Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Llano Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow its own policy and regulatory requirements to promptly notify physicians and resident representatives after significant events. One resident with dementia, psychotic disorder, and hemiplegia alleged staff abuse on two occasions, but the NP and responsible party were not notified, and there was no documentation of such contact. In a separate incident, two cognitively impaired, fully dependent residents receiving hospice or palliative care were within hearing distance of a verbal altercation between CNAs, yet their physicians and representatives were not notified despite staff and the DON acknowledging that protocol required such notification.
Food storage and sanitation practices were deficient in the kitchen. Surveyors found multiple frozen, refrigerated, and pantry items that were unlabeled, improperly dated, or expired, along with uncovered food left on a prep table and trash containers without lids. The DM and ADM stated food should be labeled with dates received and opened, expired items should be discarded, and trash cans should have lids, but the DM reported she had not received kitchen policy training and was unaware of the lid requirement for the dishwashing-area trash can.
Failure to complete comprehensive care plans and hold required care conferences. The facility did not document a comprehensive care plan for one resident after the comprehensive MDS, and several residents had no documented quarterly or annual care plan conference despite significant cognitive and functional impairment. Records showed residents with diagnoses such as dementia, stroke, cerebral palsy, dysphagia, depression, and severe assistance needs for ADLs, while the DON and SW stated care planning was a team process and should occur within the required timeframes.
Failure to honor resident meal preferences and provide posted meal alternates. Surveyors found no alternate menu posted during multiple meal observations, and several residents reported the same breakfast and limited sandwich choices were served repeatedly despite requests for different foods. Staff interviews showed inconsistent knowledge of alternate meal availability and how resident preferences were obtained, while the facility policy required an alternate meal with starch, protein, and vegetable based on the menu.
A resident with severe cognitive impairment and total-assist needs for dressing and grooming was observed in the dining room with her brief completely showing on one side. Another resident pointed out the exposure and covered it with a blanket. CNA and leadership interviews confirmed the resident had not been properly dressed before dining, and both the DON and ADM identified the situation as a dignity and privacy concern.
Failure to provide prescribed adaptive eating equipment: A resident with dementia, dysphagia, and severe protein-calorie malnutrition was care planned to use a cup with a built-in straw and a scoop plate at meals, but during a dining room observation she was given a regular cup with an unattached straw instead of her sippy cup. Staff interviews showed shared responsibility for tray checks, but the DON stated she had never ordered adaptive equipment and that the resident's care plan had not yet been reassessed or updated despite discussion that she no longer needed the device.
Survey Results Binder Not Readily Available: The facility failed to keep the survey results binder posted in a visible, accessible location for residents and families. Observations showed the binder was not displayed in the lobby or elsewhere in the building, and residents reported they did not know how to access it. When the ADM retrieved it from his office, it contained only one annual survey and did not include the required prior survey results and POCs; the BOM/AD also stated she did not know where the binder was or its contents.
Two residents with significant cognitive impairment did not have properly completed or documented advance directives, including missing signatures and unclear designation of medical decision-makers. Staff relied on incomplete records and inconsistent processes, resulting in invalid OOH-DNR orders and confusion about who was authorized to make medical decisions.
The facility failed to employ a qualified Dietary Manager, leaving the HR staff, who lacked necessary credentials, to manage the dietary department. This situation arose after the previous manager's termination, with no corporate dietary oversight since then. The DON confirmed the absence of a qualified manager, impacting the facility's ability to meet residents' nutritional needs.
The facility's kitchen failed to meet food safety standards, with issues such as improper hair restraint use, overflowing trash, a dirty ice machine, and a malfunctioning dishwasher. Temperature logs for food and equipment were not maintained, and staff did not follow proper hand hygiene protocols. These deficiencies were observed to potentially place residents at risk of foodborne illness.
Multiple residents with significant physical and cognitive impairments were found to have their call lights out of reach on repeated occasions, despite care plans and facility policy requiring accessibility. Staff interviews confirmed awareness of the requirement, but could not explain the ongoing failure to ensure call lights were accessible, resulting in unmet needs for these residents.
