proper hand
hygiene was cross contamination and infection.
Record review of the facility's policy titled “Hand hygiene” dated 11/12/2017 indicated in part:
“Staff involved in direct resident contact will perform proper hand hygiene
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676034
If continuation sheet
Page 4 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676034
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brady West Rehab & Nursing
2201 Menard Hwy
Brady, TX 76825
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
procedures to prevent the spread of infection to other personnel, residents and visitors. Staff will perform
hand hygiene when indicated using proper technique consistent with accepted standards of practice.
Before applying and after removing personal protective equipment (PPE) including gloves.
Record review of the facility's policy titled “Incontinence care” dated 2/14/2020 indicated in
part: “Purpose – To outline a procedure for cleansing the perineum and buttocks after an
incontinence episode. If feces present, remove with toilet paper or disposable wipe by wiping from front of
perineum toward rectum. Discard soiled materials and gloves. Wash hands.
2. Record review of human resource records for NA A indicated NA A was hired on 05/05/2025. NA A
completed a Tuberculosis Health Risk Screen on 05/05/2025. NA A was not tested for Tuberculosis upon
hire.
Record review of human resource records for MA F indicated MA F was hired on 08/23/2024. MA F was
tested for Tuberculosis and completed a Tuberculosis Health Risk Screen on 08/19/2024. MA F did not
complete an annual Tuberculosis Health Screen since 08/19/2024.
Record review of human resource records for the ADON indicated the ADON was hired on 07/23/2025. The
ADON completed a Tuberculosis Health Risk Screen on 07/24/2025. The ADON was not tested for
Tuberculosis upon hire.
Record review of human resource records for the Director of Rehab indicated the Director of Rehab was
hired on 02/01/2023. The Director of Rehab did not complete a Tuberculosis Health Risk Screen and
Tuberculosis test upon hire. The Director of Rehab completed a Tuberculosis Health Risk Screen on
06/12/2024. The Director of Rehab did not complete an annual Tuberculosis Health Screen since
06/12/2024.
During an interview on 09/04/2025 at 3:43 PM the Human Resources staff member said she had provided
everything that was performed for NA A, MA F, the ADON, and the Director of Rehab. She said what was
missing was not completed. She said that could cause TB issues for all residents and staff. She said
Nursing staff were responsible for performing TB tests and annual screening.
During an interview on 09/04/2025 at 4:22 PM with the Regional Director and the Admin, the Regional
Director said the lapse in Tuberculosis screening and testing was a problem. The Regional Director said
they were currently rectifying it now.
Record review of the facility's policy titled “Infection prevention and control program” dated
03/26/2024 indicated in part: “The facility has established and maintains an infection prevention and
control program designed to provide a safe, sanitary and comfortable environment and to help prevent the
development and transmissions of communicable diseases and infections as per accepted national
standards and guidelines. The designated infection preventionist is responsible for oversight of the program
and serves as a consultant to our staff and infectious diseases, resident room placement, implementing
isolation precautions, staff and resident exposures, surveillance and investigations of exposures of
infectious diseases. Standard precautions – all staff shall assume that all residents are potentially
infected or colonized with an organism that could be transmitted during the course of providing resident
care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene
procedures”.
Record Review of the facility's policy titled “Infection Control-Tuberculosis Screening and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676034
If continuation sheet
Page 5 of 6
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676034
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brady West Rehab & Nursing
2201 Menard Hwy
Brady, TX 76825
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Testing Guideline revised 5/1/25 indicated in part: “Tuberculosis (TB) screening and/or testing of
residents and health care personnel is recommended as part of a TB Infection Prevention and Control Plan.
Facilities must ensure adherence to local regulations as well as state and federal regulations. TB screening
is a process that includes: a baseline individual TB risk assessment, TB symptom evaluation, A TB test
unless a prior positive test is documented and copy supplied by employer. Annual screenings after hire are
required for all healthcare personnel.”
HJ
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676034
If continuation sheet
Page 6 of 6
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Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0211GeneralS&S Cno actual harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521GeneralS&S Cno actual harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
FAQ · About this visit
Common questions about this visit
What happened during the September 4, 2025 survey of BRADY WEST REHAB & NURSING?
This was a inspection survey of BRADY WEST REHAB & NURSING on September 4, 2025. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BRADY WEST REHAB & NURSING on September 4, 2025?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordanc..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.