Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eagle Pass Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to date prepared thickened beverages, refrigerate opened jars of jalapenos and salad dressing, properly seal a container of vanilla cream icing, and date a beverage container in the dining room. These actions were not in accordance with professional standards and facility policies for food storage and safety.
All resident rooms were found to be below the required 80 square feet per resident, with measurements and interviews confirming that each double-occupancy room provided less than the mandated space. The Administrator and Maintenance verified the deficiency after measuring the rooms and reviewing facility records.
A CNA did not receive the required annual training on resident rights, as confirmed by personnel record review and staff interviews. The facility uses a computer-based system to assign and track annual trainings, but there was no documentation that the CNA completed the resident rights training. When asked, the facility could not provide a policy outlining required annual trainings, including resident rights.
The facility did not accurately update and post daily nurse staffing information, as the staff posting incorrectly showed no Medication Aides present while one was working, and staff were observed making corrections to the posting during the shift. Responsibility for updating the posting was unclear, and there was no formal policy guiding this process.
A resident with severe cognitive impairment and a history of wandering was left unsupervised in a dining area, allowing him to exit through an unlocked door. The resident was found outside the facility after a fall, with no injuries noted. The door had not been properly secured, and exit doors were only checked once daily for security prior to the incident.
The facility failed to ensure proper catheter care and infection control for several residents, leading to potential risks of urinary tract infections. Catheter drainage bags and tubing were observed touching the floor, and staff did not follow proper infection control protocols.
The facility failed to ensure that three nurse aides who had been employed for more than four months completed a competency evaluation program. Despite their lack of certification, they were working as full-time staff members providing ADL assistance to residents. The HRD and DON confirmed that these nurse aides had attempted but failed to pass the competency evaluation program and were shadowed by CNAs.
The facility failed to maintain an effective infection prevention and control program. A Medication Aide did not perform hand hygiene between glove changes, did not sanitize the blood pressure cuff between residents, and did not use proper PPE for residents on contact isolation. Additionally, a housekeeper did not clean her hands before putting on new gloves and cleaning another room. These lapses in protocol could lead to cross-contamination and infection spread among residents.
The facility failed to inform a resident's Responsible Party of the risks, benefits, and options after a psychiatrist recommended discontinuing a medication. Despite regular visits and communication, the family member was unaware of the recommendation, and the medication continued to be administered. The MD and ADON were also not informed, and the DON claimed to have notified them verbally but did not document it.
The facility failed to develop and implement a comprehensive care plan for a resident's oxygen therapy, including self-administration and use of a pulse oximeter. Staff did not consistently document oxygen saturation levels or the administration of oxygen, despite the resident's multiple respiratory diagnoses and intact cognition.
A facility failed to ensure proper dialysis care and documentation for a resident with end-stage renal disease. Incomplete records and lack of communication with the dialysis center led to inadequate monitoring of the resident's condition.
The facility failed to ensure all dumpsters were equipped with drain plugs, posing a sanitary and safety hazard. Two out of three dumpsters lacked drain plugs, and the staff were unaware of the necessity of these plugs. The Maintenance Supervisor claimed the city removed the plugs during an inspection but had no evidence to support this.
The facility failed to maintain accurate medical records for a resident with multiple diagnoses, resulting in conflicting information about the resident's mobility status and risk assessments. The discrepancies were noted between the Admitting MDS, Elopement Risk Assessment, Fall Risk Assessment, and nursing progress notes.
The facility failed to submit accurate RN staffing information for 11 days in Fiscal Year Quarter 1 of 2024. The CCN, who was present on those days, did not complete timesheets due to her salaried status, leading to non-compliance with CMS guidelines.
The facility failed to provide mandatory QAPI training to three staff members (an LVN, another LVN, and a CNA). Record reviews showed no evidence of training, and interviews revealed that the HRD and ADM were unaware of the training deficiencies.
