Above 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 Colonial Pines Healthcare Center during CMS and state inspections, most recent first.
Incomplete meal intake documentation was found for four residents with cognitive impairment and varying levels of assistance with meals. CNA flow sheets did not show evening meal percentages for multiple days, even though staff stated CNAs were responsible for charting intake after each meal and charge nurses were responsible for checking completion. Observations showed the residents eating and consuming more than 75% of meals, while the DON and administrator confirmed the missing intake entries and noted the electronic record did not alert staff when documentation was absent.
Pest control was ineffective when a live roach was observed crawling under a dining table while residents were eating lunch. Staff said roaches were an ongoing problem in the dining area and on hallway A, and the ADM acknowledged the issue and that pest control treated the facility every two weeks. Records showed repeated pest service visits, but the dining room still had roaches.
Soiled Wheelchair Left Uncleaned: A resident with stroke, dysphagia, severe cognitive impairment, and dependence for all ADLs was observed multiple times in a wheelchair that remained soiled with old food particles and thick white residue. Staff said night CNAs were responsible for cleaning wheelchairs weekly, but the wheelchair stayed dirty across observations and there was no place to document that the equipment had been cleaned.
Late Quarterly MDS Assessment: A resident with stroke and dysphagia did not have a quarterly MDS completed within the required 92-day timeframe. The prior quarterly assessment was completed, but the next quarterly MDS was not signed until after it was overdue. The Corporate Reimbursement Nurse said internet issues delayed the signature, and she only reviewed the tracking report monthly; the DON and Administrator stated the MDS nurse was responsible for timely completion and expected assessments to be completed per regulations.
Incomplete Comprehensive Care Plan for a Resident with Multiple Needs: A resident with stroke, dysphagia, severe cognitive impairment, hospice services, wheelchair use, and limited ROM had a comprehensive care plan that did not reflect current transfer status requiring a mechanical lift, hospice care, swallowing needs requiring an altered diet, or contracture-related mobility limitations. Staff interviews confirmed the MDS assessment should generate and update the care plan, but the plan remained inaccurate after the facility changed to a new charting system.
Failure to support wheelchair positioning and contracture management: A resident with stroke, dysphagia, severe cognitive impairment, and ROM limitations was observed in a wheelchair with both legs and feet dangling and no footrests on multiple occasions, and her left-hand contracture device was not consistently in place. The care plan and physician orders did not reflect contracture management, and staff interviews confirmed the resident should have had leg support and a hand device to help prevent worsening contractures.
Worn Mechanical Lift Slings Left in Use: A resident with severe cognitive impairment, stroke, dysphagia, hospice care, and total ADL dependence was observed in a wheelchair with a lift sling pad under her, and the sling loops were faded on multiple observations. Staff interviews showed the sling was being washed with towels and bleach, while the DON, Administrator, and Housekeeping Director stated slings should be inspected for wear and not bleached or dried, and the facility policy required lift slings to be in good working condition.
Failure to Follow EBP During Incontinent Care: Two CNAs provided incontinent care to a resident with a diabetic toe wound and did not wear gowns, even though EBP was ordered and PPE was available. The resident had dementia, was totally dependent for ADLs, and was always incontinent. One CNA said she did not think the resident required EBP, while the other later acknowledged they should have worn a gown and gloves because the resident had a blue tag by his name. The ADON, DON, and Administrator stated the resident was on EBP for his wound and that gowns and gloves were required for direct care.
The facility failed to maintain an effective pest control program, resulting in a fly infestation in hallways, resident rooms, and dining areas. Observations showed flies on beds, tables, and food, with residents noting the issue was worsened by nearby chicken litter. Staff interviews revealed a lack of awareness and communication about the problem, and pest control measures were insufficient, with no specific treatments for flies during visits.
The facility failed to consistently log and monitor medication refrigerator temperatures as required by policy, compromising the storage of flu vaccines, TST vials, and insulin pens. Interviews with the ADON and DON confirmed the lack of compliance with temperature monitoring, which could affect medication efficacy.
The facility failed to prepare pureed diets to the required consistency for residents with dysphagia and other conditions, using incorrect methods involving bread and water instead of recommended liquids. This practice, based on outdated instructions, posed a risk of choking and inadequate nutrition. The current dietician was unaware of this method, which deviated from facility recipes and policies.