Surveyors found that indoor temperatures in the facility consistently exceeded policy limits, with readings up to 84°F in resident rooms and common areas. Staff and residents reported ongoing discomfort and inadequate responses to complaints about the heat, including delays in providing fans and lack of regular temperature monitoring. Facility policies required maintaining safe temperatures, but these were not followed, resulting in an environment that was uncomfortable and potentially unsafe for residents.
Surveyors identified that two residents received antihypertensive medications without required vital sign checks, as ordered by their physicians, resulting in a medication error rate above 5%. A medication aide administered Lisinopril and Losartan without verifying blood pressure or pulse, and there was no documentation of these vital signs in the electronic health record. Staff interviews confirmed the omission and acknowledged the necessity of following medication administration parameters.
Surveyors found that food storage containers and various food items in the kitchen were not properly sealed, labeled, or dated, with many items being expired or inadequately secured against contamination. Perishable foods in the refrigerator and freezer were also improperly stored, and the ice machine was observed to have mold. Staff interviews revealed a lack of awareness and adherence to the facility's food storage policies.
Staff failed to follow infection control protocols during Foley catheter care, wound care, and meal tray delivery for three residents, including not performing hand hygiene or changing gloves as required. These lapses occurred despite staff training and facility policies emphasizing the importance of infection prevention.
A resident's Ozempic medication was misappropriated, leading to a delay in administration. The resident, with multiple health conditions including Type 2 Diabetes, was prescribed Ozempic to manage their condition. Despite the resident's assurance of not missing doses, the medication went missing after being administered by a nurse. An investigation revealed a medication aide noticed the medication in a discontinued box but did not report it. The facility's administrator noted the use of agency staff might have contributed to the issue.
Two residents' assessments were not accurately updated, including one case where a discontinued indwelling catheter was still documented on the MDS. Despite physician orders and care plans reflecting the catheter's removal, the assessment remained incorrect due to a lack of timely updates and communication among staff. Facility policy requires RN oversight and certification of MDS accuracy, which was not followed.
A resident who was fully dependent on staff for eating, due to multiple medical and cognitive conditions, was repeatedly left waiting for extended periods after meal trays were delivered, without immediate feeding assistance. Staff and policy indicated that dependent residents should be fed as soon as their tray is delivered, but observations and interviews confirmed that the resident was left unattended with his meal tray, leading to delays in receiving necessary care.
A resident with an indwelling Foley catheter did not receive proper infection control during catheter care, as a CNA failed to change gloves or sanitize hands between cleaning the peri-area and the resident's bottom. This lapse was observed during care and acknowledged by the CNA, with staff interviews confirming the importance of infection control to prevent urinary tract infections.
A resident's room and bathroom were found to have multiple unresolved maintenance and cleanliness issues, including a hole in the wall, missing toilet tank lid, dust and dirt on the ceiling, and warped, moldy flooring with a strong urine odor. Despite the resident reporting these problems to administration and maintenance, no repairs were made, and facility records showed no formal grievances filed.
Failure to Notify Physician and Representatives After Allegations of Abuse and Staff Altercation
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with residents’ physicians and representatives when there were significant changes in residents’ physical, mental, or psychosocial status, including allegations of abuse and exposure to a staff altercation. For one resident (R#1), who had hemiplegia, thrombocytopenia, psychotic disorder with hallucinations, dementia, and socially inappropriate behaviors requiring antipsychotic medication, the facility did not notify her physician or responsible party following two separate incidents on 2/27/26 and 3/5/26 in which she alleged staff were abusive to her. Although an investigation was conducted for at least one of these incidents, there was no documentation that the nurse practitioner (NP) or the resident’s representative were notified, and the responsible party later reported he had not been informed of any such incidents. The deficiency also includes the facility’s failure to notify the physicians and representatives of two other residents (R#2 and R#3) after they were within hearing distance of a verbal altercation between CNAs on 2/20/26. R#2 had unspecified dementia without behavioral disturbance, psychotic disturbance with hallucinations, anxiety, a language disorder, and was on hospice care, fully dependent on staff for activities of daily living and receiving antidepressants and opioids. R#3 had essential hypertension, major depressive disorder, generalized anxiety disorder, dementia with severely impaired cognition (BIMS of 3), was on palliative care, fully dependent on staff for activities of daily living, and was receiving antidepressants and anticonvulsants. The DON stated that physical assessments were completed for both residents and no injuries were noted, but she could not confirm that their NPs or representatives were notified of the event. Interviews with staff confirmed that the facility’s protocol required nurses to assess residents involved in incidents and to notify the administrator (ADM), DON, NP, and residents’ representatives. LVN A and LVN B both described this protocol but were not on duty during the incidents and could not explain why notifications were not made. The DON acknowledged that for the 2/27/26 incident involving R#1, the NP and representative were not notified and that this step was missed. The ADM reported attempts to contact R#1’s son by phone but could not explain the lack of NP and representative notification and stated that documentation of such notifications was expected in the Provider Investigation Report, which did not contain this information. Review of the facility’s Accidents/Incidents policy and related in-service topics showed that every incident was to be documented and that family, DON, and provider were to be notified every time, which did not occur in these cases.