The facility failed to ensure that all staff received training in compliance and ethics, affecting five out of sixteen staff members reviewed. The HR Director confirmed that these staff members were assigned the training but had not completed it via the company's contracted training site, Relias. The Administrator was unaware of the lack of training and acknowledged the risk of staff being unaware of corporate compliance and ethics. The facility did not have a specific policy for ethics training.
The facility failed to implement policies and procedures to prevent abuse and neglect for three residents. Incidents involving resident altercations and a fall resulting in injury were reported late by the new administrator, exceeding the facility's two-hour reporting policy.
The facility failed to report alleged abuse and neglect within the required two-hour timeframe. In one case, a resident with severe cognitive impairment hit another resident, and the incident was reported over four hours later. In another case, a resident with moderate cognitive impairment fell and fractured her nose, and the incident was also reported after four hours. The Administrator admitted delays due to being new and needing time to complete the reporting process.
A resident with severe cognitive impairment did not receive timely treatment for a foot injury, which was noticed by a nursing assistant but not reported. The injury was later identified by another nursing assistant, leading to a delay in care. The resident was sent to the hospital and diagnosed with a laceration and a mildly displaced fracture.
The facility failed to ensure all nursing staff had the necessary competencies to care for residents, leading to incidents where a resident suffered a fractured toe and another experienced a fall with a potential head injury. In-service training was incomplete, and the facility relied on corporate assignments and quizzes without comprehensive oversight.
The facility failed to thoroughly investigate three reported incidents involving resident abuse, neglect, exploitation, or mistreatment. One resident sustained a foot laceration during a shower, another had a knee fracture discovered at the hospital, and an unoccupied shower room caught fire. Investigations were incomplete, lacking staff statements and detailed reports.
A resident with severe cognitive deficit fell during a mechanical lift transfer due to improper sling placement by a CNA. The incident was witnessed by another CNA, and the resident was taken to the hospital to rule out a head injury. The ADON recommended termination of the responsible CNA, who did not return to work.
The facility failed to maintain a fire watch from 10:00 PM through 8:00 AM while the fire alert system was offline, potentially placing residents at risk. The ADM and MS were aware of the issue but did not ensure continuous monitoring.
The facility failed to post current nurse staffing data, displaying outdated information from over a week prior. The ADON admitted to neglecting the update, and the facility's policy on postings was not provided to the investigation team.
The facility failed to ensure an active governing body and an engaged administrator responsible for managing the facility. The ADM was unfamiliar with state licensure and compliance requirements, deferring decision-making to department heads, and was not involved in investigating incidents or in-servicing staff. Interviews with staff confirmed the ADM's lack of interaction and hands-on management.
Failure to Properly Store, Date, and Refrigerate Food and Beverages
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, and labeling of food and beverages. Specifically, a tray of prepared and poured glasses of thickened beverages was found in the walk-in refrigerator without any date labels. An opened jar of jalapenos, marked with a received date and labeled to refrigerate after opening, was found in the pantry instead of being refrigerated. Additionally, a large opened plastic container of vanilla cream icing was left with the lid open and not properly sealed, and a half-used bottle of salad dressing, which required refrigeration after opening, was also found unrefrigerated in the pantry. In the dining room, a beverage container with water was present on the counter without a date indicating when it was prepared. Interviews with the Dietary Manager (DM) and the Administrator confirmed that these items should have been properly dated, sealed, and refrigerated according to facility policy and food safety standards. The DM acknowledged that improper storage and lack of dating could result in food items going bad. Record reviews showed that staff had previously received in-service training on labeling, dating, and food storage, and facility policies required food to be covered, dated, and stored at appropriate temperatures. The observed deficiencies were in direct violation of these established procedures and professional standards for food service safety.
