Health inspection·November 19, 2025

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few think there was any negative impact to the residents due to CNA A working with an expired certification, but being in compliance with the their licensure body was required. During an interview with the DON on [DATE] at 7:06 PM, she stated she was not aware of CNA A having an expired certification prior to it being identified on [DATE]. The DON stated the staff should remember when their expiration dates were but believed HR provided them with information of when their expiration was coming up. The DON stated HR was responsible for reviewing and verifying staff certifications were active and she did not know how they were reviewed, how often they were reviewed or when they were last reviewed prior to [DATE]. The DON stated she did not run or receive any reports or updates from HR on staff's certification statuses. The DON stated HR was the only person who reviewed certifications and did not know why CNA A's expired certification was not identified. The DON stated CNA A's nurse aide certification was currently expired when reviewed it on [DATE] and she had been working the floor and providing care to residents with an expired certification for about 4 months. The DON stated CNAs were not allowed to work with an expired certification because they were providing direct patient care. The DON stated they identified CNA A had an expired certification on [DATE] when they pulled personnel files, the DON stated in response they removed CNA A from the schedule. The DON stated, based on facility policy, certifications had to be kept up to date and active and in this situation staff did not follow this policy. The DON stated although it was a big oversight, staff were trained, had skill check offs and knew how to do their job, and stated the only negative impact would be a nurse aide not having an active certification would mean they were not in compliance with the regulation not that they didn't know how to provide care. During an interview with HR on [DATE] at 7:22 PM, she stated she was not aware CNA A's nurse aide certification was expired prior to identifying it on [DATE]. HR stated she helped staff with employment verification and it was the staff responsibility to upload their items in TULIP and verify their certification. HR stated both her and the staff were responsible for verifying their certifications were active and it should be checked every 3 to 4 months. HR stated she checked certifications upon hire and then yearly and employees were responsible for keeping up with their certifications. HR stated she checked staff certification on the nurse aide registry or would run it through another website registry. HR stated she would not send a report or updates to the DON or Administrator. HR stated she was the only person who reviewed certifications and did not know how or why she did not identify CNA A's expired certification. HR stated she had not sent any reminder to CNA A about her certification needing to be renewed. HR reviewed CNA A's certification status and confirmed it was expired. HR stated CNA A worked for about 4 months at a rate of about 40 hours per week providing care to residents with an expired certification. HR stated nurse aides were not able to work with an expired certification and they had to be certified due to providing patient care. HR stated when she identified CNA A had an expired certification she reached out to her and filled out her employee verification and told CNA A to submit it into TULIP and contact them. HR stated the facility policy stated staff had to be current with their certification and had to notify them about any expirations as it was part of their responsibility. When asked if the facility staff followed their policy in this situation HR did not answer question directly and stated, I should have checked. HR stated nurse aides not having an active certification could negatively impact residents because of them not following the proper patient care protocols and the liability added. During an interview with CNA A on [DATE] at 7:34 PM, she stated she had just found out the morning of [DATE] that her certification was expired when HR messaged her. CNA A stated she was not aware prior to this. CNA A stated her certification expired in June of 2025. CNA A stated she was used to the facility and HR letting her know before her certification expired, but it was her responsibility to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676398 If continuation sheet Page 2 of 3 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 676398 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fox Hollow Post Acute 310 America Dr Brownsville, TX 78526 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 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete make sure her certification was renewed and active and she should have checked and known, but she had not checked. CNA A stated she worked at the facility proving patient care since her certification expired about 3 to 4 months or longer. CNA A stated she worked with and provided care to a lot of residents during that time. CNA A stated you could not work as a nurse's aide with an expired license because you had to be certified to work with patients. CNA A stated in response to identifying her certification was expired the facility took her off the schedule on [DATE]. CNA A stated the facility policy stated they could not work without a certification. CNA A stated she did not follow the facility policy in this situation. CNA A stated not having an active nurse aide certification could negatively impact residents because the facility would have to find someone to replace her and pick up her shifts. Record review facility's policy titled, Licensure, Certification, and Registration of Personnel, with an updated date of 09/2018, stated, 3. A copy of recertifications (e.g., annual, bi-annual, etc., as applicable) must be presented to the Human Resources Director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record. 4. Our facility conducts employment background screening checks, reference checks, license verifications and criminal conviction investigation checks in accordance with current federal and state laws.s failure could place residents at risk of not being provided the appropriate care. Event ID: Facility ID: 676398 If continuation sheet Page 3 of 3