Food Storage, Labeling, and Sanitation Deficiencies
Penalty
Summary
The facility failed to properly store, label, date, and discard food items in the kitchen, including items in the walk-in refrigerator, freezer, and dry food pantry. During the initial kitchen tour, surveyors observed multiple frozen items without complete labels or discard dates, including freezer bags of Philly meat, meat pies, chicken enchiladas, chicken, pork chop, and breaded pork. In the walk-in refrigerator, surveyors observed unlabeled bottles of liquid, opened and unlabeled bread and buns, opened gallon containers of salad dressings, tartar sauce with an unclear date written on the outside, sliced cheese and turkey breast with only partial dating, tortillas with no labels, potato salad past the manufacturer’s use-by date, and opened breakfast links and bread without labels or dates. Surveyors also observed extensive food storage problems in the dry pantry area. Items included cereal containers without discard dates, macaroni, spaghetti noodles, egg noodles, powdered milk, powdered sugar, cornbread mix, sugar, muffin mix, corn meal with an expired use-by date, flour, scalloped potatoes with an expiration date of 4/16/2025, cornbread stuffing mix with an expiration date of 8/20/25, grits with an open date and use-by date that did not match, tomato juice with an expiration date of 5/29/25, and additional boxes of grits with expiration dates of 8/8/2025. The report also noted trash containers in the dishwashing area and next to the stove that were not properly covered with lids. On follow-up observation, surveyors again found food left uncovered on a food preparation table, including a container of smothered chicken from lunch and a pan of broccoli. The same labeling and storage problems remained in the freezer, refrigerator, and pantry, including unlabeled liquids, opened bread and buns, opened salad dressings, turkey breast stored on top of tortillas with juices dripping into the bowl, and potato salad past its use-by date. Interviews with the DM and ADM confirmed that food items were expected to be labeled with dates received and opened, that expired food should be discarded, and that trash cans should have lids, but the DM stated she had not received training on kitchen policies and was unaware the trash can in the dishwashing area required a lid.
Failure to Complete Comprehensive Care Plans and Hold Required Care Conferences
Penalty
Summary
The facility failed to develop a complete comprehensive care plan within 7 days of the comprehensive assessment and failed to prepare, review, and revise care plans through care plan conferences for multiple residents. The report identified that care plan conferences were not documented for Resident #22, Resident #5, Resident #2, Resident #6, and Resident #8, and that Resident #30 did not have a comprehensive care plan documented in the clinical record after the comprehensive MDS was completed. The facility’s policy stated that the comprehensive care plan was to be developed within 7 days after completion of the comprehensive MDS and prepared by an interdisciplinary team. Resident #30 was admitted with diagnoses including traumatic subarachnoid hemorrhage, anxiety disorder, insomnia, hypertension, morbid obesity, repeated falls, syncope, and collapse. The comprehensive MDS reflected severe cognitive impairment with a BIMS score of 6, and section GG showed the resident required assistance with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, and transfers. The record contained a baseline care plan and one care conference report dated 8/27/25, but no comprehensive care plan was documented in the clinical record. Resident #22 had diagnoses including type 2 diabetes, dysphagia, dementia, depression, osteoarthritis, muscle wasting and atrophy, hyperlipidemia, and hypertension, with a BIMS score of 13 and assistance needs for eating, oral hygiene, personal hygiene, dressing, bathing, toileting, and transfers. The care conference record showed conferences on 05/01/25, 11/20/24, and 08/01/24, but none between 11/20/24 and 05/01/25 and none between 05/01/25 and the survey date. Resident #5 had diagnoses including cerebral palsy, major depressive disorder, iron deficiency anemia, osteoarthritis, hypokalemia, dysphagia, weakness, unsteadiness on feet, cognitive communication deficit, muscle wasting and atrophy, hypertension, and insomnia, with a BIMS score of 10 and total assistance needs for personal hygiene, dressing, bathing, toileting, bed mobility, and transfers. The last recorded care conference for Resident #5 was 06/26/24, and the report reflected no care conference from that date through the annual MDS assessment. Resident #2, Resident #6, and Resident #8 also had significant cognitive and functional impairment documented in their MDS assessments, and their records showed either only one care conference or care conferences that were not documented as required by the facility’s process.
