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 Five Points Of Pflugerville during CMS and state inspections, most recent first.
A cognitively impaired male resident with schizophrenia, major depressive disorder, and generalized anxiety disorder became upset during care when a CNA controlled his bed remote and did not comply with his request. During in-room care with two other CNAs present, the resident used profanity toward the CNA, and the CNA responded by yelling back and using profane, derogatory language, including statements about cleaning the resident and asserting her own rights. Other CNAs reported hearing the CNA curse at the resident, and the LVN on duty was informed of an altercation and spoke with the resident about what occurred. In a later interview, the CNA admitted repeating the resident’s profane remarks back to him. The facility’s abuse policy defined verbal abuse as willful use of disparaging or derogatory language toward a resident, and the CNA had previously been trained on abuse/neglect and resident rights.
Staff were observed serving food trays to residents without performing hand hygiene between each resident. Two newly hired CNAs admitted to forgetting to use hand hygiene despite having received training. Other staff, including an LVN and the DON, confirmed that hand hygiene is required by facility policy when serving meals.
The facility did not ensure accurate documentation of overnight care for four residents, including one on hospice who was found deceased, with no records of care or monitoring from 10:00 p.m. to 6:00 a.m. Staff interviews revealed inconsistent understanding of documentation expectations, and review of records showed missing entries for required ADL assistance and monitoring, despite care plans mandating frequent checks and interventions.
A resident with multiple medical and cognitive conditions was issued a discharge notice for non-payment, but the facility did not provide a discharge summary, plan, or adequate notification to the resident, responsible party, or ombudsman. The discharge notice lacked a specific destination, and staff interviews revealed no finalized discharge plan or proper communication, contrary to facility policy.
The facility failed to update the care plans for three residents to reflect changes in their activity levels, placing them at risk of not having their needs reviewed and revised appropriately. The Activity Director acknowledged that the care plans should have been revised to reflect the residents' current activity needs, as the lack of updates could affect their quality of life and mood.
The facility failed to provide adequate personal hygiene and grooming for three residents, leading to deficiencies in nail care and facial hair management. A resident with severe cognitive impairment was found with unclean and uneven fingernails, while another resident with Alzheimer's disease had unclean and rough nails. Additionally, a female resident with multiple health conditions was observed with facial hair, indicating a lack of adherence to grooming care plans. Staff interviews revealed inconsistencies in care documentation and awareness of care schedules.
The facility failed to ensure the Dietary Manager (DM) wore a beard guard properly while in the kitchen, as observed over three days. The DM was seen with facial hair visible during food preparation and service, contrary to the facility's dress code policy. Interviews confirmed that hair restraints are required to prevent contamination, and the DM is responsible for enforcing this policy.
A facility failed to maintain an effective infection control program as Student Nurse A and Student Nurse Aide G did not perform hand hygiene between resident interactions during meal service. They touched contaminated surfaces before handling food for multiple residents, despite being trained on infection control. Staff interviews confirmed the expectation for hand hygiene to prevent cross-contamination, which was not adhered to, posing a risk of bacterial contamination.
The facility failed to serve meals to residents in a timely and organized manner, affecting their dignity and quality of life. Three residents were served at different times, contrary to the facility's policy of serving all residents at a table before moving to the next. The DON and ADM acknowledged the lack of communication between nursing and dietary staff, which led to this issue.
A facility failed to implement a comprehensive care plan for a resident with multiple diagnoses, including toxic encephalopathy and parkinsonism, who was at risk for falls. The care plan required a fall mat beside the bed and the bed in the lowest position, but observations showed the mat was not consistently in place, and the bed was not always lowered. Staff interviews confirmed the expectation for fall mats to be in place, but the facility did not adhere to this requirement.
The facility failed to provide individualized activities for three residents with cognitive and physical impairments, leading to a deficiency in meeting their well-being needs. Despite care plans requiring one-on-one activities, these residents received minimal engagement, with staff acknowledging the difficulty in providing consistent activities due to facility constraints.
