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 Palo Pinto Nursing Center during CMS and state inspections, most recent first.
Menu Not Followed for Pureed Meal Tray: A resident on a puree diet with orders for thickened liquids did not receive a pureed roll on his lunch tray. Staff stated the tray should have included the roll, but it was omitted while dietary staff were distracted in the kitchen. The ADMN stated residents should receive every item listed on the menu and that the DM was responsible for ensuring trays contained all food items.
Survey results were not readily accessible because the binder was kept in a bin down a hallway instead of the lobby, and there was no prominent sign showing where to find it. The binder was missing the most recent survey and investigation results, and a resident with intact cognition and a family member stated they were unaware the findings were available or where to locate them.
Two student nurse aides worked full-time beyond the 120-day limit without obtaining CNA certification, with one aide performing direct care duties and not completing the required exam due to lack of proper identification. The DON was unaware of the certification time limit and had only recently taken over responsibility for monitoring CNA certification.
Two CNAs failed to don gowns while providing incontinent care to a resident on Enhanced Barrier Precautions, despite signage and PPE availability. The resident had a history of sepsis, MRSA, and C. difficile. Both CNAs acknowledged the lapse, citing haste and unfamiliarity, and the DON confirmed the expectation for gown use per facility policy.
Two residents in a facility suffered injuries due to the failure to implement comprehensive care plans. One resident, with a history of cerebral infarction and hemiplegia, sustained a femur fracture after being improperly transferred by a hospitality aide. The care plan did not reflect the need for a two-person assist with a Hoyer lift. Another resident, with multiple diagnoses including nasal bone fracture and repeated falls, experienced several unwitnessed falls due to non-compliance with asking for assistance during transfers. The care plan did not address her non-compliance or update her transfer status, leading to staff being unaware of her needs.
A resident with a history of cerebral infarction and hemiplegia suffered a femur fracture after being improperly transferred by a non-certified aide without the required two-person assistance. The aide, whose certification had expired, attempted the transfer alone, leading to the accident. The facility's policies were not followed, and the care plan was not accurately reflected in the Kardex system.
The facility failed to maintain food safety standards, with issues in dish machine sanitization, improper hair restraints, and inadequate hand hygiene among dietary staff. The dish machine did not meet required chlorine levels, and staff did not fully cover their hair or wash hands after touching their faces, risking food contamination.
Two residents experienced inadequate housekeeping in their rooms, with food debris, dust, and cobwebs left unaddressed. A housekeeper admitted to insufficient training and oversight, leading to persistent unclean conditions. The facility lacked a specific cleaning policy, relying on general resident rights guidelines.
The facility failed to ensure proper dialysis care and coordination for two residents, as evidenced by incomplete dialysis communication sheets and lack of physician orders for dialysis treatment and access site monitoring. Interviews revealed a lack of awareness and training among staff regarding the completion and use of these communication sheets, leading to deficiencies in care coordination.
A facility failed to maintain an effective infection control program, as a nurse did not disinfect a blood pressure cuff between residents, and a CNA did not change soiled bed linen after incontinence care. These actions were against the facility's policies, which emphasize preventing cross-contamination and infection spread.
The facility failed to maintain an effective pest control program, resulting in flies in the kitchen, dining room, and resident rooms. Observations showed flies landing on food preparation surfaces and food items. Staff interviews revealed a lack of awareness and communication about the issue, despite pest control measures like UV lights and aerators. Pest control reports from June to August 2024 consistently documented fly issues, indicating an unresolved problem.
A resident with a history of cerebral infarction and hemiplegia sustained a femur fracture after being improperly transferred by an uncertified hospitality aide. The aide, whose certification had expired, attempted the transfer alone, contrary to the resident's care plan requiring two-person assistance. The facility failed to report the incident as neglect within the required timeframe.
The facility failed to manage medications properly on Nurses Cart Hall 3, as a resident's controlled medication blister pack had broken seals with pills still inside. RN J did not notice the issue during the narcotics count, posing a risk for drug diversion. The DON stated that such medications should be discarded, but the facility's policy was not followed.