Failure to Honor Resident Meal Preferences and Provide Posted Meal Alternates
Penalty
Summary
The facility failed to accommodate resident food allergies, intolerances, and preferences for 4 of 7 residents reviewed for food and nutritional services. Surveyors found that breakfast meal alternates were not offered, a daily alternate for lunch and dinner was not posted, and resident food preferences were not being honored on meal cards. Observation of the menu posting on 09/02/25 at 9:45 AM, 11:00 AM, and 5:15 PM showed no alternate menu posted. During a confidential Resident Council meeting, multiple residents reported that their meal preferences were not being met. One resident stated the same breakfast was served every day, including scrambled eggs and link sausage, and that requests for different breakfast choices such as fried eggs, omelets, and fruit had not resulted in change. That resident also stated they were on a no-salt diet related to right-sided heart failure and that family brought food from outside daily because the resident felt the facility food did not meet dietary needs. Another resident stated the DM was disrespectful when asked for different food choices, and another stated only pimento cheese and bologna were offered for sandwiches. Residents also stated they had asked for meal of the month options but received it only once, and one resident stated pork, spaghetti, and fish continued to be served even though those were foods they did not like. In interviews, the DM stated alternate meal options were available and that residents could request them from the kitchen door or through nursing staff, but also acknowledged that she had only received one day of training from a sister facility and had since self-taught some processes. The DON stated she was unsure whether a printed alternate menu existed and said residents could ask staff what the alternate meal option was for the day. The ADM stated the daily meal and alternate were supposed to be posted outside the kitchen and that meal preferences were obtained on admission and at care plan meetings. Record review of the facility alternate meal policy stated the alternate should include a starch, protein, and vegetable based on the menu items served.
Resident Seated in Dining Room With Brief Exposed
Penalty
Summary
The facility failed to treat Resident #10 with respect and dignity when she was observed in the dining room with her brief completely showing on one side. Resident #10 was a [AGE]-year-old female admitted on 01/21/2025 with spastic quadriplegic cerebral palsy, muscle wasting and atrophy, cognitive communication deficit, major depressive disorder, generalized anxiety disorder, and moderate intellectual disabilities. Her MDS indicated a staff assessment for mental status showing severe impairment, and her care plan identified her as total assist for dressing and grooming. During an observation on 9/3/2025 at 5:26 PM, Resident #10 was seated in the dining area with her brief exposed, and another resident at the same table told her the brief was showing and pulled up her blanket to cover it. CNA A stated the resident had been wearing a dress that had not been pulled down over the brief and acknowledged the situation could be a rights issue and affect the resident negatively. The DON and ADM stated residents should be properly clothed before coming to dining and both identified a brief exposed in the dining room as a dignity and privacy concern. The facility's resident rights and dignity policies stated residents have the right to safe, decent, and clean conditions, to be treated with courtesy, consideration, and respect, and to privacy.
