Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bastrop Lost Pines Nursing And Rehabilitation Cent during CMS and state inspections, most recent first.
A resident with moderate intellectual disability, vascular dementia, bipolar disorder, severe cognitive impairment, and documented wheelchair dependence for mobility and transfers was subjected to verbal, mental, and physical abuse by an LVN and CNAs during toileting care. Video showed staff making profane, demeaning comments about the resident’s incontinence, telling the resident to shut up, calling her nasty, stating she needed a psych ward, and removing her wheelchair while she sobbed on the toilet. Despite care‑planned need for wheelchair use and extensive assistance, staff refused to return the wheelchair, stated she did not need it, and directed her to walk from the bathroom to the bed while providing only minimal assist, during which she fell and struck her left knee, later documented as bruised with a contusion. The resident was repeatedly left alone in the bathroom while crying, and her distress and complaints of knee pain were dismissed as fake crying, constituting a failure to protect her from abuse and neglect.
Failure to Maintain Required RN Coverage: The facility did not have an RN on duty for at least 8 consecutive hours a day on multiple days reviewed, and the DON was listed as the only RN on the schedule for an extended period. The ADM stated there was no policy for RN coverage, while the DON said she was in the building only Monday through Friday and available by phone otherwise. Staff stated an RN should always be available and that some care tasks were outside the LVN scope.
Failure to Care Plan Shower Refusals: The facility did not develop person-centered care plans for three residents who repeatedly refused showers. Although each resident had bathing assistance needs and shower sheets documented refusals, the care plans did not address bathing preferences or refusal patterns, and progress notes did not document the refusals. Staff interviews confirmed that the residents refused showers and that such refusals should have been reflected in the care plan.
Two residents with complex medical needs were exposed to potential cross-contamination when a medical assistant failed to perform hand hygiene between providing care to each of them. The staff member did not wash hands or use sanitizer after removing a blood pressure cuff from one resident and before entering the next resident's room to provide similar care, despite facility policies requiring hand hygiene between resident contacts.
Surveyors found that several residents with significant physical and cognitive impairments were living in rooms that were not kept clean, with trash, food crumbs, and soiled bathrooms observed. Staff interviews revealed confusion about cleaning responsibilities, especially when housekeeping was unavailable, and residents reported dissatisfaction with room cleanliness. Facility policies required daily cleaning, but these were not consistently followed, leading to unclean and uncomfortable living conditions.
A medication cart containing both prescribed and over-the-counter medications was found unattended and unlocked near the dining room entrance. The medication aide responsible was away from the cart and did not notice the surveyor accessing it. Interviews confirmed that staff were trained on medication storage, but the cart was left unlocked due to distraction, in violation of facility policy requiring medication carts to be locked when not in use.
A medication cart containing prescribed and over-the-counter drugs was found unattended and unlocked near a dining room entrance. The medication aide responsible had left the cart unsecured while away at the nurses' station, despite being trained on proper medication storage. Interviews with the DON and ADM confirmed staff training and policy requirements for medication security, and facility policy review supported the need for carts to be locked and attended at all times.
The facility failed to maintain a safe and homelike environment, with deficiencies including a detached sink basin, scuffed and peeling walls, a bed without a footboard, and improperly closing windows. Residents reported these issues, but delays in maintenance and lack of a formal repair policy contributed to the persistence of these problems.
Two residents who were unable to perform their own ADLs did not receive proper nail care, resulting in long, uneven, and unclean fingernails with a blackish substance present. Despite care plans and facility policy requiring regular nail care, staff did not ensure nails were cleaned and trimmed as needed, and neither resident had refused care. Staff interviews confirmed awareness of responsibilities but revealed the deficiency in providing necessary hygiene services.
A resident with quadriplegia and bilateral hand contractures was not evaluated or treated for therapy services despite physician orders and care plan interventions. The therapy team was unaware of the order due to communication failures, resulting in the resident not receiving necessary therapy or use of splints for over two months. Staff interviews revealed confusion about responsibility for applying hand braces, and the facility lacked a policy for contracture management.
Staff failed to prevent a resident with cognitive impairment from placing her bare hands into an unattended ice chest, resulting in cross-contamination, and did not intervene despite witnessing the event. Additionally, a nurse and CNA did not wear gowns while providing direct wound care to two residents under Enhanced Barrier Precautions, even though signage and PPE were available and care plans required their use.
