BRENHAM, TX - Federal inspectors issued an immediate jeopardy citation to Focused Care At Brenham after a complaint investigation revealed the facility failed to obtain ordered laboratory tests for a resident with chronic respiratory failure, placing multiple residents at risk of serious harm due to systemic failures in lab monitoring and physician notification.
Immediate Jeopardy Declared for Lab Failures
The Centers for Medicare & Medicaid Services (CMS) complaint survey, completed on February 1, 2025, found that the Brenham, Texas facility violated F-Tag 770, which requires nursing homes to provide laboratory services as ordered by physicians. The deficiency was classified at the immediate jeopardy level — the most serious category in the federal enforcement system — indicating that the failure posed an immediate risk to resident health or safety.
The citation centered on Resident #1, described as a male resident with a diagnosis of chronic respiratory failure with hypoxia, a condition in which the body does not receive adequate oxygen. For patients with this diagnosis, timely laboratory monitoring is not optional — it is essential. Blood tests track oxygen-carrying capacity, organ function, and metabolic stability. When ordered labs are not drawn or results are not reported, clinicians lose visibility into whether the resident's condition is stable or deteriorating.
Chronic respiratory failure with hypoxia requires careful, ongoing clinical surveillance. Laboratory values such as arterial blood gases, complete blood counts, and metabolic panels provide the data physicians need to adjust supplemental oxygen, medications, and other interventions. Without that data, a resident's condition can worsen undetected, potentially leading to respiratory distress, organ damage, or cardiac events.
The inspection report confirmed that ordered labs for this resident were not collected, though the full clinical details of the timeline and consequences were documented in the complaint investigation record.
Systemic Breakdown in Lab Tracking
Inspectors found that the lab failure was not an isolated incident but reflected broader systemic problems within the facility's laboratory monitoring processes. When the Director of Nursing (DON) and Assistant Director of Nursing (ADON) conducted an internal audit on January 29, 2025 — after the problem was identified — they reviewed lab orders across the facility to determine whether other residents had been affected.
The audit found no additional residents with outstanding uncompleted lab orders at that time, but the fact that such an audit had never been routine pointed to a gap in the facility's quality assurance practices. Prior to the citation, the facility had no standardized lab tracking system in place at nursing stations, no formal process for confirming that lab results were received and reported to physicians, and no regular audits to catch missed orders.
As part of its corrective action, the facility implemented several new measures beginning January 29, 2025:
- Lab tracking binders were placed at each nurse's station - Staff were directed to report all lab results to the physician or nurse practitioner immediately - Abnormal results were to be reported to the DON or designee and documented in each resident's electronic medical record - Proof of physician notification — including signature, date, time, and method of communication — was required on lab report sheets - Any lab draw that could not be completed on the scheduled day was to be communicated to the physician immediately
Staff In-Services and Monitoring
During the survey on February 1, 2025, inspectors verified that the facility had conducted in-service training for nursing staff. Between 8:39 AM and 3:21 PM, the surveyor interviewed multiple employees — including the activities director, social worker, one agency LVN, one RN, and four LVNs from different shifts — all of whom confirmed they had been trained on the new lab monitoring protocols.
Staff members confirmed they understood the requirements for immediate physician notification, documentation in the electronic medical record, use of the lab tracking binder, and the expectation that lab draws not completed on a given day would be escalated to the physician without delay.
The facility's medical director confirmed in an interview at 8:39 AM on February 1 that he had been informed of the immediate jeopardy declaration.
By 4:30 PM on February 1, 2025, inspectors notified the administrator that the immediate jeopardy had been removed. However, the facility remained cited at a level of no actual harm with a scope of pattern — meaning inspectors determined the corrective systems needed further evaluation before the facility could demonstrate sustained compliance.
Second Resident's Labs Unreviewed for Two Weeks
A related but separately cited deficiency — F-Tag 773 — revealed additional failures in the facility's lab notification process involving a different resident. This citation, classified at the minimal harm or potential for actual harm level, documented a case in which abnormal laboratory results went unreviewed by a physician for approximately two weeks.
