Brush Country Nursing and Rehabilitation Safety Audit & Violations | Austin, TX

Standard Identification Protocol

CITATION DATEJanuary 1, 2026

F-TAG: 0880

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 two of three residents (Resident #10 and Resident #24) reviewed for infection control. The facility failed to ensure MA S sanitized the blood pressure device and cuff between use with Resident #10 and Resident #24. This failure could place residents at risk of cross-contamination and infections. Findings include: Record review of Resident #10's face sheet, dated 06/15/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10's relevant diagnoses included breast cancer, difficulty swallowing, difficulty walking, anxiety and dementia. Record review of Resident #24's face sheet, dated 06/15/23, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #24's relevant diagnoses included heart failure, kidney failure, difficulty swallowing, difficulty walking, anxiety, depression, post traumatic stress disorder, and bi-polar disorder with mania episodes. In observation of MA S on 06/13/23 at 9:10 AM, she obtained Resident #24's blood pressure by placing the device cuff on her right wrist. MA S failed to sanitize the blood pressure device and cuff before or after use with Resident #24. In observation of MA S on 06/13/23 at 9:18 AM, she obtained Resident #10's blood pressure by placing the device cuff on her left wrist. MA S failed to sanitize the blood pressure device and cuff before or after use with Resident #10. In interview with MA S on 06/13/23 at 9:48 AM, she stated she forgot to sanitize the blood pressure device and cuff between use on Resident #24 and Resident #10. She stated the facility had educated her on sanitizing shared use equipment but during the time of observation, she forgot. She stated it was important to sanitize shared use equipment for infection control purposes. In interview with ADON W on 06/15/23 at 10:19 AM, he stated all staff were expected to sanitize shared use equipment between resident use. He stated MA S should have sanitized the blood pressure cuff and device between use with residents in her care. He stated it was important to sanitize shared use equipment between resident use to prevent infection and cross-contamination. He stated it was the floor nurse who oriented and trained MA S to ensure she adhered to infection control policies and procedures. In interview with the DON on 06/15/23 at 10:59 AM, she stated all staff were expected to sanitize shared use equipment between resident use. She stated MA S should have sanitized the blood pressure cuff and device between use with residents in her care. She stated it was important to sanitize shared use equipment between resident use to prevent infection at the facility. She stated MA S was agency sourced staff, and it was expected she was trained in infection control policies and procedures by the agency. She stated MA S was oriented by a staff nurse before being able to work on her own; but stated there was not any documentation of a facility generated skills check-off or competencies for review. In interview with the Administrator on 06/15/23 at 1:22 PM, she stated she expected all staff to sanitize shared use equipment between resident use. She stated it was important to sanitize shared use equipment between resident use for infection control purposes. She stated it was the DONs responsibility to ensure staff adhere to infection control policies and procedures. Record review of the facility's, undated, policy, Cleaning and Disinfection of Resident Care Items and Equipment, revealed: d. Reusable items are cleaned and disinfected or sterilized between residents.

Scope & Severity (CMS Alpha)

Potential for Harm

Standard Identification Protocol

Brush Country Nursing and Rehabilitation

Safety Pulse

Regional Context

Quick Stats

Was your loved one injured at Brush Country Nursing and Rehabilitation?

Violation History

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Provide care and assistance to perform activities of daily living for any resident who is unable.

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.

Provide safe, appropriate pain management for a resident who requires such services.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Prepare residents for a safe transfer or discharge from the nursing home.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Ensure each resident receives an accurate assessment.

PASARR screening for Mental disorders or Intellectual Disabilities

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Provide activities to meet all resident's needs.

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Keep all essential equipment working safely.

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Provide safe and appropriate respiratory care for a resident when needed.

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

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.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

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.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Provide and implement an infection prevention and control program.

Keep residents' personal and medical records private and confidential.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Keep residents' personal and medical records private and confidential.

Provide and implement an infection prevention and control program.

Regional Safety Benchmarking

Full Evidence Dossier

Need help understanding this audit?