A resident with significant medical conditions and moderate cognitive impairment had an OOH-DNR form in their record that was missing required signatures, including the physician's. Staff were aware of the incomplete documentation and attempted to obtain the necessary signature but did not follow up adequately. The facility lacked a policy on timely physician signatures for DNR forms, and staff believed a temporary DNR without a physician's signature could be used, resulting in the resident's wishes not being properly documented.
A resident with severe cognitive impairment and a history of UTIs was given daily prophylactic antibiotics without meeting infection criteria or being monitored for side effects. Facility staff did not question the necessity of the order, and the antibiotic stewardship policy requiring monitoring and justification was not followed.
Surveyors found seven expired disposable syringes with needles in a medication cart, with staff interviews revealing inconsistent practices for checking expiration dates and no specific policy for removing expired supplies.
A resident with severe cognitive impairment and multiple medical conditions was prescribed prophylactic Bactrim without a specified duration or monitoring for side effects, despite not meeting infection criteria. Facility staff did not question the appropriateness of the antibiotic order or follow the facility's antibiotic stewardship policy, which requires clear indication, duration, and use of McGeer’s criteria for infection.
A resident with severe cognitive impairment and multiple health conditions was not properly offered or documented for influenza and pneumococcal vaccinations. The medical record and consent forms did not accurately reflect the resident's representative's wishes or vaccination history, and required education was not provided. Staff interviews confirmed that the process for obtaining immunization consent and history was not consistently followed.
A facility did not ensure a resident's right to an advance directive was respected when a DNR order was not followed. Despite clear documentation of the DNR status in multiple records, nursing staff initiated CPR without verifying the resident's code status. The incident involved LVN A, MA L, and CNA J, who did not effectively communicate or confirm the DNR status before starting CPR. This highlights a gap in staff adherence to protocols for verifying code status during emergencies, despite existing training and procedures.
Abuse and Neglect During Toileting and Transfer Resulting in Resident Fall and Knee Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal, mental, and physical abuse and neglect during toileting and transfer care. The resident was a 75‑year‑old female with moderate intellectual disabilities, vascular dementia (moderate, without behavioral disturbance), bipolar disorder, and severe cognitive impairment (MDS score of 7). Her care plan and functional assessments documented that she used a wheelchair for mobility, could not take four steps, and required supervision/touching assistance for sit‑to‑stand and bed‑to‑chair transfers, as well as partial to extensive assistance for toileting and transfers. She also had documented communication problems related to a hearing deficit and unclear speech, and a care plan focus on attention‑seeking behaviors with interventions directing staff to speak calmly, divert attention, and ensure a safe environment. On the evening in question, video footage showed the resident in her bathroom in a wheelchair when an LVN entered, turned the wheelchair toward the grab bar, and instructed the resident to stand, stating she could not lift her. As the resident stood holding the grab bar, the LVN commented that the resident was “doing all that faking” and, when the resident defecated, the LVN reacted by saying “Eww” and “gross,” and later “Jesus Christ” and “oh my God” while leaving the resident standing partially unclothed. The resident then maneuvered herself to sit down hard on the toilet without staff present. Subsequent video segments showed the LVN outside the open bathroom door, within the resident’s hearing, telling a CNA that the resident had “shit everywhere and shit on me” and that the resident thought it was funny. The LVN and CNA discussed the resident’s behaviors, with the CNA stating the resident “knows better” and calling it a behavior problem, and the LVN agreeing and describing the resident as someone who hits and grabs staff. Further video showed the LVN re‑entering the bathroom, removing the resident’s wheelchair, and telling the resident that what had occurred was the “nastiest shit” she had ever seen, that the resident thought it was funny, and that the resident should be ashamed. While the LVN cleaned the floor and the resident’s feet, the resident began sobbing, and the LVN repeatedly told her to stop crying, stating “what are you crying for shitting yourself,” and telling her she needed to be in a psych ward. Another CNA entered and agreed it was a behavior, and both staff continued to speak derogatorily about the resident in her presence. The LVN and CNA B discussed cleaning the soiled wheelchair and stated the resident would not have a wheelchair and “doesn’t need a wheelchair,” with CNA B telling the resident she was “nasty” and to stop touching herself. The resident was left alone on the toilet sobbing at times while staff were outside the bathroom. In later video segments, CNA B and the LVN were in the bathroom with the resident, who was sobbing while standing and holding the grab bar as CNA B applied a brief. The LVN told the resident “cry cry cry, shut up, just seriously shut up,” and stated that if the resident went to the psych ward she would not think it was funny, adding “you should cry, nasty” and “you ain’t getting your