Failure to Provide Minimum Square Footage per Resident in All Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in all 46 resident rooms reviewed. Observations of rooms in multiple halls revealed that each room was set up for double occupancy, with beds positioned close to the doorframes and privacy curtains resting on the edge of the beds and in the doorway. Interviews with the Administrator and Maintenance confirmed that none of the rooms met the minimum square footage requirement, as all measured less than 160 square feet, resulting in less than 80 square feet per resident. Record reviews, including room measurements and Form 3740 Bed Classifications, further substantiated that all resident rooms were designated for double occupancy but did not meet the required space per resident. The Administrator acknowledged that the facility did not have a room size waiver and was unaware of the exact room sizes until measurements were taken, confirming the deficiency.
Failure to Provide Annual Resident Rights Training to CNA
Penalty
Summary
The facility failed to provide mandatory annual training on resident rights to one of its certified nursing assistants (CNA C). Review of personnel records showed that CNA C, hired in August 2023, did not have documentation of having completed the required annual resident rights training for the period reviewed. The facility utilizes Relias, a computer-based training program, to assign and track annual trainings, with notifications sent to both employees and their department heads when trainings are due. However, there was no evidence that CNA C completed the resident rights training as required. Interviews with the HR, DON, and Administrator confirmed that the facility's process relies on email notifications and that it is the responsibility of both employees and department heads to ensure completion of annual trainings. Despite these procedures, the required training for CNA C was not documented. Additionally, when requested, the facility was unable to provide a policy specifically addressing required annual training, including resident rights training, prior to the survey exit.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately post daily nurse staffing information at the beginning of each shift, as required. On the observed date, the daily staff posting was displayed in public view but incorrectly listed zero Medication Aides (MAs), despite an MA being present and working that morning. During the same period, a registered nurse was seen updating the staffing numbers on the board, indicating that the information had not been kept current. Interviews with staff revealed that responsibility for updating the posting alternated between office staff and charge nurses, with the Director of Nursing stating that charge nurses handled this task on weekends. The Administrator confirmed the importance of accurate daily postings and acknowledged that there was no formal policy in place for this process.
Failure to Prevent Elopement and Accident Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
A deficiency occurred when the facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment and a known risk for wandering. The resident, an 85-year-old male with diagnoses including unspecified dementia, anxiety disorder, and unspecified convulsions, had a BIMS score of 6, indicating severe cognitive impairment, and was identified as a significant elopement risk. Despite care plan interventions and a physician order for 30-minute monitoring, the resident was left unsupervised in the dining room while staff retrieved other residents. During this period of inadequate supervision, the resident exited the facility through an unlocked dining room door. The door was found to be unlocked at the time, and the facility was unable to determine which staff member had left it unsecured. The resident was discovered outside the facility, lying on the ground near the dining room door, having sustained a fall during the elopement. Upon assessment, the resident showed no signs of injury and reported no pain. Prior to the incident, exit doors were only checked once daily for lock and alarm functionality. Staff interviews confirmed that the resident was left alone in the dining room and that the elopement occurred during this lapse in supervision. The facility's failure to maintain a secure environment and provide adequate supervision directly led to the resident's elopement and fall.
Failure to Maintain Proper Catheter Care and Infection Control
Penalty
Summary
The facility failed to ensure appropriate treatment and services for residents with indwelling urinary catheters, leading to potential risks of urinary tract infections. Resident #38's catheter drainage bag was observed touching the floor while the resident was eating lunch in the dining room. Despite being aware of the issue, the staff did not take immediate corrective action, which could lead to infection due to contamination from the floor. The resident's care plan specifically mentioned maintaining the drainage bag off the floor, which was not adhered to during the observation. Resident #11's catheter care was improperly managed by CNAs who did not follow proper infection control protocols. The catheter bag and tubing were observed touching the floor, and the CNAs did not change gloves appropriately during the catheter care process. The DON incorrectly stated that it was acceptable to touch the catheter tubing with contaminated gloves, which contradicts standard infection control practices. This negligence in following proper procedures could lead to infections. Similar issues were observed with Residents #55, #17, and #48, where their catheter drainage bags and tubing were found touching the floor. Despite the facility's policy and care plans indicating that catheter bags should be kept off the floor to prevent infections, these guidelines were not followed. Staff members acknowledged the problem but did not take adequate steps to rectify it, thereby increasing the risk of urinary tract infections for these residents.