Menu Not Followed for Pureed Meal Tray
Penalty
Summary
The facility failed to ensure the menu was followed for 1 of 2 residents reviewed who received a pureed meal. Resident #18, an [AGE]-year-old male admitted with diagnoses including anorexia, heart failure, and feeding difficulties, had physician orders for a pureed texture with moderately thickened honey consistency and a care plan noting that he was on a puree diet. During a lunch observation, Resident #18's tray left the kitchen without a pureed roll, even though the menu required one for his meal. During interview, the DM stated the resident should have had a pureed roll and that the cook was responsible for ensuring it was on the tray. The DM said the omission occurred because dietary staff were distracted by the state surveyor being in the kitchen. [NAME] A stated residents were to receive everything listed on the menu and that it was her responsibility to ensure all items were on the meal tray; she also stated she became distracted by the chicken waiting to be cooked. The ADMN stated residents should have received every item listed on the menu, including a pureed roll for residents on a pureed diet, and that the DM was responsible for ensuring trays contained all food items on the list. Facility policy stated the menus would be followed and served as written.
Survey Results Not Readily Available to Residents and Visitors
Penalty
Summary
Residents were not able to easily view the nursing home's survey results or communicate with advocate agencies because the survey binder was not displayed in the lobby and there was no sign indicating that survey results were available or where to locate them. Instead, the survey binder was observed in a bin down a hallway to the right of the lobby, with small print labeling it as survey results outside the binder and on the bin. The binder did not contain the results from the investigation visit on 04/10/2025 or the most recent recertification visit on 08/20/2024. Resident #10, a male with diagnoses including CAD, HTN, renal disease, and hyperlipidemia, had a BIMS score of 14 indicating intact cognition. During an interview, Resident #10 and a family member stated they were not aware that survey findings were available or where to find them. The ADMN verified that the binder lacked the investigation and recertification results and stated she was responsible for keeping it updated. She also stated the label outside the bin was not prominent for visitors and that residents and visitors would not have access to survey and investigation results without asking for them.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that two student nurse aides (SNA A and SNA B) who had worked more than four months were certified as required. Review of employee files showed that both SNA A and SNA B had been employed full-time beyond the 120-day limit without obtaining CNA certification numbers. SNA A reported working continuously since his hire date and performing nurse aide duties, including assisting with transfers and patient care tasks, despite not being certified. He attempted to take the certification test but was turned away due to not having the proper identification and had not yet registered to retake the test. SNA B was also found to be working full-time without certification, but was not available for interview. The Director of Nursing (DON) acknowledged during an interview that she was unaware of the time limit for certification and had recently assumed responsibility for monitoring CNA testing and certification. The prior ADON was previously responsible for this oversight. Documentation from the facility and state guidelines confirmed the requirement for nurse aides to complete training and certification within 120 days of employment. The job description signed by SNA A also indicated understanding of the 120-day certification requirement.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program by not following Enhanced Barrier Precautions for a resident with a history of sepsis, MRSA, and Clostridium difficile. During an observation, two CNAs entered the resident's room, which had an Enhanced Barrier Precautions sign posted and personal protective equipment available outside, to perform incontinent care. The CNAs washed their hands and donned gloves but did not wear gowns as required. There were no gowns in the room at the time. Both CNAs later acknowledged they should have worn gowns and attributed their oversight to being in a hurry and unfamiliarity with the resident, as well as not recalling their last in-service on enhanced barrier precautions. The DON confirmed that the expectation was for staff to wear gowns when providing direct care to residents on Enhanced Barrier Precautions and stated that staff had been previously in-serviced on this protocol. The facility's policy required the use of gowns and gloves during high-contact care activities for residents with multi-drug resistant organisms or certain medical conditions. The failure to follow these procedures was observed and confirmed through staff interviews and record review.