chair.” Despite the resident’s documented need for wheelchair use and extensive assistance, CNA B held the resident’s arm and directed her to walk from the bathroom to the bed, telling her “you’re walking, hush come walk” while the resident said “no” and continued sobbing. The resident attempted to take a step, fell, and her left knee hit the floor. Subsequent video showed CNA B telling the resident she was not going to get her chair and that she knew how to walk, lifting her to a standing position and escorting her with minimal assistance to the bed while the resident held the wall and pulled up a loose brief. Both staff continued to accuse her of “fake crying” and dismissed her complaints as she rubbed her left knee. A skin assessment later documented bruising to the front left knee acquired in‑house, and a psychiatric assessment noted a contusion on the knee. The facility’s own records and interviews confirmed that the resident’s care plan and functional status required wheelchair use and assistance for transfers and toileting, and that she was a high fall risk. The ADON and other staff stated they would never ask this resident to walk from the bathroom to the bed and that she had not been known to walk, and that extra wheelchairs were readily available. The administrator and DON, after reviewing the videos, characterized the staff behavior as verbal and physical abuse, including making the resident walk without her wheelchair when she requested it, speaking to her in a demeaning and profane manner, and failing to treat her with dignity and respect. The resident’s responsible party reported receiving multiple distressed calls from the resident stating she was not allowed to have her wheelchair and later observed the wheelchair placed outside the room. A forensic interview video later showed the resident crying when asked if she had been hit, pushed, or left alone in the bathroom. The survey identified this as past noncompliance at the level of Immediate Jeopardy, beginning on the date of the incident and ending several days later.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 48 of 90 days reviewed for RN coverage. Record review of daily staffing showed zero hours worked by an RN on multiple dates between 11/03/2025 and 01/30/2026. The facility also failed to ensure the DON was not acting as the charge nurse when the facility had an average daily occupancy of more than 60 residents. Record review on 1/30/2026 of the Facility Monthly Schedule LVN/RN showed the DON was the only RN on staff from 11/20/2025 to 1/30/2026. During observation at the front entrance, the posted 12-hour nursing schedule showed one RN listed for 01/30/2026. The ADM stated the facility never had a census under 60 and had no policy in place related to nurse scheduling or RN coverage. The DON stated she was available by phone 24/7 and in the building Monday through Friday from 9:00 a.m. to 7:00 p.m., and that other RNs filled in on weekends. LVN E stated an RN should be available Monday through Friday and that if an RN was unavailable, someone was called in or the Regional RN filled in. LVN F stated an RN should always be on duty and that if an RN were not available, residents could be put at risk because some tasks were outside the LVN scope.
Failure to Care Plan Shower Refusals
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for Residents #10, #18, and #56 because their repeated refusals to take showers were not care planned. Each resident had an ADL self-care performance deficit and was receiving bathing or showering assistance, but their care plans did not include bathing preferences or refusals to shower or bathe. The report states that the facility’s care plans were expected to include measurable goals, interventions, and resident-specific needs identified in the comprehensive assessment. Resident #10 was an [AGE]-year-old female with diagnoses including pleural effusion, type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema, and acute respiratory failure with hypoxia. Her care plan reflected that she required maximum assistance with showering during scheduled shower times and as necessary, and her MDS showed a BIMS score of 15 with no cognitive impairment. Facility shower sheets documented that she refused showers on at least two occasions, but her progress notes did not document those refusals. Resident #18 was an [AGE]-year-old female with vascular dementia, type 2 diabetes mellitus with diabetic chronic kidney disease, and hemiplegia and hemiparesis following intracranial hemorrhage affecting the right dominant side. Her care plan reflected extensive assistance with showering three times per week and as necessary, and her MDS showed a BIMS score of 8 with moderate cognitive impairment. Facility shower sheets documented multiple shower refusals, but her progress notes did not document the refusals. A family member stated concern that the resident was not being bathed and reported that she sometimes smelled bad. Resident #56 was an [AGE]-year-old male with dementia, an implantable cardiac defibrillator, and alcohol abuse. His care plan included bathing and showering interventions such as avoiding scrubbing, patting dry sensitive skin, checking nail cleanliness, and providing a sponge bath when a full bath or shower could not be tolerated, but it did not include bathing preferences or refusals. His MDS showed a BIMS score of 15 with no cognitive impairment. Facility shower sheets documented repeated shower refusals over multiple dates, but his progress notes did not document the refusals. Staff interviews confirmed that residents refused showers, that refusals were recorded on shower sheets, and that staff believed shower refusals should be included in the care plan, but the care plans for these residents did not reflect those refusals.
