Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Falcon Ridge Rehabilitation during CMS and state inspections, most recent first.
A resident with cerebral palsy and hemiplegia was transferred from bed to a motorized wheelchair by a CNA using a mechanical lift without the required second staff member. After the transfer, the resident fell outside when a lift vest strap became entangled in the scooter wheel, resulting in a shoulder fracture and skin tears. Facility policy and the resident's care plan both required two-person assistance for such transfers, and the CNA had recently received training on this procedure.
A medication cart containing prescription drugs, OTC medications, and narcotics was found unlocked and unattended while the assigned RN was away responding to a resident emergency. Facility policy and staff interviews confirmed that medication carts must be locked when out of staff sight, but the cart was left unsecured, making medications accessible to unauthorized individuals.
A resident with chronic pain and diabetic neuropathy did not consistently receive scheduled Biofreeze Gel 4% for pain management within the required timeframes, with multiple late or missed doses. Staff did not follow the physician's order or facility policy for medication administration, and documentation of refusals and communication with the provider were inconsistent.
A facility failed to update a resident's care plan to include hospice services, despite the resident's admission to hospice care. The resident, with multiple health conditions, did not have hospice care reflected in their care plan, which is required by the facility's policy. Interviews with the ADON and DON confirmed the oversight, highlighting the importance of updating care plans to reflect changes in a resident's status.
The facility failed to store food according to professional standards, as observed when a loaf of bread was found on the floor in the dry storage area. Interviews with the Dietary Manager and Dietician confirmed the responsibility of kitchen staff to keep food off the floor to prevent contamination. The Administrator reiterated the facility's policy requiring food to be stored at least six inches off the floor to avoid pest issues.
A deficiency was identified when a trash dumpster was observed with its lid open, contrary to facility policy. Interviews revealed that kitchen staff were responsible for keeping the lid closed, but there was confusion about accountability. The open lid posed a risk of attracting pests, potentially endangering residents.
A resident with severe arm contractures was unable to access his call button, which was found hanging towards the floor and not functioning. The CNA responsible for repositioning the resident admitted to forgetting to place the call pad within reach. The LVN was unaware of the issue, and the facility's policy requiring call lights to be within reach was not followed.
A resident with spastic quadriplegic cerebral palsy did not receive weekly skin assessments as required by their care plan, leading to a rash being discovered late. The facility's TXN, DON, and ADM acknowledged the oversight, which was against the facility's policy for weekly skin evaluations by a licensed nurse.
The facility failed to provide scheduled showers to two residents who required assistance with activities of daily living. One resident received only six showers over nearly two months, while another received ten showers over a month and a half, despite being scheduled for three showers a week. Staff interviews revealed inconsistencies in documentation and communication, contributing to the deficiency in care.
The facility failed to provide an adequate activity program for two residents, leading to boredom and dissatisfaction. A cognitively intact resident found the activities, mainly TV-based, unengaging, while a bed-bound resident received no room visits or personalized activities. Scheduled activities were not conducted as planned, and residents were not informed of cancellations, violating facility policy.
A facility failed to develop a timely and accurate baseline care plan for a resident, with incorrect dates and missing critical care needs such as language preference, incontinence care, and mobility device use. The care plan was not updated following falls, and the facility lacked an MDS coordinator to ensure proper documentation.
A resident with severe cognitive impairment and a history of falls sustained a wrist fracture after falling in her room. The facility failed to follow the care plan, which required floor mats at the bedside, and the resident's wheelchair was found unlocked. Staff interviews confirmed the absence of the fall mat, despite its importance due to the resident's fall history.