A resident with multiple health conditions did not have his meal preferences obtained or RD recommendations for snacks and supplements implemented, leading to dissatisfaction with meals and potential health risks. The facility failed to follow its policy on meal service and snacks, and the discontinuation of nutritional supplements was done without proper consultation.
The facility failed to properly store Probiotics in the medication refrigerator on the secure unit, where they were kept with staff food and drinks. Staff interviews revealed that all staff had access to the refrigerator, and there was no temperature log maintained. The Director of Nurses acknowledged that medications should not be stored with food and drinks and that the Probiotics should have been in the medication room.
A resident with severe cognitive impairment did not receive meals according to his preference for large portions, as documented in his care plan and physician orders. Despite expectations for dietary staff and nurses to ensure meal tickets matched the meals served, the resident received a normal portion size, contrary to his documented preferences.
A resident with dementia and a history of falls was moved by a CNA without a nurse's assessment after an unwitnessed fall, contrary to facility policy. The CNA panicked and moved the resident to a wheelchair, risking potential harm. The resident was later assessed by an LVN and found uninjured.
A resident with osteoporosis was not transferred according to her care plan, resulting in her sliding to the ground and sustaining femur fractures. Staff failed to use a hoyer lift as required, and the incident was not documented or assessed as a fall. The resident later died from complications following surgery. The facility's policies on transfer protocols and documentation were not adhered to, leading to this deficiency.
A resident in an LTC facility was not transferred according to her care plan, which required a hoyer lift with two-person assistance. Instead, staff attempted to transfer her without the lift, resulting in her sliding to the ground. The incident was not immediately reported or documented, and the resident later developed bilateral femur fractures, leading to her death after surgery. Staff interviews revealed a lack of awareness of the resident's transfer status and failure to adhere to facility policies.
The facility failed to document and report changes in skin condition for two residents, both with severe cognitive impairment. One resident had a dark purple blister on his finger, and another had a bruise and skin tear, none of which were documented in their charts. Staff interviews revealed a lack of awareness and documentation, contrary to facility policies requiring skin assessments and notifications.
A resident on Eliquis was unable to undergo a scheduled tooth extraction because the facility failed to hold the medication as recommended. Despite the resident's request for dental services due to pain, the procedure was canceled, causing ongoing discomfort and frustration. Interviews revealed a breakdown in communication and procedure adherence, as the recommendation to hold the blood thinner was not properly entered into the system.
The facility failed to provide adequate supervision to prevent falls for two residents, resulting in one resident sustaining a hip fracture. Despite having care plans with specific fall prevention interventions, the facility did not consistently implement these measures, and fall risk assessments were not completed as required.
The facility failed to meet PASARR requirements for a resident who needed a customized manual wheelchair (CMWC). The wheelchair was approved on 2/15/24, but the facility did not order it until 2/26/24, missing the 2/22/24 deadline. This delay caused a postponement in the resident receiving her Medicaid Entitled Service, impacting her ability to participate in necessary therapies and mobility activities.