Failure to Perform Hand Hygiene Between Resident Care Activities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents who required assistance with personal care. Direct observation revealed that a medical assistant (MA) did not perform hand hygiene after providing care to one resident and before providing care to another. Specifically, the MA removed a blood pressure cuff from the first resident, exited the room without washing hands or using hand sanitizer, and then entered the second resident's room and removed a blood pressure cuff from that resident, again without performing hand hygiene before or after contact. Both residents involved had significant medical histories and were at increased risk for infection. One resident had a urinary catheter, surgical incisions, and wounds, with care plans and physician orders indicating the need for enhanced barrier precautions and close monitoring for infection. The other resident had multiple chronic conditions, including diabetes and cognitive impairment, with care plans highlighting the risk for infection and the need for monitoring and reporting signs of infection. The facility's own policies required staff to perform hand hygiene before and after resident contact and when moving between resident rooms, in accordance with accepted standards of practice. Despite these policies, the observed failure to perform hand hygiene between resident care activities constituted a breach of infection control protocols, as confirmed by staff interviews and review of facility policies.
Failure to Maintain Clean and Comfortable Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to maintain clean and comfortable resident rooms for four out of eleven residents reviewed. Observations revealed that multiple resident rooms contained trash, food crumbs, used paper towels, and dried spilled substances such as coffee on the floors. In one case, a resident's bathroom had a brown substance around the base of the toilet, used paper towels on the floor, and a black ring in the toilet. These conditions were directly observed during the survey and were corroborated by interviews with residents and staff. The residents affected had significant physical and/or cognitive impairments, including conditions such as mononeuropathy, heart disease, chronic kidney disease, muscle wasting, joint replacements, and amputations. Their care plans indicated varying levels of assistance required for mobility and activities of daily living, with some residents being dependent on staff for picking up objects or cleaning. Interviews with residents revealed dissatisfaction with the cleanliness of their rooms, with some stating they had to wait for housekeeping to return or had to request cleaning from staff. One resident reported not seeing anyone clean her room during her stay, and another stated that the room felt unclean and not homelike when not properly maintained. Staff interviews indicated a lack of clarity and consistency regarding responsibility for cleaning resident rooms, especially outside of housekeeping hours. Housekeeping staff reported that rooms were cleaned daily, but acknowledged that rooms were often dirty in the mornings before cleaning began. CNAs and other staff stated that they were responsible for cleaning when housekeeping was unavailable, but there was confusion about monitoring and follow-through. Facility policies reviewed by surveyors required daily and as-needed cleaning of resident rooms, but these policies were not consistently implemented, resulting in the observed deficiencies.
Unattended and Unlocked Medication Cart Found During Survey
Penalty
Summary
A deficiency was identified when a medication cart (MC #1) on the 300-hall was found unattended and unlocked, containing both prescribed and over-the-counter medications. The medication aide (MA A) responsible for the cart was observed at the nurses station, away from the cart, which was positioned by the dining room entrance. The state surveyor was able to open the drawers and take pictures without being noticed by MA A. During interviews, MA A confirmed she had been trained on medication storage and acknowledged the policy required the cart to be locked when not in use, admitting she forgot to lock it due to being distracted. Further interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that while staff had been trained on medication storage, the DON was unfamiliar with the specific policy details, and both the DON and ADM stated that the person using the cart was responsible for ensuring it was locked. The facility's policy, last revised in 2019, specifies that only licensed nurses or certified medical aides may carry keys and that the cart must be locked at all times when not in use. The failure to secure the medication cart was attributed to staff distraction and lack of adherence to established procedures.