The facility failed to maintain a clean and safe environment in the 400-hall dining room and hall, with dirty floors, torn baseboards, and exposed sheetrock. A resident with COPD had a dusty box fan in her room, posing a respiratory risk. Staff interviews revealed unclear responsibilities for cleaning and maintenance, contributing to these deficiencies.
A dietary aide worked without a food handler's certificate for 2-3 months, as the facility failed to ensure certification within 30 days of hire. The Dietary Manager and Dietician missed this oversight, potentially risking foodborne illness for residents.
The facility failed to store and manage food according to professional standards, as expired yogurt was found in the refrigerator. Staff interviews revealed unclear responsibilities for checking expiration dates, with some admitting to insufficient time for thorough checks. The facility's policy requires all foods to be labeled and dated, but this was not consistently followed, posing a risk of foodborne illness to residents.
The facility failed to maintain a gas stove in safe operating condition, with one burner not lighting automatically and all burners having carbon buildup. The Maintenance Director was not informed of the issue until a surveyor's entry, despite previous cleaning during a mock survey. The lack of consistent preventive maintenance posed a risk of fire or gas exposure.
The facility failed to enforce its smoking policy, as staff were observed smoking in undesignated areas and improperly disposing of cigarette butts. Despite the facility's policy requiring smoking in designated areas, staff admitted to smoking outside the 400 hall, which is not a designated smoking area. The administrator was unaware of this non-compliance, although the staff handbook clearly outlines the smoking rules.
A resident with intellectual disabilities and urinary retention was observed without a privacy cover on their urinary drainage bag, compromising their dignity. The resident was seen in bed and in a wheelchair without the cover, and staff interviews revealed that the responsibility for ensuring the cover was in place fell on the nursing staff. The facility's administrator acknowledged the oversight and initiated staff training to address the issue.
A resident with intellectual disabilities and a urinary catheter was observed with the catheter drainage bag improperly positioned and without a privacy cover, leading to a deficiency in care. The LVN responsible was unaware of the issue, and the ADON and DON confirmed the oversight, acknowledging the risk of urinary tract infections due to improper catheter care.
A resident with multiple medical conditions and moderate cognitive impairment experienced verbal abuse during incontinence care. The incident was witnessed by two CNAs and confirmed through an investigation. The abusive CNA was terminated.
A facility failed to prevent verbal abuse when a CNA told a resident to 'shut up' during incontinence care. The resident, who had multiple medical conditions and moderate cognitive impairment, initially denied hearing the comment but later confirmed it. The incident was reported by two other CNAs and highlights a lapse in the facility's abuse prevention policies.
Incomplete Meal Intake Documentation for Four Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for 4 of 4 residents reviewed for meal intake documentation. For Residents #5, #6, #17, and #35, the nurse aide flow sheets for January 2026 did not document evening meal intake percentages from 01/01/2026 through 01/20/2026. The report states that these residents were all on the secured unit and that meal intake percentages were expected to be recorded after each meal. Resident #5 had diagnoses including hypertension, anxiety, and schizophrenia, with severe cognitive impairment and a BIMS score of 04. She required supervision with meals, had a care plan addressing cognitive loss and risk for dehydration and malnutrition, and had a stable weight of 112.4 pounds. Resident #6 had Alzheimer’s disease, hypertension, and depression, with severe cognitive impairment and a BIMS score of 03; she was independent with meals and had a stable weight of 145 pounds. Resident #17 had Alzheimer’s disease and hypertension, severe cognitive impairment with a BIMS score of 01, required moderate assistance with meals, and had a stable weight of 87 pounds. Resident #35 had dementia, COPD, and a history of CVA, moderate cognitive impairment with a BIMS score of 05, was independent with meals, and had a stable weight of 118 pounds. During observations, Resident #5, Resident #6, Resident #17, and Resident #35 were seen eating meals and consuming greater than 75% of their meals. Staff interviews confirmed that CNAs were responsible for documenting meal intakes after each meal, that the charge nurses were responsible for monitoring completion of the CNA flow sheets, and that the electronic record did not alert staff when meal intake percentages were missing. The DON stated she was working with corporate IT because the evening meal intakes were not available to view, and the administrator stated meal intakes were expected to be recorded in the medical record.
