Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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:
Residents Affected - Few
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.
Findings include:
Record review of Resident #74's face sheet dated 05/15/2024 revealed a [AGE] year-old female admitted
on [DATE] with a diagnosis of cellulitis of groin (bacterial infection involving the inner layers of the skin),
herpes virus vulvovaginitis (viral infection caused by herpes simplex virus causing inflammation of the
female genitalia), chronic viral Hepatitis C (viral infection that causes inflammation of liver),
hypothyroidism-unspecified (condition where the thyroid gland does not produce enough hormones),
Schizoaffective disorder-bipolar type (a mental disorder in which a person experiences a combination of
symptoms of Schizophrenia and mood disorder), and depression-unspecified (mood disorder causing
persistent feeling of sadness and loss of interest).
Record review of Resident #74's discharge MDS assessment dated [DATE] revealed section A2105
discharge status was Short-Term General Hospital. MDS assessment reflected section A was signed for by
the MDS Coordinator and ADM.
Record review of Resident #74's Transfer/Discharge Report dated 04/03/2024 revealed Resident #74 was
discharged to home with a signature from Resident #74 dated 04/03/2024 at 12:44 PM.
In an interview and observation on 05/16/2024 at 09:50 AM the MDS Coordinator stated she remembered
Resident #74. The MDS coordinator was observed reviewing Resident #74's record and stated she
remembered that Resident #74 was discharged home. The MDS coordinator stated she was in charge of
completing all facility MDS assessments and had completed the discharge MDS for Resident #74 and
marked incorrectly that the resident was sent to the hospital when she was really sent home. She stated it
was her expectation that the assessments were 100 percent accurate. She said an inaccurate MDS could
affect the care of the resident and that staff want to ensure the care plans and MDS assessments
accurately represent the residents.
In an interview on 05/16/2024 at 10:00 AM the ADM stated it was the MDS Coordinator who was
(continued on next page)
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 5
Event ID:
745004
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
745004
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Brixton at Horseshoe Bay
15101 West Fm 2147
Horseshoe Bay, TX 78657
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
responsible for completing MDS assessments and that he then signs off on them after completion. The
ADM stated it was his expectation that all assessments completed were accurate. The ADM stated that an
incorrect MDS assessment could affect different things depending on which section was incorrect but has
the potential to affect payments and/or care plans. He stated he remembered Resident #74 and that the
resident was discharged home after certain behaviors from Resident #74 that prevented the facility from
being able to provide care.
Record review of the MDS 3.0 Completion policy last revised 11/2023 reflected:
According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate,
and standardized assessment of each resident's functional capacity using the RAI specified by the state.
Care plan team responsibility for assessment completion:
a.
Interdisciplinary responsibility for completion of MDS sections:
i.
Persons completing part of the assessment must attest to the accuracy of the section they completed by
signature and indication of the relevant sections.
The RN coordinator signs, dates, and attests (in section Z0500A) to timely completion of the RAI once all
other disciplines have completed their sections.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
745004
If continuation sheet
Page 2 of 5
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
745004
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Brixton at Horseshoe Bay
15101 West Fm 2147
Horseshoe Bay, TX 78657
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
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 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.
Residents Affected - Some
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].
Record review of the Medical Diagnosis Sheet for Resident #70 dated 04/09/2024 reflected he had an
unspecified fracture of left femur (broken thighbone), subsequent encounter for closed fracture with routine
healing.
Record review of the Comprehensive MDS for Resident #70 dated 04/16/2024 reflected he had a BIMS
score of 3 indicating severe cognitive impairment. His functional abilities and goals reflected he required
supervision or touching assistance for personal hygiene.
Record review of the Care Plan for Resident #70 dated 04/18/2024 reflected he had an ADL self-care
performance and mobility deficit. Goal: Resident will be clean, well groomed, and appropriately dressed
thought the review date 7/24/2024. Interventions: Check nails are clean, trimmed and filed.
Observation and interview on 05/14/2024 at 9:12 AM of Resident #70 revealed he had jagged fingernails
that were 3/4 inch past the fingertips on both hands. He stated My nails need filing. I could use someone to
help me file them.
Observation on 05/15/2024 at 09:05 AM of Resident #70's fingernails which revealed they were still long
and jagged on both hands.
Observation and interview on 05/15/2024 at 1:51 PM of Resident #70 revealed he still had long and jagged
fingernails. CNA A was in his room and observed his nails. Resident #70 stated he would allow her to trim
and file his nails.
In an interview on 05/15/2024 at 2:01 PM RN B stated she was a regular staff and had worked at the facility
for 3-4 months. She stated she had the right side of the 100 hall which included Resident #70. She noted
he had long, jagged fingernails and could scratch himself. She stated the lack of nail care could be a dignity
issue. She stated since she had to give residents their medications, she had not been able to do a full set of
observation rounds that day.
Record review of the undated Face Sheet for Resident #52 reflected she was an [AGE] year-old female
admitted to the facility on [DATE].
Record review of the Medical Diagnosis Sheet for Resident #52 dated 06/19/2023 reflected she had a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
745004
If continuation sheet
Page 3 of 5
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
745004
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Brixton at Horseshoe Bay
15101 West Fm 2147
Horseshoe Bay, TX 78657
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
diagnosis of Unspecified Dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to
such an extent that it interferes with a person's daily life and activities) and Type 2 Diabetes Mellitus (a
long-term condition in which the body has trouble controlling blood sugar and using it for energy) with other
diabetic kidney complication.
