Ebony Lake Nursing And Rehabilitation Center
Ebony Lake Nursing and Rehabilitation Center in Brownsville, TX — inspection on April 29, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During interview on 4/29/26 at 5:53 p.m., the DON stated that LVN D did not follow up with the doctor regarding the discoloration because it was part of the fall incident on 4/9/26.
The DON stated LVN D did not have to follow up with the physician and that there was not a negative outcome.
The DON stated that the change of condition or skin assessment was not done because it was part of the fall from 4/9/26.
Record review of the facility policy titled, Notification of Changes implemented date 10/24/22, revealed the following: It is the purpose of this policy is to ensure that the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
675635 04/29/2026
Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520
CNAs to reference and carry out proper care residents required.
Record review of the facility's policy
consistent with resident's rights, that incudes measurable objectives and timeframes to meet a
comprehensive assessment
675635 04/29/2026
Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520
investigate, and review any accidents or incidents that occur or allegedly occur, on facility property
675635 04/29/2026
Ebony Lake Nursing and Rehabilitation Center 1001 Central Blvd Brownsville, TX 78520
During an observation on 4/28/26 at 2:15 p.m., revealed CNA A and CNA B entered Resident #1's room and placed supplies on the bedside table. CNA A washed her hands, donned a gown and gloves. CNA A removed Resident #1's soiled brief and placed it in the trash can. CNA A removed her gloves and donned gloves without washing or sanitizing her hands. CNA A then cleaned Resident #1's peri-area, removed her gloves, but did not wash or sanitize her hands before donning new gloves. CNA A and CNA B washed their hands before and after the procedure only.
During an interview on 4/28/26 at 2:25 p.m., with CNA A, she stated I should have sanitized or washed my hands before donning new gloves.
She stated she should have washed her hands or used hand sanitizer between glove changes. CNA A stated, I forgot about it because I was nervous.
She stated the potential negative outcome could be a spread of infection.
She stated she had training on infection control, and handwashing.
During an interview on 4/29/26 at 5:53 p.m., with the DON, she stated hands should be washed if gloves were visibly soiled or staff could use hand sanitizer between glove changes.
She stated the ADON and DON were responsible for monitoring the staff for compliance with infection control.
She stated the potential negative outcome could be cross contamination or infection even though the staff had the gloves as a barrier, they still could contaminate or give the resident an infection.
Review of facility's policy on Infection Prevention Control Program with a date implemented 5/13/23 revealed This facility has established and maintains 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 disease and infections as per accepted national standards and guidelines.
Review of the Center for Disease Control and Prevention website, on 5/6/26 (https://www.cdc.gov/handhygiene/providers/index.html), Know when to clean your hands:Immediately before touching a patient.Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices.Before moving from work on a soiled body site to a clean body site on the same patient.After touching a patient or patient's surroundings.After contact with blood, body fluids, or contaminated surfaces.Immediately after glove removal.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.