Pest Control Program Failed to Keep Dining Area Free of Roaches
Penalty
Summary
The facility failed to maintain an effective pest control program and did not keep the dining room free of pests and rodents. During an observation on 01/19/2026 at 11:45 a.m., a live roach was seen crawling on the floor underneath a dining table while residents were eating lunch. The Medical Records Director walked over and stepped on the roach and killed it. The Medical Records Director stated that roaches were a problem in the dining area and on hallway A. During interviews on 01/21/2026, the Floor Tech said there had been a problem with a resident hoarding food in a room on the A hallway, but the facility cleaned everything out of the room and treated the area. The Maintenance Director-Housekeeping Supervisor said the roaches were an ongoing problem in the facility and that contracted pest control had treated the facility on 01/17/2026. The Administrator said he knew about the roach problem in the dining area, that pest control treated the area every two weeks, and that he contacted the pest control company on 01/20/2026 after being made aware of roaches in the dining room. Record review showed multiple pest control invoices documenting treatment of the interior, hallways, kitchen, dining room, lobby, and exterior building, along with granules for ants and other crawling insects. The facility policy stated it shall maintain an ongoing pest control program to keep the building free of insects and rodents.
Soiled Wheelchair Left Uncleaned
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for Resident #41 by allowing her wheelchair to remain soiled with old food particles and thick white residue on multiple observations. Resident #41 was an [AGE]-year-old female with diagnoses including cerebral infarction (stroke) and dysphagia, and her quarterly MDS indicated a BIMS of 00, dependence on staff for all ADLs, use of a wheelchair, mechanically altered diet, hospice care, and functional limitation of range of motion to both upper and lower extremities. During observations, she was seen in her wheelchair at the nurses’ station, near the dining room, and in the activity room, and the wheelchair remained visibly soiled each time. Record review showed Resident #41’s care plan identified late effects of CVA with decreased mobility and the need for a wheelchair. Staff interviews indicated the night CNAs were responsible for cleaning resident wheelchairs at least weekly, with the night nurse expected to ensure the cleaning was completed, but staff also stated there was no place to document that equipment had been cleaned. The DON and Administrator both stated resident equipment was to be cleaned weekly, with oversight by night shift and administration, and the Administrator said the facility expected resident care equipment to be kept clean and sanitary. An undated wheelchair cleaning schedule showed Resident #41’s wheelchair was to be cleaned on Wednesday night, and the facility policy stated resident general equipment would be cleaned on a routine basis in accordance with manufacturer specifications and guidelines.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly MDS assessment for one resident within the required three-month timeframe. Resident #41, a female admitted with diagnoses of cerebral infarction (stroke) and dysphagia, had a quarterly MDS completed on 09/19/2025, but the next quarterly MDS was not completed until 01/06/2026, making it 17 days overdue. The record review showed that the assessment was not signed until after the required due date. During interview, the Corporate Reimbursement Nurse said she oversaw MDS assessments at the facility and stated that quarterly reviews should be completed at least every 92 days. She explained that internet issues prevented her from signing the 12/18/2025 quarterly MDS until 01/06/2026, and that she only reviewed the report used to track completed and transmitted assessments monthly. The DON said the MDS nurse was responsible for timely completion of assessments, and the Administrator said he expected all MDS assessments to be completed according to regulations.
Incomplete Comprehensive Care Plan for Resident with Multiple Care Needs
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for Resident #41 that reflected current medical needs. Resident #41 was an [AGE]-year-old female admitted with diagnoses of cerebral infarction (stroke) and dysphagia. Her quarterly MDS assessment dated 12/18/2025 showed a BIMS of 00, dependence on staff for all ADLs, use of a mechanically altered diet, hospice care, wheelchair use, and functional limitation of range of motion to both upper and lower extremities. Review of the comprehensive care plan dated 12/19/2025 showed it did not reflect the resident’s current transfer status requiring a mechanical lift, hospice services, swallowing difficulties requiring an altered diet, or a contracture with mobility limitations. The order summary showed an order for hospice services and a pureed diet, but no order related to contractures or mechanical lift use. Staff interviews indicated the MDS assessment should generate the care plan and that the care plan should be reviewed and revised with each assessment, but Resident #41’s care plan was not accurate after the change to the new charting system.