Record review of the Quarterly MDS for Resident #52 dated 03/07/2024 reflected she had a BIMS score of
10 indicating moderate cognitive impairment.
Record review of the Care Plan for Resident #52 dated 6/13/2024 reflected she required assistance with
ADL's r/t impaired mobility, increased weakness, poor cognition, poor health. Goal: She will be clean,
well-groomed through the review date 06/11/2024. Interventions: Check nails are clean, trimmed and filed.
Licensed Nursing to complete nail care.
In an observation and interview on 05/14/2024 at 9:56 AM revealed Resident #52's fingernails were
3/4-inch past the fingertips and jagged. She stated her family member had not been to the facility in a long
time to trim and file her nails .
Observation and interview on 05/15/2024 at 9:16 AM revealed Resident #52's fingernails were still long and
jagged. She stated, I need them trimmed and filed.
In an interview on 05/15/2024 at 1:44 PM CNA A stated Resident #52 was a diabetic and the nurse would
need to trim her fingernails. CNA A noted the resident's nails were long and needed to be cleaned. She
stated bacteria could be under her nails, she could scratch herself, get a wound and an infection .
In an interview on 05/15/2024 at 1:55 PM in Resident #52's room, LVN C stated she was an agency nurse
and she thought nail care was performed by the weekend staff. LVN C noted Resident #52's nails were long
and jagged with brown/yellow debris underneath. LVN C stated there could be food, feces, anything under
her nails. She stated the resident could get skin tears and an infection.
Record review of the undated Face Sheet for Resident #32 reflected she was an [AGE] year-old female
who was admitted to the facility on [DATE].
Record review of the Medical Diagnosis Sheet for Resident #32 dated 07/17/2023 reflected she had a
diagnoses of Unspecified Dementia (loss of cognitive functioning, thinking, remembering, and reasoning, to
such an extent that it interferes with a person's daily life and activities.)
Record review of the Quarterly MDS for Resident #32 dated 04/23/2024 reflected she had a BIMS score of
7 indicating severe cognitive impairment. The functional abilities and goals indicated she was independent
with her personal hygiene.
Record review of the Care Plan for Resident #32 dated 07/26/2023 reflected she required assistance with
ADL's r/t increased weakness, poor cognition. Impaired mobility and pain. Goal: She will be clean,
groomed. Interventions: Check nails are clean, trimmed, filed.
Observation and interview on 05/14/2024 at 9:59 AM in Resident #32's room revealed her fingernails were
jagged and 3/4 inch past the fingertips. She stated No one ever offers to trim or file them. I get a bath three
times a week. I don't ask them to trim my nails when they're in a hurry. They don't have time to trim nails.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
745004
If continuation sheet
Page 4 of 5
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
745004
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Brixton at Horseshoe Bay
15101 West Fm 2147
Horseshoe Bay, TX 78657
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Observation and interview on 05/15/2024 at 9:17 AM revealed Resident #32's fingernails were still long,
jagged and with brown debris underneath. Resident #32 was observed using a fingernail to pick brown
debris out from under her other fingernails. She stated she had not received nail care in a long time.
In an interview on 05/15/2024 at 1:44 PM CNA A noted Resident #32's fingernails needed to be cleaned
and trimmed. CNA A stated there could be bacteria under her fingernails, she could scratch herself, get a
wound and an infection .
In an interview on 05/15/2024 at 1:59 PM in Resident #32's room, LVN C noted the resident's nails were
long, jagged and she could get skin tears., She stated she could have bacteria under her nails. She stated
she was responsible as a CN to follow-up behind the aides but stated she did not look at nails all of the
time.
In an interview on 05/16/2024 at 10:22 AM the ADON stated I do not look at residents' nails. The Charge
Nurses do rounds and aides do the nails. but no one person has responsibility over that. When we do our
rounds in the morning we look at the condition of the room and make sure they have water. The potential
risk to the resident is they could have bacteria under their nails and get an infection. They also put their
fingers in their mouths. They could get a skin tear with an infection. They could scratch another resident or
employee. Their nails could get caught on something and rip it off.
In an interview on 05/16/2024 at 10:27 AM the DON stated the nurses and CNAs were responsible for nail
care and the nurses should have been checking the resident's nails. She stated residents could have
bacteria or fungal infections under their nails and if they scratched themselves, they could get a skin tear
and infection. She stated their plan going forward was that she and the ADON were planning to do audits
and actually look at the residents' nail care.
In an interview on 05/16/2024 at 10:32 AM the ADM stated his expectations were for fingernails to be
cleaned routinely and trimmed, as necessary. He stated if the residents' nails were dirty or long the staff
needed to go ahead and get them taken care of. He further stated long, jagged nails could cause skin tears
and infections.
Record review of a facility Policy titled Nail Care dated 11/2021 and reviewed /revised 11/2022 and 11/2023
reflected Policy: The purpose of this procedure is to provide guidelines for the provision of care to a
resident's nails for good grooming and health.
1.
Routine nail care, to include trimming and filing, shall be provided on shower days between scheduled
occasions as the need arises when residents allow. Principles of Nail Care: a) Only licensed nurses shall
trim or file fingernails of residents with diabetes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
745004
If continuation sheet
Page 5 of 5
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Back to topCitations
2 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.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
FAQ · About this visit
Common questions about this visit
What happened during the May 16, 2024 survey of THE BRIXTON AT HORSESHOE BAY?
This was a inspection survey of THE BRIXTON AT HORSESHOE BAY on May 16, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE BRIXTON AT HORSESHOE BAY on May 16, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.