Failure to Provide Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a male resident with cerebral palsy, hemiplegia, and borderline intellectual functioning from his bed to his motorized wheelchair using a mechanical lift without the required assistance of a second staff member. The resident's care plan and facility policy both specified that mechanical lift transfers must be performed by two staff members. Despite having received recent training and competency checks on this procedure, the CNA conducted the transfer alone. Following the transfer, the resident went outside in his motorized scooter. While moving along the sidewalk, he fell to the left side onto the pavement, sustaining a left shoulder fracture and skin tears to his right hand and face. The resident reported that a strap from his mechanical lift vest became tangled in the wheel of his scooter, causing the fall. The incident was witnessed and documented by facility staff, and emergency medical services were called to assist the resident, who was subsequently transported to the hospital and diagnosed with a left shoulder fracture. Interviews with the resident, responsible party, and facility leadership confirmed that the transfer was performed by only one staff member, contrary to policy and training. The resident expressed feeling unsafe during the transfer and was aware that two-person assistance was required. Facility records showed that the CNA involved had received recent in-service training and had signed off on the policy requiring two staff for mechanical lift transfers.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medication cart (MC #1) was observed unlocked and unattended on the 100-hall, containing residents' prescription drugs, over-the-counter medications, and narcotics secured in a locked box within the cart. The responsible RN was not present on the hall at the time, and the cart was accessible to other staff, residents, or visitors. The RN later stated she had been trained on medication storage policies, which require the cart to be locked any time it is out of the staff member's sight, and acknowledged she left the cart unlocked when responding to a resident emergency and forgot to secure it. Interviews with the ADON and ADM confirmed that facility policy mandates medication carts be locked when unattended, and that the person assigned to the cart is responsible for ensuring it is secured. Both managers stated that monitoring is conducted through observation, and reiterated the risk of unauthorized access if the cart is left unlocked. Review of the facility's Medication Labeling and Storage Policy further confirmed the requirement for all drugs and biologicals to be stored in locked compartments when not in use.
Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident received scheduled pain management treatment in accordance with professional standards of practice and the resident's care plan. The resident, who had a history of chronic pain related to bilateral lower extremity amputation, joint pain, muscle wasting, and diabetic neuropathy, was prescribed Biofreeze Gel 4% to be applied to his hands twice daily at 8:00 am and 8:00 pm. Review of the Medication Administration Record (MAR) showed that the medication was frequently administered outside the required one-hour window before or after the scheduled time, and on several occasions, it was not administered at all, including a full day when no doses were given. Interviews with the resident revealed that he often requested his pain medication from CNAs, but the requests were not always relayed to the nursing staff. The resident reported not receiving his Biofreeze as ordered and had to approach the nurses' station to ask for it. Observations confirmed that the resident was actively seeking his medication from staff. Nursing staff interviews indicated confusion regarding documentation of refusals and the timing of administration, with staff sometimes delaying administration based on the resident's preference but without a corresponding physician order to allow for such flexibility. Staff also failed to document refusals appropriately, and there was no evidence that the physician was consistently notified when the resident did not take the medication as scheduled. Facility policy required that scheduled medications be administered within one hour before or after the scheduled time, which was not consistently followed for this resident. The Director of Nursing and other staff acknowledged the deviations from policy and the lack of adherence to the physician's order for scheduled administration. The failure to provide the medication as ordered and within the required timeframe resulted in the resident not receiving consistent pain management as outlined in his care plan.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was receiving hospice services. The resident, an elderly female with multiple diagnoses including COPD, chronic congestive heart failure, anxiety, pneumonia, and type 2 diabetes, was admitted to the facility and began receiving hospice services from a specified agency. Despite the initiation of hospice services, the resident's care plan did not reflect this change in status, as it lacked any mention of hospice care. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that hospice services should have been included in the care plan to ensure proper care for the resident. The DON acknowledged that a change in a resident's status, such as the initiation of hospice care, necessitates an update to the care plan. The facility's policy and procedures also require the development and implementation of a comprehensive care plan when a resident's clinical status changes. The failure to update the care plan could result in residents not receiving appropriate care, as noted by the ADON.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its only kitchen, specifically in the dry storage area. During an observation, a loaf of bagged bread was found on the floor, which is against the facility's policy that requires food to be stored at least six inches off the floor. This oversight was confirmed through interviews with the Dietary Manager, who had been employed at the facility for one month, and the Dietician. Both acknowledged the responsibility of the kitchen staff to ensure food is kept off the floor to prevent cross-contamination and food-borne illnesses. The Administrator also confirmed the facility's policy and expectations regarding food storage, emphasizing the importance of keeping food off the floor to avoid pest control issues. The facility's Nutrition Policies and Procedures, revised in June 2023, clearly state that dry storage guidelines focus on maintaining a clean, dry area free of contaminants, with food stored at least six inches off the floor. The failure to comply with these guidelines poses a risk of attracting insects and rodents, potentially leading to food-borne illnesses among residents.
