Health inspection·November 19, 2025

F 0839 Employ staff that are licensed, certified, or registered in accordance with state laws. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure before allowing an individual to serve as a nurse aide, registry verification was received that the individual had met competency evaluation requirements for 1 of 3 employees (CNA A) reviewed for nurse aide registry verification. The facility failed to ensure CNA A had a current nurse aide certification while employed at the facility, while actively providing care for residents.This failure could place residents at risk of not being provided the appropriate care. The findings include: Record review of application software used by the facility to manage employee documents revealed CNA A's nurse aide certification expired on [DATE]. Record review of Texas Unified Licensure Information Portal's Nurse Aide Public Registry, on [DATE] at 4:24 PM, revealed CNA A's nurse aide certification status was expired and listed her certification expiration date as [DATE].Record review of Texas Unified Licensure Information Portal's Nurse Aide Public Registry defined a nurse aide registry status of expired to indicate This nurse aide's registration is expired. The nurse aide is currently not employable as a nurse aide in a licensed nursing facility in the state of Texas.Record review of CNA A's timecard, from [DATE] till [DATE], revealed she worked a total of roughly 716 hours.Record review of CNA A's timecard for [DATE] revealed she last worked on [DATE] at 6:14 AM.During an interview with the Administrator on [DATE] at 6:15 PM, he stated he was not aware of CNA A having an expired certification prior to it being identified on [DATE]. The Administrator said staff members were responsible for renewing their certifications and verifying their certifications were active and HR was used as a failsafe. The Administrator stated he was not able to recall the exact date of expiration for CNA A's nurse aide certification but he did see it and confirmed it was expired. The Administrator stated CNA A had been working the floor and providing care to residents since the day of her expired certification (which at that time was thought to be [DATE]). The Administrator stated CNA A worked roughly 4 months and around 700 hours with an expired certification. The Administrator stated when they identified CNA A's certification was expired on [DATE], they removed her from the schedule and prompted her to complete her renewal. The Administrator stated prior to her certification expiring no one had sent any communication to CNA A regarding her upcoming expiration. The Administrator stated aside HR reviewing certifications it would also be him. The Administrator stated they did not catch CNA A's expired certification due to a failed system. The Administrator stated certifications were checked probably every 3 to 6 months and the last time it was checked prior to [DATE] was probably before [DATE]. The Administrator stated they previously did not run or receive any reports regarding certification status's and on [DATE] they set up a program that would run a monthly report and send an email of the upcoming licensures and certifications that would be expiring. The Administrator stated CNAs were not allowed to work with an expired certification. The Administrator stated as per facility policy staff needed to be in good standing with tier certifications and in this situation the facility policy was not followed. The Administrator stated he did not Residents Affected - Few Page 1 of 3 676398 676398 11/19/2025 Fox Hollow Post Acute 310 America Dr Brownsville, TX 78526

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 676398 Page 2 of 3 676398 11/19/2025 Fox Hollow Post Acute 310 America Dr Brownsville, TX 78526

F 0839 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 676398 Page 3 of 3