Resident #1 under F-773 (a different individual from the immediate jeopardy citation) was a female resident with diagnoses including dementia, Type 2 diabetes, and a history of cerebrovascular accident (stroke). She was also assessed to have anemia and was on antiplatelet medication requiring bleeding precautions.
On February 18, 2025, the facility's physician visited and ordered a comprehensive metabolic panel, complete blood count, hemoglobin A1C, lipid panel, and phenytoin level. The labs were drawn on February 20, 2025, and results showed abnormal values for hematocrit (a measure of red blood cell volume), glucose (blood sugar), and albumin (a key blood protein).
The ADON signed the lab results as received on February 20 and handed them to an LVN to deliver to the physician. However, no one followed up to confirm the physician reviewed them. The results sat without physician review until March 3, 2025 — 11 days later — when the ADON finally noticed the lab had not been returned with physician orders.
Even then, the physician did not review the results until March 6, 2025 — a full 14 days after the labs were drawn.
In an interview on March 6, the ADON acknowledged the failure directly: she stated she signed the lab as received on February 20 and gave it to the LVN but "did not follow up on the lab to see if it was returned until 03/03/2025." She stated "it should have been followed up on right away to ensure the resident gets the care they need."
The LVN involved stated she "was not aware Resident #1's lab had not been followed up on" until the ADON informed her on March 3. She said the ADON was supposed to handle the follow-up and no one had assigned that responsibility to her.
The administrator confirmed that her expectation was for labs to be followed up on immediately and that she had noticed the gap during her own audit, ultimately sending the results to the physician herself on March 3.
Why Delayed Lab Review Matters
For a resident with diabetes, anemia, and a history of stroke, abnormal hematocrit, glucose, and albumin levels each carry distinct clinical significance.
Low hematocrit in a patient already diagnosed with anemia and taking antiplatelet medication can indicate worsening anemia or internal bleeding. Without physician review, the care team cannot determine whether medication adjustments, iron supplementation, or further diagnostic workup is needed.
Abnormal glucose levels in a diabetic patient may indicate that the current treatment regimen — whether insulin, oral medications, or dietary management — is not adequately controlling blood sugar. Persistently elevated glucose increases the risk of diabetic complications including neuropathy, kidney damage, and impaired wound healing. Persistently low glucose can cause confusion, falls, seizures, or loss of consciousness.
Low albumin is a marker of nutritional status and is associated with increased risk of pressure injuries, delayed wound healing, infection, and mortality in elderly nursing home residents. The physician ultimately recommended encouraging protein intake at meals three times daily — an intervention that was delayed by two weeks due to the notification failure.
Facility Policy Versus Practice
The facility's own written policy, titled "Lab Monitoring-Therapeutic Levels" and dated May 25, 2021, outlined clear expectations: all lab results were to be reviewed by a nurse who would date and time-stamp the review, abnormal results were to be faxed to the physician, and if no physician response was received within 24 hours, the nurse was required to call the physician's office. The policy further stated that the physician's office was to be notified daily until a response was received.
The inspection findings demonstrate that this policy was not followed. The abnormal lab results were received on February 20, yet no nurse called the physician's office until March 3 — well beyond the 24-hour follow-up window required by the facility's own procedures.
Regulatory Context
Focused Care At Brenham, located at 1303 Highway 290 East in Brenham, Texas, was surveyed under CMS provider number 676355. Immediate jeopardy citations represent the highest level of deficiency severity in the federal nursing home inspection system and can trigger enhanced enforcement actions including civil monetary penalties, denial of payment for new admissions, and — in cases of sustained noncompliance — termination from the Medicare and Medicaid programs.
The facility's corrective plan, including the establishment of lab tracking binders, staff in-services, and quality assurance audits, was accepted by surveyors as sufficient to remove the immediate jeopardy. However, the facility remains subject to ongoing monitoring to confirm that the new systems are effective and sustained.
Readers can review the full federal inspection report, including the facility's complete plan of correction, through the CMS Care Compare website or by contacting the Texas Health and Human Services Commission.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care At Brenham from 2025-02-01 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.