Improper Maintenance of Trash Dumpster
Penalty
Summary
The facility was found to have a deficiency related to the improper maintenance of an outside trash dumpster. During an observation, a large trash receptacle was seen in the back parking lot with its lid open, despite not being in use. This observation was made on March 18, 2025, at 9:00 AM. Interviews with the Dietary Manager, Dietician, and Administrator revealed that the kitchen staff were responsible for ensuring the dumpster lid remained closed when not in use. However, there was a lack of clarity among staff about who was specifically responsible for this task, leading to the lid being left open. The facility's policy, revised in June 2023, stated that trash cans should be kept covered and maintained in a clean, sanitary condition. The open dumpster lid posed a risk of attracting pests and rodents, which could potentially lead to disease transmission among residents. The Dietary Manager and Dietician both acknowledged the risk associated with leaving the dumpster lid open, but there was no clear accountability for ensuring compliance with the policy. This lack of adherence to the facility's policy resulted in the identified deficiency.
Resident's Call Button Inaccessible and Non-Functional
Penalty
Summary
The facility failed to ensure that a resident, who was completely dependent on staff for transfers and had severe contractures in both arms, could access his call button. On the day of the incident, the resident was found calling out for help because the call button was not within reach. The call button was a flat pad that was hanging towards the floor at the head of the bed, with the cord wrapped around the mobility bars several times. The resident stated he could not move his arms to reach the call pad, and it was also discovered that the call pad was not functioning as the light outside the resident's room did not activate when tested. Interviews with staff revealed that the call button was not placed within reach due to an oversight by a CNA who had repositioned the resident and forgot to return the call pad to an accessible position. The CNA admitted to wrapping the cord around the mobility rails to keep it out of the way and then leaving the room to attend to another resident, forgetting to reposition the call pad. The LVN in charge of the resident was unaware of the call button's inaccessibility and malfunction. The facility's policy required that call lights be placed within reach when staff left the room, which was not adhered to in this instance.
Failure to Conduct Weekly Skin Assessments for Resident
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. Specifically, the facility did not conduct weekly skin assessments for a resident as outlined in their care plan. The resident, a male with spastic quadriplegic cerebral palsy and other conditions, was admitted to the facility and had a care plan that included weekly skin assessments by a licensed nurse. However, from the time of admission until the time of the report, only one skin assessment was conducted, despite the care plan's requirement for weekly evaluations. The deficiency was identified when a rash was discovered on the resident's chest, which was not noted in the weekly skin assessments that were supposed to be conducted. The TXN, responsible for the skin breakdown prevention program, acknowledged that the assessments were not done and highlighted the importance of these assessments in identifying skin issues early. The DON and ADM also confirmed that the assessments should have been conducted weekly and expressed concern over the oversight. The facility's policy required thorough weekly skin evaluations by a licensed nurse, which were not adhered to, placing the resident at risk of untreated pressure ulcers.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that two residents, who were unable to perform activities of daily living (ADLs) independently, received the necessary services to maintain good hygiene. Resident #7, a male with diagnoses including unspecified dementia and lack of coordination, was scheduled to receive showers three times a week but only received six showers over a period of nearly two months. Observations revealed that he appeared disheveled and expressed dissatisfaction with not receiving his scheduled showers. Similarly, Resident #8, a female with similar diagnoses, was scheduled for three showers a week but only received ten showers over a month and a half. She also expressed a desire for more frequent showers, indicating that the facility did not adhere to the scheduled shower routine. Interviews with staff members, including CNAs and LVNs, revealed inconsistencies in the documentation and communication regarding the provision of showers. CNA A, who was responsible for giving showers, stated that she completed her assigned tasks but was unsure about the completion of showers by other CNAs. CNA B mentioned that she usually had time to complete her assigned showers and would inform the nurse if a shower was missed. However, LVNs C and D admitted to not checking whether showers were given, relying instead on CNAs to report any missed showers. This lack of oversight and communication contributed to the failure in providing the necessary care. The facility's policies on activities of daily living and admission agreements emphasized the importance of providing necessary care to residents who are unable to perform ADLs independently. Despite these policies, the facility did not ensure that the residents received the scheduled showers, leading to a decline in their hygiene and overall well-being. The administrator acknowledged the issue and identified discrepancies in the documentation system, which contributed to the deficiency in care.
