Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Deer Creek Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with chronic pain and other medical conditions was discharged without proper documentation of the receipt or disposition of her prescribed Oxycodone HCl. Staff interviews revealed inconsistent practices and a lack of written logs for tracking controlled substances left behind, and the DON could not provide required records, resulting in a failure to accurately reconcile controlled medications.
Surveyors identified deficiencies in food storage, labeling, and staff hygiene practices in the dietary department. Open and undated bags of sugar and flour, unsecured storage bins, and unlabeled containers were found in the kitchen and refrigerator. Additionally, a staff member with facial hair was observed in food prep areas without a required hairnet or beard guard, contrary to facility policy. Staff interviews confirmed these actions did not meet established standards for food safety and hygiene.
A meal observation found that pureed chicken tenders and broccoli were prepared using only water instead of broth or cooking juices, contrary to facility training and available recipes. Staff interviews confirmed that water was used due to lack of juices and time constraints, and that this practice could dilute the nutritional value and flavor of the food. The facility lacked a specific policy for therapeutic diets, and not all staff had access to the correct recipes.
A resident with moderate cognitive impairment and mobility issues sustained a second-degree burn after spilling hot water on her leg due to the absence of a documented assessment of her ability to handle hot liquids. Despite facility policy requiring such evaluations and individualized interventions, no hot liquid safety assessment was found in the resident's care plan, and staff determined safety measures based on general knowledge rather than structured assessment.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident did not receive treatment and care in accordance with physician orders and their own stated preferences and goals, as observed and documented by surveyors.
Two residents did not have wound care treatments documented as completed according to physician orders and care plans, with multiple missed entries on treatment administration records for post-surgical and pressure wounds. Staff interviews confirmed that documentation was required at the time of treatment, and that missing documentation indicated the treatment was not performed.
A resident with multiple health conditions and existing heel wounds did not receive wound care treatments as ordered on four occasions, as shown by missing documentation in the TAR. Nursing staff and administration confirmed that treatments must be completed and documented, and facility policy requires detailed wound care records.
A resident with a recent spinal cord stimulator implant developed swelling and tenderness at surgical incision sites, which was observed by a CNA and assessed by an LVN, but not communicated to the NP or WCN. The following day, the incision dehisced with drainage, leading to hospitalization and diagnosis of infection. Staff interviews revealed lapses in communication and unclear responsibility for monitoring and reporting changes in surgical sites, resulting in a failure to follow facility policy for timely physician notification.
A resident with a spinal cord stimulator implant developed an infection at the surgical site after staff failed to consistently monitor and assess the incisions according to professional standards. Swelling and tenderness were reported but not properly documented or communicated to the NP or wound care nurse, resulting in delayed intervention. The incision later dehisced, requiring hospitalization and antibiotic treatment. Staff interviews revealed confusion about responsibilities for wound assessment and a lack of clear documentation and communication regarding changes in the resident's condition.
A facility failed to store controlled drugs, Hydrocodone and Valium, in locked compartments, leading to the Hydrocodone going missing. The admitting nurse placed the medications in a drawer with non-controlled drugs, and the night nurse did not communicate this to the day shift nurse. The Valium was later found unsecured on a medication cart, and the Hydrocodone was never recovered.
A resident with a history of hip replacement and on anticoagulants experienced unwitnessed falls, but the facility failed to conduct necessary neurological checks and a full-body skin assessment. Despite the resident's risk factors, the required evaluations were not consistently completed, leading to a deficiency in care. Interviews with staff revealed inconsistencies in following the facility's protocol for monitoring after falls.
A resident with a history of falls and on anticoagulant medication was found with a hematoma and bruising in her vaginal area, which the facility failed to report to the State Survey agency within 24 hours. The injuries were attributed to a fall earlier that day, and despite being assessed by staff, the incident was not reported as required. The facility's policy did not specify when to report such incidents, leading to a deficiency in compliance.
Failure to Document Receipt and Disposition of Controlled Drugs
Penalty
Summary
The facility failed to establish and maintain a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation for a resident who was prescribed Oxycodone HCl. Record review showed that the resident, an older female with chronic diastolic heart failure, hypertension, and chronic pain, was ordered Oxycodone HCl as needed for pain. Upon discharge, the resident refused to take her PRN oxycodone and was picked up by a family member. However, there was no documentation of the receipt or disposition of the controlled medication, and staff interviews revealed inconsistent practices and a lack of written logs for tracking controlled substances left behind by discharged residents. Staff interviews indicated that the Director of Nursing (DON) was responsible for logging and managing narcotics and discharge records, but the DON was unable to provide a log for the medication in question. The facility relied on an electronic device for medication tracking but did not utilize written logs, and staff described varying protocols for handling medications left by discharged residents. The facility's policy required maintaining detailed records for controlled drugs, but this was not followed in the case of the resident's Oxycodone HCl, resulting in a failure to accurately reconcile controlled medications.