Unattended and Unlocked Medication Cart Found in Resident Care Area
Penalty
Summary
A deficiency was identified when a medication cart (MC #1) on the 300-hall was found unattended and unlocked, containing both prescribed and over-the-counter medications. The medication aide (MA A) responsible for the cart was observed away from the cart, engaged in conversation at the nurses' station, with her back turned and the cart positioned near the dining room entrance. The state surveyor was able to open the drawers and take pictures without being noticed by MA A. During interviews, MA A acknowledged she had been trained on medication storage and was aware of the policy requiring the cart to be locked when not in use, but stated she forgot to lock it due to being distracted. Further interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that staff had been trained on medication storage policies, which require medication carts to be locked at all times when not in use and only accessible to authorized personnel. The DON, new to the facility, was not familiar with the specific policy details but expected staff to follow them, while the ADM described monitoring practices for ensuring compliance. Review of the facility's policy confirmed that only licensed nurses or certified medical aides may carry keys and that carts must not be left unlocked or unattended in resident care areas.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. In one instance, a bathroom sink basin in a resident's room was detached from the wall, creating a significant safety hazard. Despite the resident's repeated requests for repair, the issue persisted for months. The Maintenance Director, who was new to the position, was unaware of the problem until it was brought to his attention by the administration. The lack of a timely response to maintenance requests and the absence of a formal policy on maintenance repairs contributed to the delay in addressing this critical safety concern. Another deficiency involved the condition of the walls in a resident's room, which had black scuff marks and large patches of peeling paint. The Maintenance Director was not aware of this issue, and no work order had been created to address it. The resident's family member had noticed the damage but had not reported it to the staff. The facility's failure to maintain the room in a homelike condition was evident, and the Maintenance Director acknowledged that the environment was not suitable for residents. Additionally, the facility failed to ensure that a resident's bed had a footboard, resulting in the mattress sliding off the bed. The resident had reported the issue to the administration and staff, but it took weeks for the facility to respond. The Maintenance Director was aware of concerns regarding beds on the hall but was delayed in addressing them due to being recently hired and catching up on repairs. Furthermore, windows in two rooms did not close properly, creating a potential security risk and affecting room temperature. The Maintenance Director was unaware of these issues, and no work orders were found for the repairs. The facility's lack of a systematic approach to prioritize and address maintenance concerns contributed to these deficiencies.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically nail care, for two residents who were unable to perform these tasks independently. One resident, a male with moderately impaired cognition, dementia, diabetes, and adult failure to thrive, was observed with long, uneven fingernails and a blackish/brownish substance under his nails. He reported having requested nail care from staff within the past three days but had not received it. His care plan required staff to check and trim his nails on bath days and as needed, with nurses responsible for nail care due to his diabetes diagnosis. A second resident, a female with severely impaired cognition, dementia, and generalized muscle weakness, was also observed with rough, unclean fingernails and a similar blackish/brownish substance under her nails. She was dependent on staff for all ADLs, including personal hygiene and nail care. Her care plan also required staff to check, trim, and clean her nails on bath days and as needed. Staff interviews confirmed that neither resident had refused nail care, and that both CNAs and nurses were aware of their responsibilities regarding nail care, especially for residents with diabetes. Staff interviews further revealed that nail care was expected to be performed during showers and as needed, with CNAs responsible for most residents and nurses for those with diabetes. Staff acknowledged the presence of the blackish substance and rough nails, and recognized the potential for health issues if not addressed. The facility's policy required that residents unable to perform ADLs receive necessary services to maintain good grooming and personal hygiene, which was not followed in these cases.
Failure to Provide Timely Therapy Evaluation and Interventions for Resident with Contractures
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, bilateral hand contractures, and a history of traumatic brain injury was not evaluated or treated for therapy services despite having physician orders for PT and OT evaluation and treatment. The resident was assessed as having functional limitations in range of motion for both upper extremities and was dependent on staff for most activities of daily living. Observations revealed the resident had contractures in both hands, with no splints or palm guards in use, and the resident communicated a desire for therapy services. Despite care plan interventions and physician orders for therapy evaluation and treatment, the therapy team was not made aware of the order, and the evaluation was not completed for over two months. Interviews with staff confirmed that the therapy department was unaware of the order due to a breakdown in communication, and the resident had not received therapy services or appropriate interventions such as splints or palm guards during this period. Staff interviews also indicated a lack of awareness regarding therapy orders and responsibility for applying hand braces, with some staff stating they had never seen the resident wear braces and others believing therapy staff were responsible for this task. The facility did not have a policy for contracture management or range of motion, and the delay in therapy evaluation and lack of interventions could have contributed to worsening contractures and pain for the resident. The deficiency was attributed to missed communication of therapy orders, lack of follow-through on care plan interventions, and absence of a formal policy guiding contracture management.