Failure to Ensure Nurse Aides Complete Competency Evaluation Program
Penalty
Summary
The facility failed to ensure that three nurse aides (NA E, NA F, and NA G) who had been employed for more than four months completed a competency evaluation program. Nurse Aide E was hired on 09/19/2022, Nurse Aide F on 10/06/2022, and Nurse Aide G on 08/09/2023. None of these nurse aides had completed the required training and competency evaluation program approved by the state. Despite their lack of certification, they were working as full-time staff members providing ADL assistance to residents. The HRD confirmed that these nurse aides had attempted but failed to pass the competency evaluation program and were unaware if they completed tasks independently or under supervision. The DON confirmed that these nurse aides were shadowed by CNAs and had not worked independently, but acknowledged that the expectation was for all nurse aides to become certified within four months of hire. The deficiency places residents at risk of receiving care from individuals whose skill levels have not been adequately evaluated. The facility's failure to ensure that nurse aides become certified within the required timeframe indicates a lapse in compliance with state regulations. The job description for nurse aides, which was undated, stated that they were to complete a nursing and competency program but did not specify a precise timeframe for certification. This lack of clarity and oversight contributed to the deficiency identified by the surveyors.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Medication Aide and a housekeeper. The Medication Aide did not perform hand hygiene between glove changes, did not sanitize the blood pressure cuff between residents, and did not use proper PPE when providing services to residents on contact isolation. Specifically, the Medication Aide failed to wear a gown or gloves when entering the room of two residents on contact isolation, did not sanitize the blood pressure cuff between uses on multiple residents, and admitted to not noticing the isolation signage and PPE cart outside the room. The Director of Nursing (DON) confirmed that the Medication Aide did not follow proper infection control protocols, which could lead to cross-contamination and infection spread among residents. The housekeeper also failed to adhere to proper infection control practices. After cleaning the room of two residents on contact isolation, the housekeeper did not clean her hands before putting on new gloves and proceeding to clean the next room. The housekeeper stated that she thought it was acceptable to put on new gloves without sanitizing her hands because there was no hand sanitizer available on the PPE cart. The DON confirmed that all staff are expected to perform hand hygiene before and after care and that the housekeeper should have sanitized her hands between rooms to prevent infection. The facility's policy and procedure for infection control, updated in March 2024, requires staff to wash their hands after each direct contact, don and doff PPE before and after contact with residents on isolation, and disinfect resident care equipment between uses. The failure of both the Medication Aide and the housekeeper to follow these protocols indicates a significant lapse in the facility's infection control practices, potentially putting residents at risk for the transmission of communicable diseases and infections.
Failure to Inform Responsible Party of Medication Changes
Penalty
Summary
The facility failed to ensure that Resident #34's Responsible Party was informed of the risks, benefits, and options available after a psychiatrist recommended discontinuing the Ativan/Benadryl/Haldol Gel. Despite the recommendation made on 02/27/2024, the Responsible Party was not notified, and the medication continued to be administered. The resident's face sheet indicated a history of a stroke and moderately impaired cognition, and the resident had been receiving antipsychotics, antidepressants, and antianxiety medications. The comprehensive person-centered care plan did not reflect any information related to the administration of antipsychotic medications. Interviews with the family member, MD, ADON, and DON revealed a lack of communication regarding the psychiatric evaluation and the recommendation to discontinue the medication. The family member confirmed regular visits and communication with the facility staff but was unaware of the psychiatric recommendation. The MD and ADON were also not informed of the recommendation, while the DON claimed to have notified the family and MD verbally but did not document it in the clinical records. The facility's policy on notification to family and physician was requested but not provided upon exit.