Deficient Food Storage, Labeling, and Staff Hygiene in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and staff hygiene practices. In the kitchen storage area, a partially used bag of refined sugar and a large bag of enriched flour were found open and undated on shelves. A storage bin labeled as containing flour had an unsecured lid. In the walk-in refrigerator, two plastic containers with unidentified substances were found without labels or dates, and an open package of sliced honey ham was stored in an unsealed bag alongside unsealed bags of shredded cheese in the same bin. Staff interviews confirmed that these practices did not meet facility expectations or policy, and that all food items should be dated, labeled, and stored in sealed containers to prevent contamination. Additionally, staff hygiene practices were not consistently followed. A staff member with facial hair was observed in the food preparation and dishwashing areas without a required hairnet or beard guard. The staff member acknowledged awareness of the requirement but stated he forgot to wear the protective gear. Interviews with dietary management and other kitchen staff confirmed that all staff are expected to wear hairnets or beard guards in food prep areas, and that failure to do so could result in contamination. Review of facility policies and in-service training materials further supported these requirements for food labeling, dating, storage, and staff hygiene.
Failure to Use Nutritive Liquids in Pureed Food Preparation
Penalty
Summary
The facility failed to ensure that pureed foods were prepared using methods that conserve nutritive value, flavor, and appearance for residents on a pureed diet. During a lunch observation, a cook pureed chicken tenders and broccoli using only water, rather than broth or cooking juices, to achieve the required consistency. The cook did not follow a specific recipe and added water incrementally until the food resembled pudding. The dietary manager confirmed that staff were trained to use small amounts of water but preferred broth for pureeing meats, acknowledging that water could dilute both taste and nutritional value. The registered dietitian also stated that recipes typically call for broth or cooking liquids, not water, to maintain nutritional content. Further interviews revealed that the cook was aware of the expectation to use meat or vegetable juices but resorted to water due to time constraints and lack of available juices. The dietary manager and administrator both indicated that recipes were accessible through the facility's computer system, but not all staff had them, and there was no specific policy regarding therapeutic diets. Review of in-service training materials indicated that broth, milk, or juice should be used to adjust the thickness of pureed foods, not water. This practice was not followed during the observed meal preparation.
Failure to Assess and Supervise Resident Handling of Hot Liquids Resulting in Burn Injury
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and mobility issues sustained a second-degree burn after spilling hot water on her leg. The incident happened when the resident, who had diagnoses including unspecified dementia and arthritis, accessed a hot water dispenser and spilled 180°F water onto her lap, resulting in burns to her left thigh. The resident reported the incident to staff, and subsequent assessment confirmed the injury. Review of facility records and interviews revealed that there was no documented assessment of the resident's ability to safely handle hot liquids, despite the facility's policy requiring such evaluations. The policy also outlined specific interventions and precautions for residents with difficulties handling hot beverages, such as the use of assistive devices, supervision, and individualized care planning. However, the resident's care plan did not reflect any hot liquid safety assessment or related interventions. Staff interviews indicated that while in-service training on hot beverage safety and abuse prevention had been provided, the Director of Nursing (DON) was unaware of any formal hot liquid assessment being implemented. Staff relied on general knowledge and resident diagnoses to determine safety measures, rather than a structured assessment process. This lack of individualized assessment and care planning contributed to the resident's exposure to an accident hazard, resulting in injury.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Document and Administer Wound Care per Physician Orders
Penalty
Summary
The facility failed to ensure that two residents received wound care treatment and documentation in accordance with physician orders, professional standards, and the residents' care plans. For one resident with a history of traumatic brain injury, type II diabetes, and venous insufficiency, the treatment administration record (TAR) showed that wound care for a post-surgical right calf wound was not documented as completed on eleven occasions across two months. The resident's care plan and physician orders specified daily wound care, but these were not consistently documented as performed. Another resident, with diagnoses including type II diabetes, chronic kidney disease, and hemiplegia following a stroke, had physician orders for daily wound care to both heels due to stage 4 pressure injuries. The TAR indicated that wound care for both heels was not documented as completed on four separate dates. Both residents were assessed as being at risk for pressure ulcers, and their care plans required wound care interventions as ordered by their physicians. Interviews with facility staff, including licensed nurses and administrative personnel, confirmed that treatments were expected to be documented when completed, and that a blank on the TAR indicated the treatment was not done. The facility's wound care policy outlined documentation requirements, but there was no specific policy for documentation practices. The Director of Nursing and other staff acknowledged the expectation for accurate and timely documentation of wound care, and the administrative team was responsible for monitoring this process.
