The Brazos Of Waco
Inspection Findings
F-Tag F0760
F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the error and notified the representative that the agency nurse was not to return to the facility.Record review of the hospital admission records dated 09/22/2025 was due to Metabolic Encephalopathy (a condition in which the brain does not receive enough oxygen or nutrients leading to changes in brain function) due to Valacyclovir toxicity. During an interview on 09/26/2025 at 11:32AM, LVN A stated after breakfast on 09/21/2025, Resident #1's family member stated that Resident #1 was very confused and was not answering questions appropriately. Resident #1 was Spanish speaking only and LVN Awas bilingual. LVN A stated she assessed Resident #1, and she had slurred speech and could not follow commands. LVN A stated she then notified the nurse practitioner who assessed Resident #1 and gave orders for transport to
the hospital. Record review of the Facility Investigation Report dated 09/22/2025 indicated actions taken prior to entrance were: Medication error report completed with appropriate physician and responsible party notified. The nurse responsible for medication error suspended pending further investigation. Resident report roster was completed for the 30 days of facility admissions August 23, 2025, to September 22, 2025.
These resident's hospital discharge orders were reviewed in comparison to the admitting orders entered into the electronic medical record and the Medication Reconciliation Report. There were no other errors found during the audit. Re-education of Administrative Nurses by Clinical Services Director on process of medication reconciliation with admission orders and confirmation of admission orders with physician.
DON/Designee will re-educate staff nurses, before nurse completes new admission or re-admission. Ad Hoc QAPI was held on 09/22/2025. Record Review of the Inservice Sign in sheets dated 09/22/2025 revealed staff were educated on the medication reconciliation process.During interviews on 09/26/2025 with staff, the following was stated:*At 2:43PM ADON D stated she was in-serviced by the Clinical Services Director regarding the process for medication reconciliation as documented on the in-service sign in sheet of 09/22/2025.*At 5:13PM The DON stated she was in-serviced by the Clinical Services Director regarding
the process for medication reconciliation as documented on the in-service sign in sheet of 09/22/2025. She stated weekend staffing was amended to include a member of the nursing leadership team to ensure a second nurse reviews medication reconciliation during non-business hours. She stated she, the 2 ADONs, and the MDS nurse will now work one weekend per month to provide this coverage. *At 5:14PM RN F stated she received training of second nurse review of medication reconciliation.*At 5:50PM LVN I stated
she received training of second nurse review of medication reconciliation. LVN I stated she was in-serviced by the Clinical Services Director regarding the process for medication reconciliation as documented on the in-service sign in sheet of 09/22/2025. Record Review of the Ad Hoc QAPI agenda and sign in sheet revealed the meeting was held. Record Review was conducted of the audit of resident hospital discharge orders as compared to admitting orders and outcomes were confirmed on 09/26/2025 by conducting a
Record Review of the medical records of 5 Residents selected for the random sample. Record Review of
the undated policy Medication Reconciliation was conducted on 09/26/2025. Policy statement #2 read: Residents who are being readmitted to our facility after an acute care stay will have review of the most current SNF discharge medication profile with the readmission medication orders to validate that the resident has a comprehensive and accurate medication profile.The noncompliance was identified as PNC.
The Immediate Jeopardy (IJ) began on 09/20/2025 and ended on 09/22/2025. The facility had corrected the noncompliance before the investigation began.
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The Brazos of Waco in Waco, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Waco, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Brazos of Waco or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.