Failure to Provide Prescribed Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and appropriate assistance for Resident #4 during meals. Resident #4 was a [AGE]-year-old female admitted on 08/26/2023 with unspecified dementia, dysphagia, and severe protein-calorie malnutrition. Her MDS dated 07/03/2025 showed a BIMS of 01 and limited assistance with eating. Her comprehensive care plan dated 09/02/2025 and diet profile dated 07/22/2025 both indicated she was to use a cup with a built-in straw and a scoop plate at each meal because of her nutrition-related needs. During observation of the dining room on 09/03/2025 at 5:35 PM, Resident #4 was not provided her sippy cup for the dinner meal and instead received a regular cup with an unattached straw. The DON was observed assisting her with adding sugar to her tea in the regular cup. Interviews with the DOR, DM, DC, and DON showed that staff understood adaptive equipment was to be provided at meals and that nurses and dietary staff shared responsibility for checking trays, but the DON stated she had never ordered adaptive equipment at the facility and that a morning meeting had discussed Resident #4 no longer needing a sippy cup even though the care plan had not yet been reassessed or updated. Facility policy stated assistive devices are to be based on the resident's comprehensive assessment and that a nurse responsible for the resident will monitor consistent use and document refusals or problems.
Survey Results Binder Not Readily Available
Penalty
Summary
The facility failed to ensure that the results of the most recent surveys, certifications, and complaint or incident investigations, along with any plans of correction, were readily available for residents, legal representatives, and family members to review. Observations on September 2, September 3, and September 4, 2025, showed that the survey results book was not displayed in the entry foyer or any other location in the facility. During a confidential group interview, 7 residents stated they did not know where or how to access the survey results and said they would have liked access to the information. On September 4, 2025, the ADM stated the survey binder had been removed because of painting in the building and retrieved it from a cabinet in his office. The binder was labeled for the facility and 2024 Annual Survey Results, but it contained only the August 8, 2024 annual survey results and did not include the required prior survey results from 6/28/23, 1/17/25, and 4/9/25. The ADM stated the binder should be posted in a visible and accessible location and acknowledged that keeping it in a closed cabinet in his office was not a prominent or readily available location. The BOM/AD stated she did not know where the survey binder was located and had not received training regarding the binder or its contents.
Failure to Ensure Proper Completion and Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that residents' rights regarding advance directives and medical decision-making were properly honored and documented for two residents. For one resident, the out-of-hospital do-not-resuscitate (OOH-DNR) order was not properly completed, lacking a dated physician signature and the required two witness signatures or notarization. Additionally, this resident did not have a documented medical power of attorney (MPOA) form in the medical record, and the only available statutory durable power of attorney (SDPOA) form explicitly stated it did not authorize medical decision-making. The admission agreement also failed to specify a designated MPOA, and there was confusion among family members and staff regarding who was authorized to make medical decisions for the resident. For the second resident, the OOH-DNR order was also incomplete, missing the required second signatures from witnesses and a guardian/agent/proxy/relative. Both residents had significant cognitive impairments, as documented in their medical records and care plans, which further emphasized the importance of having clear and valid advance directive documentation. Staff interviews revealed inconsistent understanding and processes regarding the review and validation of advance directives, with some staff relying on face sheets or posted lists rather than verifying the validity of legal documents. Facility policy required adherence to residents' rights to formulate advance directives and mandated regular audits of code status documentation. However, the review of records and staff interviews indicated that these policies were not consistently followed, resulting in incomplete or invalid advance directive documentation. The lack of proper documentation and clarity regarding medical decision-makers could lead to confusion and the potential for residents' wishes to be disregarded.
Deficiency in Dietary Management Staffing
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to manage the food and nutrition service, as required by the facility assessment. This deficiency was identified during an interview and record review, which revealed that the facility did not have a qualified Dietary Manager. The previous Dietary Manager was terminated on December 24, 2024, and since then, the HR staff, who lacked the necessary food handling certificate and credentials, had been managing the dietary department. The HR staff confirmed that there had been no corporate dietary manager visiting the facility since the termination. The Director of Nursing (DON) also confirmed that the facility had been without a Dietary Manager since mid-December 2024, with the HR staff temporarily managing the dietary operations, including scheduling and training, until a new manager could be hired.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Key issues included improper use of hair restraints by HR staff, an overflowing trashcan without a liner next to the handwashing station, and a dirty ice machine with mold-like substances. Additionally, the ice scoop was stored improperly with cleaning equipment, and the dishwasher was not reaching the required temperature for sanitization. These conditions were observed to potentially place residents at risk of foodborne illness. Further observations revealed that the facility did not maintain proper temperature logs for food, the dishwasher, and refrigerators. The last recorded logs for the 3-compartment sink and refrigeration temperatures were dated several months prior, and there were no logs for hot beverage temperatures or holding temperatures for cold and hot food. This lack of documentation indicates a failure in monitoring and ensuring food safety standards. Interviews with staff highlighted a lack of leadership and training in the kitchen, with the HR staff managing the kitchen in the absence of a dietary manager. Staff admitted to not following proper hand hygiene protocols, such as changing gloves and washing hands after touching contaminated surfaces. The dishwasher's malfunction and the improper storage of cleaning equipment near food preparation areas were acknowledged by staff, who recognized the potential for cross-contamination and infection risks to residents.