Failure to Complete and Document Wound Care Treatments as Ordered
Penalty
Summary
The facility failed to provide necessary wound care treatment and services consistent with professional standards of practice for a male resident with multiple diagnoses, including type II diabetes, chronic kidney disease, and hemiplegia following a stroke. The resident was identified as being at risk for pressure ulcers and had existing deep tissue injuries (DTIs) to both heels. Physician orders were in place for daily wound care treatments to both heels, including cleansing, application of a collagen sheet, and appropriate dressings. However, review of the Treatment Administration Records (TARs) for May and June 2025 showed that wound care treatments for both heels were not documented as completed on four separate occasions. Interviews with nursing staff and administration confirmed that treatments are expected to be completed and documented as ordered, and that a blank on the TAR indicates the treatment was not done. The facility's wound care policy also requires documentation of the type of care given, date and time, and the name and title of the person performing the care. The Director of Nursing, who was new to the facility, stated she expected daily treatments to be completed and documented as ordered. The lack of documentation and missed treatments could result in residents not receiving appropriate care and treatment.
Failure to Notify Physician of Change in Condition Following Surgical Procedure
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's condition, specifically regarding swelling and tenderness at surgical incision sites. The resident, a cognitively intact male with chronic pain, osteoarthritis, hemiplegia, and hemiparesis, had recently undergone a spinal cord stimulator implant. Despite documented interventions in the care plan to notify the physician as needed for potential infections, there were no physician orders to monitor the surgical sites, and staff did not communicate changes in the resident's condition to the nurse practitioner (NP) or wound care nurse (WCN) when swelling and tenderness were observed. On the day prior to the resident's hospitalization, a CNA observed swelling at the incision sites and reported it to an LVN, who assessed the sites and notified the ADON. However, the NP and WCN were not informed of these changes. The following day, the resident's incision dehisced, with drainage of blood and pus, prompting transfer to the hospital where an infection was diagnosed. Interviews with staff revealed a lack of clarity regarding responsibility for monitoring and reporting changes in surgical sites, and some staff were unaware of the need to notify the NP or WCN of such changes. Documentation and communication lapses were evident, as the NP stated she was not notified of the swelling and would have taken immediate action if she had been informed. The facility's policy required prompt notification of the physician for changes in a resident's condition, but this was not followed in this case. The deficiency was identified as Immediate Jeopardy due to the failure to ensure timely physician notification and appropriate monitoring of the resident's surgical sites, which resulted in the resident developing an infection that required hospitalization.
Failure to Monitor and Assess Surgical Site Leading to Infection
Penalty
Summary
A deficiency occurred when a resident with a history of chronic pain, osteoarthritis, hemiplegia, and hemiparesis underwent a spinal cord stimulator implant and subsequently developed an infection at the surgical site. The resident's care plan included interventions for chronic pain and neuropathy, and a revision noted the potential for infection related to the back pain stimulator. However, there were no physician orders in the electronic medical record to monitor the surgical sites following the procedure, and documentation regarding the removal of staples and the healing status of the incisions was unclear. Staff interviews and record reviews revealed that the resident's surgical sites were not consistently assessed by the nurse practitioner (NP) or medical doctor (MD) to determine if they were healed. On one occasion, swelling at the incision sites was reported to a nurse, who assessed the area and notified the assistant director of nursing (ADON), but there was no documentation of this assessment or further notification to the NP. The following day, one of the incisions dehisced, resulting in bleeding and purulent drainage, and the resident was sent to the hospital where an infection was diagnosed. Multiple staff members, including the wound care nurse and NP, stated they were not notified of changes in the resident's condition, and there was confusion among staff regarding who was responsible for monitoring and assessing surgical wounds. The facility's policy required prompt notification of changes in a resident's condition to the attending physician, but this was not followed in the case of the resident's surgical site changes. Interviews indicated that nurses were unsure whether they could determine if a wound was healed, and the NP confirmed that only a physician or NP should make that determination. The lack of clear communication, documentation, and adherence to professional standards of practice led to a delay in identifying and treating the infection, resulting in hospitalization for the resident.