Failure to Support Wheelchair Positioning and Contracture Management
Penalty
Summary
The facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with maximum practicable independence. Resident #41, a female with diagnoses of cerebral infarction and dysphagia, had severely impaired cognition, was dependent on staff for all ADLs, used a wheelchair, received hospice care, and had functional limitation of ROM to both upper and lower extremities. Her comprehensive care plan did not reflect a contracture with mobility limitations, and her physician order summary did not include an order related to contractures or use of any device. During observations, Resident #41 was seen in her wheelchair with both feet and legs dangling and no footrest present on multiple occasions, and no contracture device was present in her left hand during two observations. On a later observation, a hand device was present in her left hand. Staff interviews indicated the resident should have had footrests to support her legs and feet and a hand device to help prevent worsening of her contracture, but the CNA and LVN could not recall whether the devices had been in place. The DON and Administrator stated dependent residents should have proper support in wheelchairs and devices to prevent worsening contractures, and both said the facility did not have a policy for contracture management or position management.
Worn Mechanical Lift Slings Left in Use
Penalty
Summary
The facility failed to ensure the environment remained as free of accident hazards as possible when it did not remove worn and damaged mechanical lift slings from service for one resident. Resident #41 was a female with diagnoses of cerebral infarction (stroke) and dysphagia, a BIMS score of 00 indicating severely impaired cognition, dependence on staff for all ADLs, use of a wheelchair, hospice care, and functional limitation of range of motion to both upper and lower extremities. Her care plan did not reflect her current transfer status requiring a mechanical lift, and her physician order summary did not include an order related to use of a mechanical lift. During observations, the resident was seen in her wheelchair with a lift sling pad under her, and the sling loops were faded in color on two separate occasions. Staff interviews showed CNA B believed the fading was from routine washing, while the Laundry Aide stated lift slings were washed with towels and bleach was automatically distributed in the wash. The DON and Administrator stated slings should be inspected for fraying, fading, and wear and should not be bleached or dried, and the Housekeeping Director said he was now assigned to monitor sling wear and fading and was unaware bleach had been used on the slings until the day of the interview. The facility policy for Mechanical Lifts stated the sling should be checked to ensure it was in good working condition with no torn or ripped areas.
Failure to Follow EBP During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when CNA A and CNA B did not follow enhanced barrier precautions (EBP) while providing incontinent care to a resident with a diabetic wound on the left fifth toe. The resident’s record showed diagnoses of type 2 diabetes, morbid obesity, and dementia, and his care plan identified the left fifth toe wound. His MDS assessment documented moderate cognitive impairment, total dependence for ADLs, and that he was always incontinent of urine and bowel. His physician orders included EBP every shift, effective 12/23/2025. During observation, CNA A and CNA B entered the resident’s room to provide incontinent care. Both staff washed their hands and wore gloves, but neither donned a gown even though PPE was available on the bathroom door. CNA B prepared a basin with soap and water and used washcloths to clean the resident’s inner thighs, penis, and shaft, while CNA A turned the resident and cleaned his rectal area. The resident’s brief was removed and replaced during the care, and both CNAs removed and replaced gloves and washed their hands during the process. During interviews, CNA B said residents on EBP had blue signs by their names and PPE hanging on bathroom doors, but stated she did not think this resident required EBP. CNA A initially said she was not sure the resident required EBP, then later said they should have worn a gown and gloves because he had a blue tag by his name. The ADON, DON, and Administrator stated the resident was on EBP because of his toe wound and that staff should wear gowns and gloves for direct care, including care for residents with wounds. The facility policy stated EBP includes gown and glove use during high-contact care activities such as changing briefs.
