Ebony Lake Nursing: Missing Medical Records - TX
The inspection, conducted September 18, 2025, centered on a single resident, identified in records only as Resident 1. She had received a physician's order to have staples removed on September 23, 2024. The wound care nurse carried out that removal. Then she documented nothing.
A second staple removal order arrived on September 30, 2024, one week later. The facility's Director of Nursing told the inspector she could not explain why a second order had been generated. She said the September 30 documentation was vague. She said she was certain the staples had already come out on the 23rd because the wound care nurse had signed off somewhere in the electronic medical record, but the record itself contained no documentation of the removal having been performed.
Those two statements do not fit together cleanly. A signature that confirms removal exists, but no documentation of the removal exists. The Director of Nursing did not resolve that contradiction. She said the wound care nurse who performed the procedure was no longer employed at the facility.
When the inspector asked for the former nurse's phone number, the facility did not provide it.
The Director of Nursing said there were no negative outcomes for Resident 1, that her staples were removed on September 23 as intended, and that the only problem was the missing paperwork. That may be true. The inspection report notes the violation caused minimal harm or potential for actual harm, and only a few residents were affected. This was not an emergency. No one was in immediate danger.
But the record that survives is the one future caregivers will rely on. A home health nurse, an emergency room physician, a surgeon seeing a patient for a follow-up, a specialist reviewing a wound that isn't healing the way it should — any of them would open that chart and find no indication the staples were ever removed. They would find a second removal order dated a week after the first, with vague documentation attached. They would not find the wound care nurse. They would not be able to call her.
The facility's own Documentation in the Medical Record policy, dated October 2022, requires that each resident's medical record contain "an accurate representation of the actual experiences of the resident" and "enough information to provide a picture of the resident's progress." It requires licensed staff to document all care services in the medical record. It requires that documentation be completed at the time of service, or no later than the end of the shift in which the care occurred.
None of that happened here. The wound care nurse did not document at the time of service. She did not document by the end of the shift. She did not document before she left the facility. The Director of Nursing, asked to account for the gap nearly a year later, said she could not explain it.
What the inspection record does not contain is any indication the facility took steps to reconstruct what happened, to contact the former nurse before her departure, to flag the incomplete record for the physicians still treating Resident 1, or to audit whether other residents cared for by the same nurse had similar gaps in their charts. The inspector asked for a phone number and was turned away.
Ebony Lake's own policy says the medical record shall contain enough information to provide a picture of the resident's progress. For a period of time that included a surgical wound and its closure, Resident 1's chart offers no picture at all. Just a second order, vague documentation, and a nurse no one can reach.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ebony Lake Nursing and Rehabilitation Center from 2025-09-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 16, 2026 · Our methodology
Ebony Lake Nursing and Rehabilitation Center in Brownsville, TX was cited for violations during a health inspection on September 18, 2025.
The inspection, conducted September 18, 2025, centered on a single resident, identified in records only as Resident 1.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.