Verbal Abuse of Cognitively Impaired Resident by CNA During Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA during personal care. The resident was an adult male with schizophrenia, major depressive disorder, and generalized anxiety disorder, and had a BIMS score of 06 on a recent MDS, indicating severely impaired cognition. His care plan noted a potential for verbally abusive behaviors, with an intervention to notify the charge nurse of any abusive behaviors. On the day of the incident, the resident became upset when a CNA did not change the television channel as requested, and later during care an altercation occurred between the resident and the CNA. According to written statements from two CNAs, three CNAs, including the alleged perpetrator, were in the resident’s room to change him. One CNA reported that after they finished changing the resident, the involved CNA began cursing at the resident, telling him, "fuck me, no fuck yourself, you stupid ass. I have rights just like you," and appeared very upset. Another CNA stated that the resident had asked for the bed remote control, that it dropped on him, and that he yelled "Fuck you!" at the CNA. This CNA reported that the involved CNA yelled back at the resident, saying, "We are here cleaning your ass! Don't tell us Fuck you!," and that both the resident and the CNA were yelling at each other. The LVN on duty documented that a CNA reported the altercation to him and that he then spoke with the resident, who described what had happened. In a subsequent phone interview, the involved CNA acknowledged that she was assisting two other CNAs, that the bed remote dropped on the resident, and that the resident called her an "ugly fucking face." She stated that she told the resident he was not to speak to her that way and repeated his words back to him, and that the other CNAs only heard her repeating those words. The administrator later confirmed that an investigation determined the CNA had been verbally abusive to the resident, and that the CNA had previously received training on abuse/neglect and resident rights. The facility’s Abuse/Neglect Policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff on the 500 Hall were observed distributing and serving food trays to residents without performing hand hygiene between residents. Specifically, two CNAs were seen passing food trays, touching residents' doors, setting up trays, and moving the food cart without cleaning their hands between each resident. Both CNAs were new to the facility and reported having received hand hygiene training during orientation, but admitted to forgetting to perform hand hygiene during meal service. Interviews with additional staff, including an LVN, another CNA, and the DON, confirmed that facility policy requires hand hygiene before and after assisting residents with meals. The LVN and DON both acknowledged that failure to perform hand hygiene when serving food constitutes an infection control issue. Review of the facility's hand hygiene policy also indicated that hand hygiene is required before and after assisting a resident with meals.
Failure to Document Overnight Care for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation of care provided to four residents during the overnight shift from 10:00 p.m. to 6:00 a.m. on the dates reviewed. For one resident who was on hospice care and found deceased around 6:00 a.m., there was no documentation of care provided during the night, nor any record of a change in condition that would have required intervention. The resident's care plan required two CNAs for bed mobility and mechanical lift transfers, and staff were expected to provide incontinent care and repositioning at least every two hours. However, the resident's progress notes, medication administration records, and point-of-care documentation lacked entries for the entire overnight period, except for a single set of vital signs recorded at 1:27 a.m. The postmortem assessment indicated the resident was found unresponsive, cold to the touch, and with fixed and dilated pupils, with no evidence of care or monitoring during the preceding shift. Similarly, three other residents, all with significant cognitive and physical impairments and dependent on staff for all activities of daily living, had no documentation of care provided during the same overnight shift. Their care plans also required frequent assistance, including turning, repositioning, and incontinent care at least every two hours. Review of their point-of-care records revealed no entries for any care activities during the specified time frame. Staff interviews confirmed that CNAs and nurses were responsible for providing and documenting care at least every two hours, and that documentation was expected to be completed in the electronic health record after each task. Interviews with staff, including CNAs, nurses, the ADON, and the medical director, revealed inconsistent understanding of the facility's expectations for resident checks and documentation frequency. While some staff stated that care should be provided and documented every two hours, others were unclear about the specific requirements. The facility lacked a formal policy on rounding or checking on residents, and the documentation policy emphasized the need for timely, accurate, and complete entries in the clinical record. Despite these expectations, the absence of documentation for multiple residents during the overnight shift indicated a failure to maintain accurate medical records in accordance with professional standards.
Failure to Provide Proper Discharge Documentation and Planning
Penalty
Summary
The facility failed to properly discharge a resident by not providing all necessary information and documentation required for a safe and effective transition of care. The resident, who had significant medical and cognitive impairments including vascular dementia, major depressive disorder, type 2 diabetes with neuropathy, and bilateral below-knee amputations, was not his own responsible party. The facility issued a discharge notice for non-payment but did not document a discharge summary, discharge plan, or provide adequate notification to the resident, responsible party, or ombudsman. The discharge notice also lacked a specific address for the resident's discharge destination. Record review showed no evidence of discharge planning discussions or documentation in the nursing progress notes. Interviews with facility staff revealed that the discharge process was still ongoing, with no finalized plan or summary in place. The ombudsman and responsible party were not properly informed, and there was confusion among staff regarding the resident's discharge status and destination. The resident expressed concerns about not receiving sufficient help with his Medicaid application and uncertainty about his ability to return home, while the responsible party indicated the resident's previous home was uninhabitable and that family support was unavailable. Facility policy requires documentation of the basis for discharge and a plan to ensure a safe transition, but these steps were not followed. The lack of a documented discharge summary, plan, and proper notification could compromise the resident's continuity of care and transition to an appropriate setting, as the facility had not determined a safe discharge location or communicated effectively with all involved parties.