Failure to Implement Comprehensive Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the use of oxygen therapy. The care plan did not reflect the resident's self-administration of oxygen or the use of a pulse oximeter, and it did not specify the active order for 2 liters per minute rate as needed for oxygen or the frequency for vital signs. This oversight was identified during a review of the resident's records and through interviews with the resident and staff members. The resident, a male with multiple diagnoses including pneumonia, diabetes mellitus, anemia, acute respiratory failure with hypoxia, emphysema, chronic obstructive pulmonary disease, and chronic atrial fibrillation, had a BIMS score of 15, indicating intact cognition. The resident reported using oxygen at night and checking his own oxygen levels with a pulse oximeter. Despite this, the care plan did not address these practices, and staff did not consistently document the resident's oxygen saturation levels or the administration of oxygen. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the staff were aware of the resident's self-administration of oxygen but did not document it because the order was PRN (as needed). The DON and the Regional Compliance Nurse stated that staff were not expected to document oxygen saturation levels daily for PRN orders, even though they were checking it. This lack of documentation and the incomplete care plan could lead to inadequate monitoring and care for the resident's respiratory needs.
Failure to Ensure Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards of practice. Specifically, the facility did not maintain adequate communication, coordination, and collaboration with the dialysis facility for a resident with end-stage renal disease. The resident's comprehensive care plan included specific interventions for dialysis-related care, but the facility's documentation was incomplete and inconsistent. Several records, including pre and post-assessments, were either blank or missing vital information, such as weights, skin assessments, and vital signs. The Director of Nursing (DON) acknowledged that the dialysis center was responsible for filling out certain portions of the form, but these were often left blank, and the facility did not consistently follow up to obtain the missing information. The resident, who had a central port for dialysis, attended treatments on Monday, Wednesday, and Friday. Despite the facility's policy requiring thorough documentation and monitoring of the resident's condition before and after dialysis, multiple records were incomplete. This lack of proper documentation and communication could lead to inadequate monitoring of the resident's health status and potential complications. The facility's policy emphasized the importance of maintaining comprehensive records and monitoring the resident's condition, but these procedures were not consistently followed, leading to the identified deficiency.
Failure to Equip Dumpsters with Drain Plugs
Penalty
Summary
The facility failed to ensure all facility dumpsters were equipped with a drain plug, posing a sanitary and safety hazard. During an observation and interview, it was revealed that 2 out of 3 facility dumpsters lacked a drain plug, with one having a soda bottle lodged in the drain outlet. The Dietary Manager (DM) confirmed that the dumpsters were her responsibility but was unaware of the necessity of drain plugs. The Maintenance Supervisor (MS), with interpreter assistance from the Director of Nursing (DON), acknowledged the lack of drain plugs and stated that they were removed by the city during a recent inspection, although he had no evidence or records to support this claim. The facility's policy on Waste Control and Disposal did not include specific guidelines related to dumpster maintenance.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for Resident #213, who was reviewed for accurate medical records. The resident, a male with multiple diagnoses including dementia, type 1 diabetes, and a left femur fracture, had conflicting information in his medical records regarding his mobility status. The Admitting MDS indicated that the resident required supervision or touching assistance for transfers and ambulation, while the Elopement Risk Assessment stated that the resident was non-ambulatory and not at risk for elopement. Conversely, the Fall Risk Assessment indicated that the resident was ambulatory and had a high risk for falls. Further discrepancies were noted in the nursing progress notes, which documented the resident walking in different halls at night, contradicting the Elopement Risk Assessment. During an interview, the DON confirmed that the resident could self-propel in his wheelchair and had improved since admission. However, the DON stated that walking around did not qualify the resident for a new elopement assessment. The facility's policy on documentation emphasized the importance of accuracy and completeness, which was not adhered to in this case, leading to misinformation about the resident's care needs.