Ineffective Pest Control Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in two of four hallways, two resident rooms, and two dining areas. Observations revealed flies crawling on beds, tables, and food, with residents expressing concerns about the persistent fly problem. One resident, who was cognitively intact, noted that the issue was exacerbated by a nearby pasture where chicken litter had been applied. The facility's pest control measures were insufficient, as there were no specific treatments for flies during bi-monthly visits, and blowers intended to prevent fly entry were not consistently operational. Interviews with staff indicated a lack of awareness and communication regarding the severity of the fly problem. The Maintenance Director was unaware of the increased fly issue and had not received requests for additional interventions. The Administrator acknowledged the unsanitary conditions and potential infection risks posed by the flies but had only provided residents with fly swatters as a control measure. The facility's pest control policy stated an ongoing program to keep the building free of insects, yet the implementation was inadequate, as evidenced by the continued presence of flies.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, as observed in the medication storage refrigerator. The facility did not log and monitor the medication refrigerator temperatures for both AM and PM as required by their policy on specific dates in October 2024. This included the storage of flu vaccines, tuberculin skin testing vials, and insulin pens. The absence of twice-daily temperature checks was noted, with only a few days in October having recorded temperatures, which could compromise the effectiveness of the stored medications and vaccines. During interviews, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the failure to monitor the refrigerator temperatures, which could lead to the medication refrigerator being out of range and result in the loss of vaccine efficiency. The facility's policy requires that medications requiring refrigeration be stored at temperatures between 2°C and 8°C, with a temperature log maintained to verify compliance. The lack of consistent temperature monitoring and logging was a direct violation of this policy, potentially affecting the integrity and efficacy of the medications and biologicals stored within the facility.
Improper Preparation of Pureed Diets
Penalty
Summary
The facility failed to ensure that food prepared for residents on pureed diets met the required consistency, potentially compromising their nutritional needs and safety. Specifically, three residents with conditions such as dysphagia, dementia, and cerebral infarction were affected. The facility's dietary staff did not prepare pureed foods to the appropriate smooth texture, as observed during meal preparation. Instead, the cook added slices of white bread and hot water to the pureed meatloaf and peas, resulting in a texture that was not smooth and could pose a choking hazard. The dietary staff, including the cook and the Dietary Manager, were following incorrect instructions from a previous dietician, who advised adding bread and hot water to pureed foods. This method was believed to enhance flavor and texture, but it did not align with the facility's recipes, which recommended using broth, milk, or other liquids to achieve the correct consistency. The current dietician, who had not observed the pureeing process, was unaware of this practice and confirmed that the use of bread and water was inappropriate. The incorrect preparation method could lead to residents receiving insufficient nutrients and potentially aspirating food. The facility's policy and recipes outlined the correct procedures for preparing pureed foods, emphasizing the use of appropriate thickeners and liquids to achieve a smooth consistency. However, these guidelines were not followed, leading to the deficiency. The Administrator acknowledged the importance of preparing pureed foods correctly to ensure residents receive the full nutritional value and avoid potential health risks.
Environmental and Equipment Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the 400-hall dining room and hall, as well as for a resident's personal equipment. Observations revealed that the dining room floors were dirty with a sticky substance and dark grime, with a thick buildup around the edges of the walls. The baseboards were torn, stained, and pulled away from the wall, and there were chips in the paint and exposed sheetrock. Additionally, there were dried discolored substances on the walls near and under the sinks. The floor at the exit door on hall 400 had torn and raised black tape material, and the wall going into the shower room hallway had breaks in the sheetrock. Interviews with staff indicated a lack of regular deep cleaning and maintenance, with responsibilities unclear between housekeeping and maintenance staff. A resident with chronic obstructive pulmonary disease (COPD) was found to have a box fan in her room that was covered in dark brown dust and lint. The fan was used to help her breathe, but the buildup of dust and lint posed a risk to her respiratory health. The resident was unaware of the fan's condition, and housekeeping staff were uncertain about who was responsible for cleaning such equipment. The Director of Nursing (DON) acknowledged that housekeeping should clean equipment used by residents, but there was no housekeeping supervisor to oversee these tasks. Interviews with the Maintenance Director and Administrator confirmed that the housekeeping department was responsible for cleaning fans and other equipment. The facility's maintenance policy indicated that the maintenance department was responsible for maintaining the building and equipment in a safe and operable manner, but the lack of clarity in roles and responsibilities contributed to the deficiencies observed. The unclean environment and equipment could potentially affect residents' safety and well-being.