Failure to Maintain Infection Control Protocols for Ice Chest and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses involving both staff and residents. One incident involved a resident with severe cognitive impairment who was observed placing her bare hands into an unattended ice chest located in a hallway. The resident had visible dried residue on her hand and was able to access the ice without staff intervention, despite the presence of the Infection Control Preventionist, who acknowledged witnessing the event but did not redirect the resident or remove the ice chest. Interviews with staff confirmed that the ice chest was not to be left unattended in hallways and that residents touching the ice constituted cross-contamination, yet the protocol was not followed in this instance. Additional deficiencies were observed during wound care for two residents with significant medical needs, including chronic wounds and pressure ulcers. Both the Wound Care Nurse and a CNA failed to don gowns while providing direct care to these residents, despite clear signage indicating Enhanced Barrier Precautions (EBP) and the availability of personal protective equipment outside the rooms. The residents in question had physician orders and care plans specifying the use of gowns and gloves for high-contact care activities due to their risk factors, such as open wounds and medical devices. Staff interviews confirmed knowledge of the EBP requirements, but the protocol was not followed during the observed care. Facility policies reviewed indicated that the Infection Preventionist is responsible for developing and implementing an ongoing infection prevention and control program, including ensuring staff compliance with national standards and guidelines. Despite these policies and prior in-service training on EBP, staff failed to adhere to established infection control procedures during the observed incidents, resulting in potential cross-contamination and failure to prevent the transmission of communicable diseases.
Failure to Ensure Valid DNR Documentation Due to Missing Physician Signature
Penalty
Summary
The facility failed to ensure that a resident's Out of Hospital Do-Not-Resuscitate (OOH-DNR) form was properly completed with all required signatures, including that of the physician. Upon review, it was found that the resident, who had diagnoses of severe chronic kidney disease and a displaced fracture of the femur, had selected a DNR code status and this was reflected in the care plan and physician orders. However, the OOH-DNR forms in the resident's clinical record were missing critical signatures from the resident, witnesses/notary, and the physician, rendering them invalid. Interviews with facility staff revealed that the social worker was aware that the DNR forms were not valid due to missing signatures and had attempted to obtain the physician's signature by emailing the doctor multiple times, but did not follow up further. The social worker also placed a temporary DNR in the file while waiting for the physician's signature, under the belief that it could be used in the interim. The administrator and DON both stated that they would honor a DNR without a physician's signature, and there was no facility policy specifying a timeframe for obtaining the physician's signature on the DNR form. The resident in question was noted to have moderate cognitive impairment and was unable to understand questions regarding her advance directives or DNR during the interview. The facility's policy required that advance directives be reviewed and discussed within 14 days of admission and annually, and state law required that the OOH-DNR form include all necessary signatures. Despite these requirements, the facility did not ensure that the DNR form was properly completed, which could result in the resident's wishes not being honored.
Failure to Monitor and Justify Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the use of prophylactic antibiotics. A female resident with severe cognitive impairment and a history of encephalopathy, urinary tract infection, and dysphagia was admitted with an order for daily Bactrim as prophylaxis, despite not meeting McGeer's criteria for infection at the time. The care plan only included monitoring for UTI symptoms, with no interventions or monitoring related to antibiotic use. The antibiotic clinical review form indicated that the resident did not meet the criteria for infection, yet the antibiotic was still prescribed and administered. Interviews with facility staff revealed that antibiotics were started or continued based on practitioner orders without questioning their necessity, even when used prophylactically. The ADON responsible for infection control acknowledged not being aware of CDC guidelines against prophylactic antibiotic use and admitted to following orders without further review. The DON confirmed awareness of the prophylactic antibiotic order and stated that nurses were expected to question such orders, but this did not occur. The facility's antibiotic stewardship policy required monitoring and justification for antibiotic use, which was not followed in this case.