Deficient Activity Program Fails to Meet Residents' Needs
Penalty
Summary
The facility failed to provide an activity program that met the interests and needs of two residents, leading to a deficiency in the quality of life and mental stimulation for these individuals. Resident #1, who was cognitively intact with a BIMS score of 14, expressed dissatisfaction with the activity program, noting that activities such as Bingo were infrequent and that most activities involved watching TV, which he found boring. Despite his complaints to the Activity Director (AD) and nursing staff, no actions were taken to address his concerns. Resident #1's care plan required 1:1 visits and outdoor-themed activities, but these were not implemented effectively. Resident #2, who was moderately cognitively impaired with a BIMS score of 10, also reported a lack of engaging activities, particularly as she was bed-bound following a fall. Her care plan did not include any notes related to activities, and she stated that the AD did not visit her room or attempt to engage her in activities. Like Resident #1, she expressed feelings of boredom and noted that the AD and nursing staff did not respond to her complaints. The facility's failure to notify residents of canceled or postponed activities further contributed to the residents' dissatisfaction and lack of engagement. The facility's activity calendar was not adhered to, with scheduled activities such as the Price is Right Show and Exercise and Music not taking place as planned. The AD admitted to not informing nursing staff to turn on the TV for the Price is Right Show and did not contact a volunteer to confirm their assistance with the Exercise and Music activity, leading to its cancellation. The AD also failed to notify all residents of the changes to the activity schedule, which was a requirement according to the facility's policy. This lack of communication and organization resulted in residents feeling bored and neglected, as evidenced by their feedback during interviews.
Failure to Develop Timely and Accurate Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required. The baseline care plan for the resident was dated incorrectly, with problem start dates and approach dates recorded as occurring before the resident's actual admission. This discrepancy indicates that the care plan was not timely or accurately assessed, which is a critical requirement for ensuring effective and person-centered care. The care plan for the resident did not address several important aspects of her care needs, including her preferred language, incontinent care, delirium, cognitive loss/dementia, activity preferences, and communication needs. Additionally, the care plan inaccurately reflected the resident's mobility device as a wheelchair instead of a walker, which was noted in the resident's functional abilities and goals. These omissions and inaccuracies in the care plan could potentially affect the quality of care provided to the resident. Furthermore, the facility did not update the resident's care plan following incidents of falls that occurred after her admission. The care plan lacked revisions to address these falls, and there was no evidence of a fall mat being placed next to the resident's bed as a preventive measure. The facility's administrator acknowledged that the care plan was not up to date and attributed this to staffing shortages, including the absence of an MDS coordinator responsible for ensuring accurate assessments and care plan documentation.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident's care plan, which required floor mats to be placed at the bedside, was followed. During an observation, no fall mat was found beside the resident's bed, despite the care plan specifying this intervention. Interviews with staff revealed that the resident had never had a floor mat in her room, indicating a lack of adherence to the care plan. The resident, who had a history of falls and severe cognitive impairment, sustained a fall in her room, resulting in a fractured left wrist. The incident occurred when the resident attempted to transfer from a wheelchair to the bed without the necessary supervision or safety measures in place. The wheelchair was found unlocked, and the absence of a floor mat, as required by the care plan, contributed to the fall. Interviews with nursing staff confirmed that the resident's fall interventions were not properly implemented. Staff members acknowledged the importance of the floor mat due to the resident's history of falls and injuries. The facility's fall management policy emphasized the need for individualized interventions, but these were not effectively executed in this case, leading to the resident's injury.
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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 Hutto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Gabriel Rehabilitation And Care Center | 4.5 mi | ★★★★★ | 5 | 2 |
| Five Points Of Pflugerville | 5 mi | ★★★★★ | 2 | 0 |
| Trinity Care Center | 5.3 mi | ★★★★★ | 9 | 0 |
| Pflugerville Nursing And Rehabilitation Center | 5.6 mi | ★★★★★ | 1 | 0 |
| Bel Air At Teravista | 6.7 mi | ★★★★★ | 4 | 0 |
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