Deficiency in Food Handler Certification for Dietary Staff
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service, as evidenced by the lack of a current food handler permit for one of the dietary staff, Dietary Aide H. During an observation, it was noted that Dietary Aide H was working in the kitchen without a food handler's certificate. The Dietary Manager, responsible for ensuring staff completed their food handler certification training upon hire and every two years, was unsure why Dietary Aide H had not completed the training. Dietary Aide H had been working at the facility for 2-3 months without the certification and was no longer employed as of the last day of observation. The Dietician, who reviewed kitchen systems including food handler certificates every two weeks, missed the fact that Dietary Aide H did not have the certification during her last check. The Administrator expected the Dietary Manager to ensure dietary staff obtained their food handler certificates within 30 days of hire, in accordance with the Texas Administrative Code. The absence of a specific facility policy for obtaining food handler certification contributed to this oversight, potentially placing residents at risk for foodborne illness due to improper food handling.
Deficiency in Food Storage and Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the storage, preparation, distribution, and serving of food. During an inspection of the kitchen's cooler/refrigerator, it was observed that two 32-ounce containers of vanilla Greek yogurt were stored past their expiration dates. Interviews with various staff members, including a dietary aide, the dietary manager, and the dietician, revealed a lack of clarity and consistency in the responsibility for checking and disposing of expired foods. The dietary manager mentioned that she checks for expired foods on Fridays when receiving food deliveries, while the dietician emphasized that expired foods should be checked daily. The facility's policy on food storage requires that all foods be covered, labeled, and dated, and that no expired foods remain in the refrigerator. However, the staff interviews indicated a shared but poorly defined responsibility for monitoring expiration dates, with some staff members admitting to not having enough time to check every item. The administrator confirmed that all foods should be used or disposed of by their use-by date to prevent potential foodborne illnesses, which could pose a risk to residents consuming expired foods.
Gas Stove Maintenance Deficiency
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically a gas stove with six burners. One of the burners, located at the right back, did not light automatically and had excess carbon buildup. This issue was observed during a survey on 10/27/24. The Maintenance Director, who had been working at the facility for 6-7 years, was not notified of the malfunction until the surveyor's entry on 10/27/24. He cleaned the burner on the same day, which resolved the lighting issue. However, the buildup of grease and carbon on the burners was a recurring problem, as noted by the Maintenance Director and other staff members. Interviews with various staff members, including the Dietary Manager and the Dietician, revealed that the stove had been an issue during a previous mock survey, and the Maintenance Director had cleaned the burners at that time. Despite this, the problem persisted, indicating a lack of consistent preventive maintenance. The facility's policy on maintenance schedules was reviewed, which stated that the Maintenance Director is responsible for ensuring that equipment is maintained in a safe and operable manner. The Administrator acknowledged the potential hazard of the stove not working properly, which could lead to a fire or gas exposure, posing a risk to both employees and residents.
Non-Compliance with Smoking Policy by Staff
Penalty
Summary
The facility failed to adhere to its established smoking policy, which mandates that smoking should only occur in designated areas and that smoking materials must be disposed of properly. Observations on 10/27/24 revealed cigarette butts in a plastic cup and on the outside keypad near the exit door of the 400 hall, an area not designated for smoking. Interviews with staff confirmed that these cigarette butts belonged to staff members, not residents, and that the designated smoking area was located outside the main dining room. An LVN and a CNA admitted to smoking in the undesignated area, with the CNA acknowledging that she left cigarette butts on the ground, intending to dispose of them at the end of her shift. The facility administrator was unaware of staff smoking outside the 400 hall and stated that the smoking policy was intended for residents but expected staff to follow the same rules. The facility's team member handbook specifies that smoking should occur only in designated areas and that smoking materials should be discarded in appropriate receptacles.