Expired Syringes Found on Medication Cart Due to Inconsistent Expiration Checks
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to accepted professional principles, as evidenced by the presence of seven expired disposable syringes with needles in the top drawer of the 100 hall Nurses' Medication Cart. During observation, these expired supplies were found, and interviews with staff revealed inconsistent practices regarding the frequency of checking for expired items. The LVN stated that floor nurses were responsible for checking expiration dates as they go, while the DON indicated that staff should check carts daily, and the ADM expected checks at least weekly. There was no specific policy in place for the removal of expired supplies.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program (IPCP) that included an antibiotic stewardship program with protocols and a system to monitor antibiotic use. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including encephalopathy, urinary tract infection, and dysphagia, was admitted with an order for prophylactic Bactrim without a specified duration or monitoring for side effects. The resident's care plan addressed bladder incontinence and monitoring for UTI symptoms, but did not include interventions related to antibiotic use. The antibiotic clinical review for the resident did not document any symptoms meeting McGeer Criteria for infection, and it was noted that the resident did not meet the criteria for infection at the time the antibiotic was prescribed. Interviews with facility staff revealed that antibiotics were started or continued based on practitioner orders without questioning the appropriateness, even when used prophylactically, contrary to CDC guidelines and facility policy. The ADON responsible for infection control acknowledged not questioning the order and not being aware that prophylactic antibiotic use was not recommended. The DON confirmed awareness of the prophylactic antibiotic order and stated that there was no approved indication for such use, and that staff were expected to question such orders and complete the required antibiotic clinical review. The facility's policy required all antibiotic prescriptions to specify dose, duration, and indication, and to use McGeer’s criteria to define infections, which was not followed in this case.
Failure to Accurately Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure that each resident was properly offered influenza and pneumococcal immunizations, as required. Specifically, one resident with severe cognitive impairment, hemiplegia, and gastrostomy status was not accurately assessed or documented for her immunization status. The resident's medical record did not reflect her vaccination history for influenza and pneumonia, and the consent form for these vaccinations did not accurately represent her representative's wishes. The form indicated a refusal for the influenza vaccine without a documented reason or history of previous vaccinations, and acceptance of the pneumonia vaccine without any documentation of prior vaccination history or education provided. Interviews with facility staff revealed that the process for obtaining immunization consent and history was not consistently followed. The resident's responsible party stated she wanted the resident to receive all recommended immunizations, contradicting the documentation in the medical record. The ADON acknowledged that the resident had not received the pneumonia vaccination since admission and that her wishes were not accurately reflected in the record. The facility's infection prevention and control policy required offering and documenting immunizations and education, but these steps were not completed for this resident.
Failure to Honor Resident's DNR Status During Emergency Response
Penalty
Summary
The facility failed to ensure the resident's right to formulate an advance directive for Resident #3, who had a DNR in place, resulting in a violation of the resident's right to experience the dying process as predetermined. Despite clear documentation of Resident #3's DNR status in various records, including the face sheet, care plan, physician orders, and Out-of-Hospital Do-Not-Resuscitate Order, nursing staff failed to follow emergency protocol. When Resident #3 became unresponsive, LVN A initiated CPR without verifying the resident's code status, leading to a situation where CPR was administered against the resident's wishes. This failure to honor the advance directive could have significant emotional and physical implications for the resident, as evidenced by the distress expressed by the family members. During interviews with staff members involved in the incident, it was revealed that there was a lack of clarity and adherence to protocols regarding verifying a resident's code status before initiating CPR. LVN A, MA L, and CNA J were present during the incident but did not effectively communicate or confirm Resident #3's DNR status before CPR was initiated. Despite in-services and training provided to staff on how to access a resident's code status in the electronic health record system, there was a breakdown in following these procedures in a timely manner during the emergency situation. The failure to prioritize and verify the resident's advance directive before providing life-saving measures highlights a critical gap in staff knowledge and adherence to facility policies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 51 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bastrop
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Nursing And Rehabilitation Center Of Bastr | 0.1 mi | ★★★★★ | 1 | 0 |
| Silver Pines Nursing And Rehabilitation Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Towers Nursing Home | 13.9 mi | ★★★★★ | 3 | 0 |
| Elgin Nursing And Rehabilitation Center | 17.6 mi | ★★★★★ | 2 | 0 |
| Oakcrest Nursing And Rehabilitation Center | 23 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.