Failure to Update Care Plans for Residents' Activity Needs
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for three residents were reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for three out of eight residents reviewed for care plans. The care plans for these residents were not updated to reflect changes in their activity levels, which placed them at risk of not having their needs reviewed and revised as necessary to ensure appropriate care. Resident #47, a female with cerebral palsy, severe intellectual disabilities, and autism, had a care plan that did not reflect her need for one-on-one activities. Despite her activity preference for watching cartoons and listening to music, her care plan was not updated to indicate her need for individualized activities. The Activity Director acknowledged that the care plan should have been revised to reflect these needs, as the lack of updates could affect the resident's quality of life, potentially leading to feelings of isolation or depression. Similarly, Resident #59, who had diagnoses including Alzheimer's disease and chronic pain, was not provided with an updated care plan to reflect her need for one-on-one activities. Although her activity participation record indicated she required one-on-one interaction five days a week, this was not documented in her care plan. The Activity Director admitted that the care plan should have been revised to match the resident's current activity needs. Resident #70, with vascular dementia and visual impairments, also had a care plan that was not updated to reflect her preference for one-on-one visits in her room. The Activity Director confirmed that the care plan should have been revised to document this preference, as the lack of documentation could lead to the resident being encouraged to participate in activities she did not prefer, potentially affecting her mood and behavior.
Deficiencies in Personal Hygiene and Grooming for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, leading to deficiencies in personal hygiene and grooming. Resident #20, a male with severe cognitive impairment and multiple health conditions, was observed with unclean and uneven fingernails, despite requiring assistance with personal hygiene. The care plan for Resident #20 included regular nail care, but observations revealed a lack of adherence to this plan, as the resident's nails were not properly maintained. Similarly, Resident #77, a female with Alzheimer's disease and severe cognitive impairment, was found with unclean and rough fingernails. Despite the care plan specifying the need for assistance with personal hygiene, including nail care, the resident's nails were not adequately maintained. Interviews with staff indicated a lack of awareness regarding the last time the resident's nails were trimmed or cleaned, and there was no documentation of refusal of care by the resident. Resident #56, a female with severe cognitive impairment and multiple health conditions, was observed with facial hair, indicating a failure to provide adequate grooming. The care plan required regular shaving during scheduled showers, but the resident was observed with facial hair over several days. Interviews with staff revealed inconsistencies in documenting care refusals and a lack of adherence to the care plan. The Director of Nursing acknowledged the expectation for female residents to be shaved unless otherwise documented, but there was no explanation for the lack of documentation regarding the resident's refusal of care.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the use of hair restraints in the kitchen. Observations over three consecutive days revealed that the Dietary Manager (DM) did not properly wear a beard guard, leaving facial hair visible while serving and preparing food. This was noted during lunch meal service and food preparation activities, where the DM was seen with the beard guard down under the chin, contrary to the facility's dress code policy. Interviews with the DM, Director of Nursing (DON), and Administrator (ADM) confirmed that hair restraints, including beard guards, are required for all kitchen staff to prevent hair from contaminating food. The DM acknowledged the requirement but could not explain why he failed to comply. Both the DON and ADM emphasized that the DM is responsible for ensuring compliance with hair restraint policies in the kitchen. The facility's dress code policy mandates that dietary staff with facial hair must wear beard nets while in the dietary department.