Failure to Ensure Call Lights Were Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five residents who required assistance, as observed on multiple occasions. Direct observations revealed that the call lights for these residents were either hanging down to the floor, tucked under the mattress, or positioned several feet away from the residents, making them inaccessible. These observations were made on several dates, and in some cases, the call lights remained out of reach over multiple days. The residents affected had care plans specifically stating that call lights should be kept within reach and that staff should encourage their use. The residents involved had significant medical and cognitive needs, including diagnoses such as cerebral palsy, quadriplegia, dementia, Alzheimer's disease, psychotic and mood disturbances, muscle weakness, and communication deficits. Their care plans and Minimum Data Set (MDS) assessments indicated that they required extensive or total assistance with bed mobility, transfers, and toileting. Some residents were unable to make themselves understood or were dependent on staff for all activities of daily living, further emphasizing the importance of having call lights accessible. Interviews with staff, including CNAs, an RN, a medication aide, the DON, and the administrator, confirmed that they had been trained on resident rights and facility policy, which required call lights to be within reach at all times. Staff acknowledged the importance of this practice for resident safety and the ability to request assistance. Despite this, staff were unable to explain why the call lights were not consistently placed within reach, and the deficiency persisted across multiple days and residents.
Failure to Maintain Safe and Comfortable Temperatures for Residents
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels for residents, with indoor temperatures recorded by surveyors ranging from 82 to 84 degrees Fahrenheit in various areas, including resident rooms, hallways, and the medication room. Staff and residents reported ongoing issues with the air conditioning system, with temperatures regularly exceeding the facility's policy range of 71-81 degrees. Despite staff and resident complaints about the heat, there was no evidence of consistent temperature monitoring or documentation, and residents were not routinely offered water or assessed for heat exhaustion during periods of elevated temperatures. Multiple residents expressed discomfort due to the heat, with some stating they had to request fans or take measures themselves, such as obtaining ice from the hallway. Staff interviews revealed that the air conditioning issues had persisted for months, and complaints had been made to the DON and other management without resolution. Maintenance staff acknowledged the system's inability to keep up with outdoor temperatures and admitted to not keeping temperature logs or consistently monitoring room conditions. Facility policies reviewed by surveyors indicated that maintaining comfortable and safe temperatures was a responsibility of the maintenance department, and that a homelike environment should be provided. However, the lack of effective temperature control, failure to provide timely relief to residents, and absence of systematic monitoring contributed to an environment that was neither safe nor comfortable for residents, as directly observed and reported during the survey.
Failure to Adhere to Medication Administration Parameters Results in Elevated Error Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, resulting in a calculated error rate of 7.14% during the survey. This deficiency was identified through observation, interview, and record review, specifically involving two residents and one medication aide during medication administration. The errors occurred when the medication aide did not check vital signs as required by physician orders before administering antihypertensive medications. One resident, a male with diagnoses including hypertension, diabetes mellitus type 2, dementia, and a stage 4 pressure ulcer, had a physician order for Lisinopril with instructions to hold the medication if his systolic blood pressure was less than 110 or his heart rate was less than 60. The medication aide failed to check this resident's blood pressure and pulse prior to administration. Another resident, a female with hypertension, intellectual disabilities, diabetes, and acute kidney failure, had a physician order for Losartan with a parameter to hold the medication if her blood pressure was less than 140/90. The medication aide also failed to check this resident's blood pressure before administering the medication. Interviews with the medication aide, the interim DON, and other staff confirmed that vital signs were not checked as required and that there was no documentation of blood pressure readings for the relevant date in the electronic health record. Staff acknowledged the importance of following physician orders and the potential negative outcomes of not doing so. Facility policy and procedure for medication administration require medications to be given in accordance with prescriber orders, including any parameters such as vital signs.