Failure to Secure Controlled Drugs
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and only authorized personnel had access to the keys. This deficiency was identified during the review of a resident's controlled drug storage. Specifically, the facility did not store one bottle of Hydrocodone and one bottle of Valium for a resident in a separately locked, permanently affixed compartment designated for controlled drugs. This oversight was discovered when the Hydrocodone was reported missing, and the Valium was found unsecured on top of a medication cart. The incident began when a resident was admitted to the facility, and their family member brought in medications, including Hydrocodone and Valium. The admitting nurse, RN A, discovered that the resident had an allergy to Hydrocodone and intended to return the medications to the family. However, instead of storing the controlled drugs in the designated locked compartment, RN A placed them in a drawer with non-controlled medications. RN A communicated to the incoming night nurse, RN B, about the medications, but RN B did not pass this information to the day shift nurse, RN D, leading to the Hydrocodone going missing. The facility's investigation revealed that the controlled drugs were not entered into the controlled drug logbook upon receipt, nor were they stored under double lock as per facility policy. The Valium was later found unsecured on a medication cart by MA C, who reported it to RN D. The Hydrocodone was never recovered, and the family confirmed that it was not returned to them. The facility's policy requires controlled substances to be counted upon delivery and stored in separately locked compartments, which was not followed in this case.
Failure to Conduct Neurological Checks and Skin Assessment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. This deficiency was identified for a resident who had unwitnessed falls on two occasions and was not provided with the necessary neurological checks as per the facility's protocol. The resident, who had a history of a recent hip replacement and was on anticoagulant medication, was at risk for falls and abnormal bleeding. Despite these risks, the required neurological evaluations were not consistently completed following the falls. On the first incident, the resident was found on the floor with an abrasion to the back of her head, but neurological checks were not conducted at the required intervals. Similarly, after the second fall, the resident was found with a skin tear and later developed a hematoma in the vaginal area, yet a full-body skin assessment was not performed. The lack of thorough assessments and documentation of neurological checks persisted over several days, indicating a failure to adhere to the facility's policy for monitoring after unwitnessed falls. Interviews with the nursing staff revealed inconsistencies in the understanding and execution of the neurological check protocol. The staff admitted to not completing all necessary checks and assessments, which were crucial for monitoring potential changes in the resident's condition. The Director of Nursing acknowledged the oversight and emphasized the importance of conducting these assessments to ensure proper care and treatment of residents following falls.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin involving a resident, who was found with a deep purple hematoma in her vaginal area, to the State Survey agency within the required 24-hour timeframe. The resident, an elderly female with a history of orthopedic aftercare for a right hip replacement, osteoporosis, muscle weakness, and unsteadiness, was on anticoagulant medication, which increased her risk for abnormal bleeding. Despite the presence of a hematoma and bruising, the facility did not report the incident as required, attributing the injuries to a fall that occurred earlier that day. The incident began when a Licensed Vocational Nurse (LVN) heard a thud and found the resident on her right side with a small skin tear on her forearm. Later that day, another LVN was informed by a Certified Nursing Assistant (CNA) about abnormalities in the resident's peri-area, which included a hematoma and dark bruising. The nurse assessed the resident and noted the bruising extended from the pubis and vaginal area to the left buttock. Despite these findings, the nurse attributed the bruising to the earlier fall, assuming the resident may have hit or landed on something, and notified the Nurse Practitioner (NP) and Director of Nursing (DON). Interviews with staff revealed that the NP assessed the resident the following day and ordered tests, which returned negative results. The NP and DON both believed the injuries were consistent with the resident's recent falls and anticoagulant use. The facility's Abuse and Neglect Policy did not specify when to report such incidents to the Health and Human Services Commission (HHSC), and the Assistant Administrator (AADM) stated the hematoma was not reported because it was associated with the fall. This lack of immediate reporting of the injury of unknown origin constitutes a deficiency in the facility's compliance with reporting requirements.
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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.
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Nursing homes near Wimberley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Marcos Rehabilitation And Healthcare Center | 11.8 mi | ★★★★★ | 3 | 0 |
| Legend Oaks Healthcare And Rehabilitation-kyle | 12.1 mi | ★★★★★ | 9 | 0 |
| Hays Nursing And Rehabilitation Center | 13.1 mi | ★★★★★ | 10 | 0 |
| Cypress Healthcare And Rehabilitation Center | 13.3 mi | ★★★★★ | 2 | 0 |
| Avir At Dripping Springs | 14 mi | ★★★★★ | 2 | 0 |
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