Inadequate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of Student Nurse A and Student Nurse Aide G. During a lunch tray pass, Student Nurse A was observed delivering meal trays to multiple residents without performing hand hygiene between each interaction. She touched contaminated surfaces such as her shirt, wheelchair armrests, and the clothes of other residents before handling the food of Residents #33, #44, #7, and #36. Despite being in-serviced on hand hygiene and infection control, she admitted to possibly forgetting to sanitize her hands during the process. Similarly, Student Nurse Aide G was observed delivering meal trays in the dining room without washing or sanitizing his hands after touching potentially contaminated surfaces, including his scrub top and the armrests of wheelchairs. He handled the food of Residents #17 and #51 without performing hand hygiene, acknowledging the potential for cross-contamination. Despite receiving training on infection control and hand hygiene, he failed to adhere to the facility's policies during the meal service. Interviews with facility staff, including LVN B, the DON, and the ADM, confirmed that the expectation was for all staff to perform hand hygiene between each resident interaction to prevent cross-contamination and potential illness. The facility's policies on hand hygiene and infection control were not followed, leading to a risk of bacterial contamination and potential gastrointestinal illness among residents.
Failure to Ensure Timely Meal Service for Residents
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal service, affecting three residents. Resident #15, a male with severe cognitive impairment and multiple health issues, was served his meal at 12:00 PM, but no other residents in the dining room were served until 12:50 PM. Resident #50, a female with intact cognition and various health conditions, was served at 12:23 PM and was sitting alone. Resident #52, a female with severe cognitive impairment and several health diagnoses, was served at 12:37 PM while sitting with three other residents. The facility's dining room etiquette policy requires that all residents at a table be served before moving to another table, which was not followed. The Director of Nursing (DON) acknowledged that it is best practice for all residents to be served meals simultaneously, but this did not occur due to a lack of communication between nursing and dietary staff. The Administrator (ADM) also stated that it was expected for each table to be completely served before moving to the next, and that communication between nursing staff and the Dietary Manager (DM) was necessary to ensure this. The failure to serve meals in a timely and organized manner could place residents at risk of diminished dignity and affect their quality of life. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, and promoting an environment that enhances their quality of life. However, the observed meal service did not align with these standards, as residents were served at different times, leading to potential feelings of neglect or isolation.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's needs. The resident, a male with multiple diagnoses including toxic encephalopathy, malignant neoplasm of the temporal lobe, major depressive disorder, parkinsonism, hypertension, GERD, and cerebral edema, was at risk for falls due to an unsteady gait and combative behavior. The care plan specified that the bed should be in the lowest position with a fall mat in place beside the bed. However, observations revealed that the fall mat was not consistently placed beside the bed as required, and the bed was not always in the lowest position. Interviews with staff, including a CNA and the DON, confirmed that the fall mat was supposed to remain on the floor beside the resident's bed when the resident was in bed. The DON acknowledged that the fall mat was not consistently in place and could not explain why it was moved. The ADM also stated that the expectation was for fall mats to be in place to prevent significant injuries from falls. The facility's policy required the development and implementation of a comprehensive care plan to meet the resident's needs, but this was not adhered to, as evidenced by the improper placement of the fall mat and bed position.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs and preferences of three residents, leading to a deficiency in meeting their physical, mental, and psychosocial well-being. Resident #47, a female with cerebral palsy, severe intellectual disabilities, and autism, was supposed to receive one-on-one activities three times per week. However, during the months of January to March 2025, she only received such activities on two occasions. Observations showed that she was often left without stimulation in her room, and the Activity Director admitted to not knowing how to accommodate her communication needs. Resident #70, a female with vascular dementia and severe visual impairment, was also supposed to receive one-on-one activities three times per week. Despite her preferences for listening to music and being around animals, she only received one-on-one activities sporadically, with no visits recorded in March 2025. The Activity Director acknowledged the difficulty in providing consistent activities due to the facility's census and did not provide a reason for the lack of activities for Resident #70. Resident #59, a female with Alzheimer's disease and a language barrier, was to receive one-on-one activities five days a week. However, there was no documentation of her receiving any such activities during February and March 2025. The Activity Director noted that Resident #59's physical decline made it difficult for her to participate in group activities, and her family requested she not be isolated in her room. The lack of activities for these residents was confirmed by interviews with staff, who noted the residents' need for culturally and mentally appropriate activities.