Improper Food Storage, Labeling, and Sanitation in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, and dating of food items. Several dry food storage containers were found with lids that were not properly secured or labeled, and individually wrapped food items such as Glazed Honey Buns were not labeled or dated. Numerous bags and packages of food, including dehydrated beans, various gravy mixes, cake and bread mixes, breadcrumbs, chips, and pudding mix, were found to be expired, improperly sealed, or lacking appropriate labeling and dating. Some opened food items were only folded closed or secured with tape, which did not adequately prevent contamination. Additionally, the contents of some containers were not correctly identified, and some food items in the refrigerator and freezer were undated, unlabeled, or showed signs of freezer burn. Further observations revealed improper storage of perishable items in the refrigerator, such as sliced turkey sandwich meat and shredded cheese, which were kept in unsealed or undated Ziploc bags. The kitchen freezer contained bags of frozen vegetables and unidentified meat products that were undated and unlabeled, with some items showing ice crystals indicative of freezer burn. The ice machine in the kitchen was also found to be inadequately cleaned and sanitized, with mold observed growing under the lid. Interviews with staff indicated that the dietary manager was responsible for auditing the food supply for expired goods and ensuring proper storage practices, but was unaware of the expired items present in the kitchen. The dietary manager stated that weekly audits were conducted and that the FIFO (first-in, first-out) method was used, but could not explain the presence of expired items. The facility's own policy required all opened and bulk items to be stored in tightly covered, labeled, and dated containers, and for refrigerated foods to be tightly sealed, labeled, and dated, which was not consistently followed.
Failure to Maintain Infection Control During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for three residents during the provision of care. For one resident with an indwelling Foley catheter, a CNA performed peri-care and catheter care but did not change gloves or perform hand hygiene before cleansing the resident's bottom after handling the catheter, despite being trained on enhanced barrier precautions and Foley catheter care. The CNA acknowledged the lapse in infection control and recognized the risk of urinary tract infection as a negative outcome. Another resident with a stage 4 pressure ulcer on the left ankle received wound care from an RN who removed the old dressing, discarded dirty gloves, but did not perform proper hand hygiene before accessing clean supplies to continue the dressing change. The RN and other staff interviewed confirmed the importance of following infection control protocols, especially during wound and catheter care, to prevent the spread of infection. Additionally, a CNA was observed passing a lunch tray to a resident with a history of urinary retention and cognitive deficits without performing hand hygiene before or after the task. Multiple staff members, including CNAs, the RN, the medication aide, the interim DON, and the administrator, all stated in interviews that infection control protocols are essential and that all staff are responsible for adhering to them. The facility's policy and procedure for infection control emphasizes maintaining a safe and sanitary environment and preventing the spread of infection.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's Ozempic medication, which is crucial for managing their diabetes and weight loss. The resident, a 55-year-old male with multiple diagnoses including Type 2 Diabetes and morbid obesity, was prescribed Ozempic as part of his care plan to prevent complications related to diabetes and malnutrition. Despite the resident's statement that he had not missed any doses, the facility's records indicated that the medication went missing after being administered by a nurse. The medication was not found despite a thorough search, and the resident's primary care provider was notified to reorder the medication. The investigation revealed that a medication aide noticed the presence of what appeared to be the resident's medication in a discontinued medication box but failed to report it. The facility's administrator acknowledged the issue, noting that the use of agency nursing staff might have contributed to the misappropriation. The resident was assessed and found to have no ill effects from the delay in medication administration, and the medication was reordered and received shortly after the incident.
Inaccurate Resident Assessment Due to Failure to Update MDS
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of two residents reviewed for assessment accuracy. Specifically, one resident's Minimum Data Set (MDS) was coded as having an indwelling catheter, despite the catheter having been discontinued prior to the assessment. This discrepancy was identified through observation, interviews, and record review. For the resident in question, documentation showed a history of cerebral infarction, Alzheimer's disease, urinary retention, diabetes mellitus type 2, and a cognitive communication deficit. The resident's care plan and physician orders indicated that Foley catheter care was discontinued, yet the quarterly MDS still reflected the presence of an indwelling catheter. Direct observation confirmed that the resident did not have a catheter at the time of the survey. Interviews with facility staff, including the MDS nurse, DON, and administrator, revealed that the process for updating the MDS relied on communication from nursing staff and review of documentation such as 24-hour reports and physician orders. The MDS nurse acknowledged that the MDS had not been updated to reflect the discontinuation of the catheter, attributing the error to human oversight. Facility policy requires that a registered nurse coordinate and certify the accuracy of each MDS assessment, but this process was not followed in this instance.