Failure to Submit Accurate RN Staffing Information
Penalty
Summary
The facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format for 11 of 91 days in Fiscal Year Quarter 1 of 2024. Specifically, the facility did not submit RN staffing hours for the dates 11/24, 12/04, 12/05, 12/09, 12/10, 12/16, 12/17, 12/18, 12/21, 12/22, and 12/27. This failure was confirmed through interviews and record reviews, including the CMS Form-671 and the PBJ Staffing Data Report. The ADM confirmed that the staffing hours were submitted by the corporate office to CMS, but the days in question were likely staffed by the CCN, who, as a salaried staff member, did not complete timesheets and thus could not provide verifiable evidence of her presence at the facility. The CCN confirmed during an interview that she was present at the facility on the dates in question but did not complete timesheets due to her salaried status and had no personal schedule to evidence her presence. The facility's failure to submit accurate and complete staffing information as required by CMS guidelines could not confirm the presence of an RN during the specified dates, potentially impacting the quality of care provided to the residents. The CMS policy manual requires that direct care staffing and census data be collected quarterly and submitted timely and accurately, which the facility failed to comply with for the specified dates.
Failure to Provide Mandatory QAPI Training
Penalty
Summary
The facility failed to include mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for three staff members (LVN H, LVN I, and CNA J). Record reviews showed no documented evidence that these employees received the required QAPI training. LVN H was hired on 07/18/2023, LVN I on 06/29/2022, and CNA J on 01/17/2024. During interviews, the Human Resources Director (HRD) confirmed that the training was assigned by corporate and that her role was limited to reminding department heads of late or non-compliant training. The Administrator (ADM) was also unaware that the staff had not been trained on the facility's QAPI plan and protocols, acknowledging the risk of staff being unaware of the facility's QAPI plan.
Failure to Ensure Staff Training in Compliance and Ethics
Penalty
Summary
The facility failed to ensure that all staff received training in compliance and ethics, affecting five out of sixteen staff members reviewed. Specifically, the Director of Nursing (DON), two Licensed Vocational Nurses (LVN H and LVN I), one Certified Nursing Assistant (CNA J), and one Registered Nurse (RN K) did not have documented evidence of completing the required training. The HR Director (HRD) confirmed that these staff members were assigned the training but had not completed it via the company's contracted training site, Relias. The HRD also noted that her responsibility was limited to reminding department heads of late or non-compliant training. The Administrator (ADM) was unaware of the lack of training and acknowledged the risk of staff being unaware of corporate compliance and ethics. The facility did not have a specific policy for ethics training.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for three residents. The first incident involved a resident with severe cognitive impairment who hit another resident multiple times, resulting in slight bruising. The incident was reported to the administrator (ADM) immediately by the Director of Nursing (DON), but the ADM, who was new, took over four hours to report the incident, exceeding the facility's policy of reporting within two hours. The second incident involved a resident who fell and sustained a fractured nose. The ADM was informed of the incident soon after it occurred, but again took over four hours to report it, failing to meet the two-hour reporting requirement for allegations of neglect. The residents involved had significant medical histories, including dementia, cognitive communication deficits, and cerebral infarction. The facility's failure to promptly report these incidents as per their policy could affect any resident and contribute to abuse and neglect. The ADM acknowledged understanding the reporting requirements but cited his newness to the role as a reason for the delay. The facility's policy mandates that all allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property must be reported within two hours if they involve abuse or result in serious bodily injury.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, as required by their policy. In the first incident, a resident with severe cognitive impairment hit another resident multiple times, resulting in slight bruising. The Director of Nursing (DON) informed the Administrator (ADM) about the incident right away, but the ADM reported the incident to the authorities over four hours later, exceeding the two-hour reporting requirement. The ADM admitted that he was new and took time to complete the reporting process, despite knowing the two-hour requirement for reporting resident abuse. In the second incident, a resident with moderate cognitive impairment fell off her bed and sustained a fractured nose. The incident was unwitnessed, and the resident was sent to the hospital immediately. The staff informed the ADM about the incident soon after it occurred, but the ADM reported the incident to the authorities after four hours, again exceeding the two-hour reporting requirement for resident neglect. The ADM acknowledged that he was new and took time to complete the intake documentation, despite understanding the reporting requirements.