Failure to Implement Resident's Dietary Preferences and RD Recommendations
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. Specifically, the facility did not obtain the resident's meal preferences, which is a critical component of personalized care. The resident, who has a history of alcohol dependence with alcohol-induced dementia, anemia, hypertension, hyperlipidemia, muscle wasting, and chronic kidney disease, expressed dissatisfaction with the food, stating it was cold and unpalatable. The resident also reported never having been consulted about meal preferences and not receiving snacks between meals, which he found necessary due to frequent hunger. The facility also failed to implement and monitor the registered dietitian's (RD) recommendations for snacks with protein and Med Pass 2.0, a nutritional supplement, which were ordered but later discontinued without proper communication or documentation. The Director of Nursing (DON) acknowledged that the orders were discontinued without consulting the RD or physician, despite the resident being under his ideal body weight (IBW). The resident had refused the Med Pass 7 out of 24 times it was administered, which led to the discontinuation of the orders without exploring alternative supplements. Interviews with the Dietary Manager (DM) and the Administrator (ADM) revealed a lack of clarity and responsibility in obtaining and updating the resident's dietary preferences and implementing RD recommendations. The DM admitted to not having a dietary profile for the resident and acknowledged the potential negative impact on the resident's intake and health. The ADM confirmed that it was the DM's responsibility to obtain meal preferences and that the failure to do so could lead to decreased intake and weight loss. The facility's policy on meal service and snacks was not followed, as the resident did not receive the recommended snacks or have his preferences recorded and honored.
Improper Storage of Medications with Staff Food
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, specifically Probiotics, in the medication refrigerator located in the secure unit's dining room. The Probiotics were stored alongside staff food and open drink containers, which is against the facility's medication storage policy. Interviews with staff, including an LVN and a CNA, revealed that all staff had access to the refrigerator, and they were aware that medications should be locked but could not recall the date of their in-service training on this policy. Additionally, there was no temperature log for the refrigerator on the secure unit, and the LVN confirmed that temperatures were not documented. The Director of Nurses stated that the Probiotics should have been stored in the medication refrigerator in the medication room, not on the secure unit, and acknowledged that it was not best practice to store medications with staff food and drinks. The facility's medication storage policy was requested but not provided at the time of the survey exit.
Failure to Honor Resident's Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodates a resident's preferences, specifically for a resident who requested large portions as per his care plan and meal ticket. The resident, who had a severely impaired cognition with a BIMS score of 5, was on a regular diet with a preference for large portions and no pork. Despite these documented preferences, the resident received a normal portion size meal, which did not align with his care plan or physician orders. Interviews with the Dietary Manager, Director of Nurses, and RN A revealed that there was an expectation for the dietary staff and nurses to ensure that meal tickets matched the residents' meals. The Dietary Manager and Director of Nurses confirmed that the resident was expected to receive double portions, and the nurse was responsible for checking the meal ticket against the meal tray. However, this process was not followed, leading to the resident not receiving the correct meal portions as per his preferences and care plan.
Failure to Assess Resident Before Moving After Fall
Penalty
Summary
The facility failed to ensure that a resident received appropriate assessment and care following an unwitnessed fall. A resident, who had a history of dementia, repeated falls, and age-related physical debility, was found on the floor by a CNA. Despite knowing the protocol, the CNA panicked and moved the resident to a wheelchair without first having a nurse assess him. This action was contrary to the facility's policy, which requires a nurse to assess a resident for potential injuries before moving them after a fall. The resident's care plan indicated a high risk for falls, and the facility's policy emphasized the importance of nurse assessment to prevent further injury. The CNA admitted to the mistake, acknowledging the importance of a nurse's assessment in such situations. The incident was reported to the nurse practitioner, and the Director of Nursing confirmed that the resident was later assessed by an LVN and found to be uninjured. However, the initial failure to follow protocol could have placed the resident at risk of harm.