Failure to Ensure Privacy Cover on Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure that a resident's urinary drainage bag had a privacy cover, which compromised the resident's dignity and respect. The resident, who had intellectual disabilities, anemia, and urinary retention, was observed multiple times without a privacy cover on his urinary drainage bag. This occurred both when the resident was in bed and when he was propelling himself in a wheelchair around the facility. The lack of a privacy cover was noted by staff, including the Assistant Director of Nursing (ADON), who instructed staff to take the resident to his room to put a leg bag on him. Interviews with staff revealed that the responsibility for ensuring the privacy cover was in place fell on the nursing staff. The Licensed Vocational Nurse (LVN) assigned to the resident's hall was unaware of the drainage bag's position earlier in the day and acknowledged that the absence of a privacy cover could be a dignity issue. The Director of Nursing (DON) and ADON confirmed that the nursing staff should ensure privacy covers are used when residents are out of their rooms. The facility's administrator also acknowledged the oversight and mentioned that an in-service was started to address proper positioning of drainage bags.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a deficiency in maintaining the catheter drainage bag below the bladder level. On multiple occasions, the resident's catheter drainage bag was observed without a privacy cover and improperly positioned, either resting on the bed or hanging from the wheelchair. The resident, who had intellectual disabilities and required substantial assistance with toileting hygiene, was at risk for urinary tract infections due to these lapses in care. The Licensed Vocational Nurse (LVN) responsible for the resident's care was unaware of the improper positioning of the drainage bag after the resident returned from the emergency room with a new catheter. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the oversight and confirmed that nursing staff were responsible for ensuring the proper positioning and privacy of catheter bags. The facility's urinary catheter infection prevention policy mandates that gravity drainage bags be positioned below the bladder to prevent infections and urinary retention.
Verbal Abuse During Incontinence Care
Penalty
Summary
The facility failed to prevent verbal abuse for a resident during incontinence care. The incident occurred when a Certified Nursing Assistant (CNA) told the resident to 'shut up' and made a derogatory comment about the resident's incontinence. This was witnessed by two other CNAs who reported the incident to the Licensed Vocational Nurse (LVN) and the Administrator. The resident initially denied hearing the abusive comment but later confirmed it during an interview with the LVN. The resident involved was an elderly male with multiple medical conditions, including type 2 diabetes, chronic kidney disease, and chronic obstructive pulmonary disease. He had a moderate cognitive impairment as indicated by his Brief Interview for Mental Status (BIMS) score. During the incident, the resident was receiving incontinence care and expressed pain, which led to the abusive comment from the CNA. The facility's investigation confirmed the verbal abuse through multiple witness statements and interviews with the resident. The CNA involved was suspended pending the investigation and subsequently terminated. The facility's policy on abuse, neglect, and exploitation was reviewed, and it was found that the CNA had received training on abuse prevention. However, the incident highlighted a failure in ensuring residents were free from verbal abuse during care activities.
Failure to Prevent Verbal Abuse
Penalty
Summary
The facility failed to prevent verbal abuse for a resident during incontinence care. The incident involved a Certified Nursing Assistant (CNA) who told the resident to 'shut up' and made a derogatory comment about the resident's incontinence. This incident was witnessed by two other CNAs who reported the behavior to the Licensed Vocational Nurse (LVN) and the Administrator. The resident initially denied hearing the abusive comment but later confirmed it during an interview with the LVN, stating he did not want to get anyone in trouble. The resident involved was an elderly male with multiple medical conditions, including type 2 diabetes, chronic kidney disease, and chronic obstructive pulmonary disease. He had a moderate cognitive impairment and required substantial assistance with toileting hygiene. During the incident, the resident expressed pain, which was dismissed by the CNA with a verbally abusive remark. The resident's care plan included monitoring for anxiety and depression, but there were no immediate signs of psychosocial harm following the incident. The facility's policy on abuse, neglect, and exploitation mandates that residents must be free from abuse and that staff should be trained to prevent such incidents. Despite this, the CNA involved had received training on abuse but still engaged in verbally abusive behavior. The facility's failure to prevent this incident highlights a lapse in the implementation of its policies and procedures designed to protect residents from abuse.
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Illustrative
What surveyors actually found near you
We read the 25 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Augustine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonecreek Nursing & Rehabilitation | 1.7 mi | ★★★★★ | 6 | 0 |
| Avir At San Augustine | 3.2 mi | ★★★★★ | 4 | 0 |
| Avir At Center | 19.1 mi | ★★★★★ | 0 | 0 |
| Pine Grove Nursing Center | 19.1 mi | ★★★★★ | 3 | 0 |
| Focused Care Of Center | 19.5 mi | ★★★★★ | 3 | 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.