Failure to Provide Timely Treatment for Resident's Foot Injury
Penalty
Summary
The facility failed to provide timely treatment and care for a resident who was eventually diagnosed with a laceration and a fracture to the left foot. The incident occurred when a nursing assistant (NA AD) noticed the resident's foot bleeding before the end of her shift but did not report it to a charge nurse. The injury was only identified later by another nursing assistant (NA AC) during a transfer to bed, leading to a delay in treatment. The resident was subsequently sent to the hospital, where an x-ray revealed a mildly displaced fracture of the fifth toe proximal phalanx and a soft tissue defect. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 03, and required total assistance with activities of daily living (ADLs). The resident's care plan specified the need for a two-person lift for transfers and total care for showering. On the day of the incident, the resident had a shower recorded at 1:59 PM by NA AD, who noticed the bleeding but did not report it. The injury was not identified until around 4 PM when NA AC observed the bleeding during a transfer. Interviews with staff revealed that the injury was likely sustained during the shower with NA AD, who failed to report it. The charge nurse (LVN N) and the Assistant Director of Nursing (ADON) confirmed that the injury was not identified during the day shift and was only reported during the evening shift. The facility conducted in-service training on abuse, neglect, safe handling, reporting, and transfers on the same day as the incident, but there was no evidence of staff statements or findings in the investigation folder.
Inadequate Staff Training and Competency in Resident Care
Penalty
Summary
The facility failed to ensure that all nursing staff had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. This was evident in the cases of two residents who experienced reportable incidents. Resident #1, who had a primary diagnosis of Nutritional Marasmus and Cognitive Delays and Dementia, suffered a fractured 5th toe on her left foot. The incident was discovered by a nurse aide who noticed bleeding and reported it to an LVN, leading to the resident being sent to the ER for x-rays. The facility's in-service training following this incident was incomplete, with only 15 of 38 direct care staff receiving the necessary training on abuse, neglect, exploitation, reporting, safe handling, and transferring residents. The alleged perpetrator did not receive this training. Resident #3 experienced a fall and potential head injury due to an improper mechanical transfer. Following this incident, only 12 of 38 direct care staff were in-serviced on Hoyer Lift Transfers and safe resident handling. Interviews with the ADON and ADM revealed that the facility's in-service training was limited to specific shifts and staff, and there was no comprehensive classroom setting for return demonstrations. The ADM relied on corporate assignments and quizzes to confirm staff competencies, and the QA committee's audits were conducted by department heads without centralized oversight. The ADM did not identify concerns with the investigations until the state investigation began.
Failure to Investigate Alleged Violations Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate three reported incidents involving resident abuse, neglect, exploitation, or mistreatment. In the first incident, a resident with severe cognitive impairment sustained a foot laceration during a shower, which was not reported to nursing staff for at least two hours. The investigation lacked staff statements and was deemed insufficient. In the second incident, a resident with dementia complained of knee pain, and a subsequent hospital visit revealed a knee fracture. The investigation also lacked staff statements and other necessary investigative components. In the third incident, an unoccupied shower room caught fire due to an electrical issue. The investigation included invoices for repairs but lacked detailed reports on smoke inhalation assessments and risk assessments for residents. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) and the Administrator (ADM) were responsible for the investigations. The ADON admitted to only partially completing in-service training for staff, believing the incidents were isolated. The ADM acknowledged shortcomings in the investigation process, particularly in determining the cause of the fire and assessing resident harm. The facility's policy indicated that the ADM was the final responsible party for completing and determining the sufficiency of investigations, but the investigations were found to be incomplete and inadequate during the state investigation.