Failure to Follow Transfer Protocols Leads to Resident's Injury and Death
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. The resident, who was diagnosed with age-related osteoporosis, was supposed to be transferred using a hoyer lift with two-person assistance. However, on two occasions, the resident was not transferred according to her transfer status. On the first occasion, LVN A and CNA B attempted to transfer the resident without the hoyer lift, resulting in the resident sliding to the ground. Subsequently, LVN A, CNA B, and CNA C transferred her from the ground to the bed without using the hoyer lift. Approximately 24 hours after the inappropriate transfer, the resident's legs were swollen, red, and warm to the touch. She was transferred to the emergency room, where she was diagnosed with two femur fractures. During surgery to repair the fractures, the resident suffered an embolism and passed away. The facility also failed to ensure that LVN A completed a fall assessment or documented the incident after the resident slid to the ground during the inappropriate transfer. Interviews with staff revealed that they were unaware of the resident's transfer status and did not consider the incident a fall at the time. The facility's policies on hydraulic lift usage, fall prevention, and documentation were not followed, leading to the resident's injury and subsequent death. The noncompliance was identified as past non-compliance, and the immediate jeopardy situation began and ended on specific dates, with the facility correcting the noncompliance before the survey began.
Failure to Follow Transfer Protocols Leads to Resident's Injury and Death
Penalty
Summary
The facility failed to ensure a safe environment for a resident, who was supposed to be transferred using a hoyer lift with two-person assistance. On two occasions, the resident was not transferred according to her transfer status. During the first incident, a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) attempted to transfer the resident without the hoyer lift, resulting in the resident sliding to the ground. Subsequently, the resident was transferred back to her bed without the use of the hoyer lift, contrary to her care plan requirements. Approximately 24 hours after the inappropriate transfer, the resident exhibited symptoms of swelling, redness, and warmth in her legs. She was then transferred to the emergency room, where she was diagnosed with bilateral femur fractures. During surgery to repair the fractures, the resident suffered an embolism and passed away. The facility's failure to follow the resident's transfer protocol and the lack of immediate incident reporting and assessment contributed to the resident's injuries and subsequent death. Interviews with staff revealed a lack of awareness and adherence to the resident's transfer status. The LVN involved admitted to not realizing the resident required a hoyer lift and failed to report the incident immediately. The CNAs involved also did not verify the resident's transfer status before attempting the transfer. The facility's policies on hydraulic lift usage, fall prevention, and documentation were not followed, leading to the resident's fall and the subsequent failure to provide necessary medical assessment and documentation.
Failure to Document and Report Skin Changes
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not identify bruising and changes in skin condition for two residents, which could place them at risk of not receiving necessary medical care, harm, and hospitalization. Resident #1, an elderly man with severe cognitive impairment and thrombocytopenia, was observed with a dark purple blister on his right middle finger, which was not documented in his chart or skin assessments. Similarly, Resident #2, an elderly woman with severe cognitive impairment, was found with a bruise on her left wrist and a skin tear on her left arm, which were not documented in her chart or skin assessments. Interviews with staff revealed a lack of awareness and documentation regarding the residents' skin conditions. LVN D, who was responsible for Resident #1, was unaware of the blister and found no documentation in the resident's chart. Similarly, LVN D was also unaware of the bruise and bandage on Resident #2 and found no documentation regarding these issues. CNAs A, B, and C stated that they would report any changes in a resident's skin to a nurse immediately, but there was no evidence that this was done for the two residents in question. RN G and LVN E stated that they would document any changes in skin condition and notify the necessary parties, but this was not reflected in the residents' records. The facility's policies and procedures for documenting and reporting changes in residents' skin conditions were not followed. The Director of Nursing (DON) and the Administrator (ADM) stated that it was their expectation for staff to complete a skin assessment, notify the physician, and document any changes in the residents' clinical records. However, there was no evidence that these steps were taken for the two residents. The facility's failure to document and report changes in skin condition could lead to a lack of appropriate medical care and intervention for the affected residents.