Failure to Provide Timely Feeding Assistance to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who was totally dependent on staff for eating was not provided timely assistance with meals. The resident, who had multiple medical conditions including cerebral palsy, functional quadriplegia, severe malnutrition, dysphagia, and cognitive impairment, was observed on several occasions to have his meal tray placed in front of him without immediate feeding assistance. Staff were seen delivering the meal tray and then leaving the room to continue passing trays to other residents, returning only after a significant delay to assist with feeding. Interviews with the resident revealed that he frequently experienced long waits before being fed, sometimes resulting in his food becoming cold and causing him distress. Staff interviews confirmed that the practice was to pass all meal trays first, including to residents who could not feed themselves, and then return to assist those needing help. Staff acknowledged that this practice was not in line with best practice or facility policy, which required immediate assistance for residents who were dependent on staff for eating. Facility policy and staff statements indicated that residents requiring feeding assistance should receive help as soon as their tray is delivered to ensure food is at the correct temperature and to prevent negative emotional and physical outcomes. Despite this, observations and interviews confirmed that the resident was left with his meal tray in front of him and had to wait for staff to return and provide feeding assistance, resulting in a failure to meet his needs for activities of daily living.
Failure to Follow Infection Control Protocols During Foley Catheter Care
Penalty
Summary
A deficiency was identified when a resident with an indwelling Foley catheter did not receive appropriate infection control during catheter care. The resident, a female with a history of Alzheimer's disease, urinary retention, neurogenic bladder, chronic kidney disease, urinary tract infection, and chronic atrial fibrillation, was observed during catheter care. The care plan indicated the need for an indwelling urinary catheter due to neurogenic bladder, with orders for catheter care every shift and as needed. During observation, a CNA performed peri-care and catheter care but failed to change gloves or sanitize hands before cleansing the resident's bottom after cleaning the peri-area and catheter tubing. This lapse in infection control protocol was directly observed, and the CNA acknowledged the need to improve infection control practices. The lack of glove change or hand hygiene between cleaning different areas of the resident's body was not in accordance with infection prevention standards. Interviews with multiple staff members, including CNAs, an RN, a medication aide, the DON, and the administrator, confirmed the importance of following infection control protocols during catheter care to prevent infections. The facility's policy and procedure for indwelling catheter use and removal also emphasized adherence to professional standards and infection prevention procedures. The failure to follow these protocols during catheter care constituted the deficiency.
Failure to Maintain Safe and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for a resident, as evidenced by multiple unresolved maintenance and cleanliness issues in the resident's room and bathroom. Observations revealed a hole in the wall behind the bedroom door, missing toilet tank lid, dust and dirt accumulation on the ceiling near the vent, and warped, moldy bathroom flooring that was pulling away from the walls and emitting a strong urine odor. These deficiencies were present during multiple observations and were not addressed despite being reported to facility administration and maintenance by the resident. The resident reported that the room had been in disrepair since admission and that complaints had been made to the facility's administration and maintenance staff, but no repairs were completed. The resident also expressed concerns about room temperature and stated a preference for privacy, often keeping the door closed and limiting interaction with staff and other residents. Facility records, including grievance logs, did not reflect any formal complaints from the resident regarding these environmental concerns. Interviews with facility staff confirmed awareness of the resident's complaints, but no immediate remedies for the environmental issues were provided.
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What surveyors actually found near you
We read the 18 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Llano
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Kingsland | 14.4 mi | ★★★★★ | 18 | 0 |
| The Brixton At Horseshoe Bay | 24.5 mi | ★★★★★ | 0 | 0 |
| Avir At Burnet | 26.8 mi | ★★★★★ | 5 | 0 |
| Granite Mesa Health Center | 27.2 mi | ★★★★★ | 9 | 0 |
| San Saba Nursing & Rehabilitation | 31.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.