Resident Falls During Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide an environment free from accident hazards and adequate supervision, resulting in a resident falling during a mechanical lift transfer. Resident #3, who has a primary diagnosis of cerebral infarction and severe cognitive deficit, fell to the ground during a transfer due to improper placement of the Hoyer sling by a CNA. The incident was witnessed by another CNA who confirmed the sling was incorrectly placed, causing the resident to fall when the lift was raised. The resident was subsequently taken to the hospital to rule out a head injury, but no injuries were found. Interviews with staff revealed that the ADON was informed of the incident and recommended the termination of the CNA responsible, who did not return to work following the incident. The ADM was unaware of the specifics of the investigation and relied on the nursing administration to handle the follow-up. The facility did not provide a specific policy on accidents and hazards when requested by the investigation team.
Failure to Maintain Fire Watch During Fire Alert System Outage
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public by not completing a fire watch from 10:00 PM on 05/30/2023 through 8:00 AM on 05/31/2023 while the fire alert system was offline. This lapse in protocol could place residents at risk of encountering fire. The fire watch was initially started on 05/29/2023 at 9:00 AM and was documented in 15-minute increments until 05/31/2023 at 1:30 PM, except for the period when the fire alert system was offline. The ADM was aware of the fire panel issue and was notified by the fire prevention vendor that a fire watch might be required until the problem was corrected. However, the ADM did not have further details and deferred to the MS for more information. The MS confirmed that he began the fire watch after being notified of the fire prevention outage on 05/29/2023 and instructed the staff to continue the fire watch forms until the system was repaired. The MS did not evaluate whether the fire watch was being continued and noted that the staff responsible for the overnight shift on 05/30/2023 through 05/31/2023 was no longer employed and could not be interviewed. The MS also mentioned that he was not interviewed by the ADM or anyone else regarding this incident. The facility's policy related to fire prevention and fire watches was requested but was not provided to the investigation team before their exit.
Failure to Post Current Nurse Staffing Data
Penalty
Summary
The facility failed to post the current nurse staffing data, as required, which was observed on 02/06/2024. The posted nurse staffing information was outdated, showing data from 01/29/2024. During an interview, the Administrator (ADM) stated that general postings were his responsibility, but the nurse staffing data was managed by the nursing department. The Assistant Director of Nursing (ADON) admitted that updating the nurse staffing data was her responsibility in the absence of the Director of Nursing (DON) and acknowledged that she had neglected to update it. The ADON also mentioned that residents and visitors could access the staff schedules at the nurses' station upon request. The facility's policy on nurse staffing data postings was requested but not provided to the investigation team before their exit.
Lack of Active Governing Body and Administrator Involvement
Penalty
Summary
The facility failed to ensure that it has an active and involved governing body responsible for establishing and implementing policies regarding the management of the facility. The administrator (ADM) appointed by the governing body was not actively engaged in the management of the facility, particularly in the investigation and in-servicing of staff following incidents. The ADM admitted to being unfamiliar with state licensure and compliance requirements and deferred decision-making to department heads, particularly in cases involving resident falls, choking incidents, or unwitnessed injuries. This lack of involvement and familiarity with the facility's operations was corroborated by interviews with direct care and administrative staff, who noted that the ADM was not interactive or hands-on in daily operations and relied heavily on department heads for recommendations and decisions. The ADM's personnel file indicated that he was hired in August 2022 and had a valid LNFA license. However, the facility's policy on the administrator's job description, which dates back to 2014, states that the administrator is accountable for the total operation of the nursing home in compliance with standards and regulations. Despite this, the ADM was not familiar with individual staff members, the medical director's expectations, or the specifics of self-reported incidents, leading to a deficiency in the facility's management and potentially affecting the health and safety of all residents.
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 36 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
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 Eagle Pass
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Hacienda De Paz Rehabilitation And Care Center | 1.2 mi | ★★★★★ | 14 | 0 |
| Maverick Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 22 | 0 |
| Whispering Springs Rehabilitation And Healthcare C | 39.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Eagle Pass Nursing And Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.