Failure to Hold Blood Thinner Leads to Cancelled Dental Procedure
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care in accordance with professional standards of practice and the resident's care plan. The resident, who was on Eliquis, a blood thinner, was scheduled for a tooth extraction. However, the facility did not hold the medication as required, leading to the cancellation of the procedure. This oversight resulted in the resident experiencing ongoing pain and frustration due to the inability to proceed with the necessary dental work. The resident, who was cognitively intact and had a history of spastic quadriplegic cerebral palsy, epilepsy, bipolar disorder, and major depressive disorder, had requested dental services due to tooth pain. Despite being placed on antibiotics for a chronic abscess, the extraction could not be performed because the facility did not follow the recommendation to hold the blood thinner. The resident expressed significant discomfort and dissatisfaction with the facility's handling of the situation, feeling neglected and in pain. Interviews with facility staff revealed a breakdown in communication and procedure. The nurse practitioner had advised that the blood thinner should be held, but this was not communicated effectively or entered into the system as an order. The Director of Nursing acknowledged the lapse, noting that the recommendation to hold the medication was not converted into an actionable order. This failure in communication and procedure adherence led to the resident's continued pain and frustration.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents reviewed for falls. Resident #1, an elderly female with severe cognitive impairment and multiple risk factors for falls, fell and sustained a hip fracture requiring surgical intervention. Despite having a care plan with specific fall prevention interventions, the facility did not consistently implement these measures, as evidenced by the lack of completed fall risk assessments between incidents and the failure to ensure all interventions were in place at the time of the fall. Resident #1's care plan included various interventions such as keeping the bed in the lowest position, using a fall mat, ensuring the call light was within reach, and encouraging the use of non-skid footwear. However, on the day of the fall, the resident attempted to transfer herself from her wheelchair to her bed without assistance, resulting in a fall that caused a femoral fracture. The CNA who discovered the fall had previously assisted the resident to the toilet and reminded her to use the call button, but the resident did not call for help before attempting the transfer. Resident #2, who had a history of hemiplegia and muscle wasting, also had a care plan with fall prevention measures. However, the facility failed to complete the required fall risk assessments for this resident as well. The DON acknowledged that the new EMR system did not trigger quarterly fall risk assessments, leading to a gap in monitoring and updating care plans. This oversight contributed to the facility's failure to adequately supervise and prevent falls for both residents.
Failure to Timely Order Customized Manual Wheelchair
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASARR) federal requirements were met for a resident who required a customized manual wheelchair (CMWC). The resident, who has multiple diagnoses including Mild Cognitive Impairment, Intellectual Disability, and Peripheral Vascular Disease, was approved for a CMWC on 2/15/24. According to the Texas Administrative Code, the facility had five business days to order the wheelchair, with a deadline of 2/22/24. However, the wheelchair was not ordered until 2/26/24, after the facility received an email reminder from the PASRR team. This delay caused a postponement in the resident receiving her Medicaid Entitled Service. During an observation on 3/1/24, the resident was found lying in bed and mentioned that she was waiting for the wheelchair to get up. Interviews with the facility's administration revealed that they were aware of the delay and had taken steps to correct it on the same day they were notified by the state. The facility currently lacks a Minimum Data Set (MDS) nurse, and the Regional RN has been assisting with MDS needs. The delay in ordering the wheelchair placed the resident at risk of not achieving or maintaining her highest practicable level of physical functioning, as she was unable to participate in necessary therapies and mobility activities in a timely manner.
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.
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What surveyors actually found near you
We read the 350 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pflugerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pflugerville Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Trinity Care Center | 4.2 mi | ★★★★★ | 9 | 0 |
| Falcon Ridge Rehabilitation | 5 mi | ★★★★★ | 2 | 0 |
| San Gabriel Rehabilitation And Care Center | 5.1 mi | ★★★★★ | 5 | 2 |
| Avir At Park Bend | 5.4 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.