Failure to Implement Comprehensive Care Plans Leads to Resident Injuries
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to significant injuries and inadequate care. Resident #24, a female with a history of cerebral infarction, dysphagia, and hemiplegia, sustained a left femur fracture due to improper transfer by a hospitality aide. The care plan for Resident #24 did not reflect the need for a two-person assist with a Hoyer lift, and the Kardex was not updated to indicate this requirement. As a result, the resident was transferred by a non-certified aide, leading to a fall and subsequent fracture. Resident #9, a female with multiple diagnoses including nasal bone fracture, sepsis, and repeated falls, experienced several unwitnessed falls due to non-compliance with asking for assistance during transfers. The care plan for Resident #9 did not address her non-compliance or update her transfer status following her falls and nasal bone fracture. This lack of communication and documentation resulted in staff being unaware of her transfer needs, contributing to her falls and injuries. The facility's failure to maintain accurate and comprehensive care plans for these residents placed them at risk for further injury. The care plans did not reflect the residents' current needs, and staff were not adequately informed or trained to provide the necessary assistance. This oversight led to Immediate Jeopardy, highlighting the potential for more than minimal harm to the residents.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for a resident, leading to a significant injury. A non-certified hospitality aide (HA) transferred the resident without assistance, contrary to the care plan that required two-person assistance for transfers. During the transfer from the toilet to the wheelchair, the resident's leg gave way, resulting in a fracture of the left femur, which required surgical intervention. The resident involved was an elderly female with a history of cerebral infarction, dysphagia, and hemiplegia, requiring substantial assistance with transfers. Despite this, the HA, whose certification had expired, attempted to transfer the resident alone, leading to the accident. The HA was not authorized to perform such transfers and should have sought assistance from a certified nurse aide or notified the nurse on duty. Interviews and record reviews revealed that the HA was aware of the resident's need for two-person assistance but proceeded with the transfer due to the absence of the CNA, who was on break. The facility's policies and procedures were not followed, and the care plan was not accurately reflected in the Kardex system, contributing to the incident.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed in the kitchen. On the specified date, the low temperature dish machine was not functioning properly, with the chlorine sanitizer levels not reaching the required 50 to 100 ppm. The Dietary Manager confirmed that the machine was not sanitizing dishes correctly due to a clogged line, which was later fixed. However, there was no documentation of sanitizer or temperature levels for that day, indicating a lapse in monitoring and recording these critical safety parameters. Additionally, the facility's dietary staff, including Dietary Aide Y, Dietary Aide Z, and the Dietary Manager, were observed not wearing effective hair restraints during meal preparation. Their hair was not fully covered, which could lead to contamination of food. Furthermore, both Dietary Aide Y and Dietary Aide Z failed to perform proper hand hygiene after touching their faces, continuing to handle food without washing their hands or changing gloves, which poses a risk of cross-contamination. The facility's policies on ware washing, personal hygiene, and food safety were not followed, as evidenced by the lack of proper documentation and adherence to hygiene practices. The Dietary Manager and aides were unaware of the deficiencies in their hair restraints and hand hygiene practices, despite having been in-serviced on these procedures. The Administrator acknowledged the importance of these practices in preventing food contamination and illness among residents.
Deficiencies in Housekeeping and Sanitation
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for two residents, leading to deficiencies in housekeeping and sanitation. Resident #43's room was observed to have food debris, hair, and trash under the bed, as well as dust and food debris on the window ledge. Despite the resident's impaired vision, he was unaware of the unclean conditions and expressed satisfaction with housekeeping services. However, observations on consecutive days revealed that the room remained unclean, with debris and dust persisting despite the removal of a paper bag. Housekeeper W, responsible for cleaning the room, admitted to not being fully trained on deep cleaning and not routinely checking under beds or cleaning window ledges. Resident #18 also experienced inadequate cleaning in her room, with window blinds and ledges left undusted and cobwebs present. The resident expressed dissatisfaction with the cleaning services, noting that housekeeping often only removed trash without sweeping or dusting. The Housekeeping Supervisor confirmed the presence of dust and cobwebs and acknowledged that the cleaning tasks were not performed as expected. The supervisor attributed the oversight to Housekeeper W's inexperience and lack of thorough training, as well as the absence of documented performance reviews or random checks for the new employee. The facility's Administrator was aware of housekeeping complaints and emphasized the importance of maintaining a clean environment for infection control and resident comfort. However, the facility lacked a specific policy for cleaning resident rooms, relying instead on a general resident rights policy. The deficiencies in housekeeping practices were attributed to insufficient training and oversight of housekeeping staff, particularly for newer employees like Housekeeper W.
Failure in Dialysis Care Coordination
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received appropriate care and coordination with the dialysis center, as evidenced by the lack of completed dialysis communication sheets for two residents. Resident #123, a cognitively intact female with multiple diagnoses including chronic kidney disease, did not have physician orders for dialysis treatment or documentation of dialysis access site monitoring. Despite being on hemodialysis, her medical records lacked necessary documentation, and she reported not receiving dialysis communication sheets until a specific date, indicating a lapse in communication and care coordination. Similarly, Resident #67, a male with end-stage renal disease, also lacked physician orders for dialysis treatment and monitoring of his dialysis access site. His records showed inconsistent documentation of dialysis communication sheets, with only one instance of communication from the dialysis center. Interviews with nursing staff revealed a lack of awareness and training regarding the completion and use of dialysis communication sheets, further contributing to the deficiency in care coordination. The facility's policy required direct communication with the dialysis team and specific physician orders for residents receiving hemodialysis, including monitoring of vascular access sites. However, the facility did not adhere to these protocols, as evidenced by the absence of physician orders and incomplete dialysis communication sheets. Interviews with the ADONs and DON highlighted a lack of oversight and training on the importance of these communication sheets, which are crucial for monitoring the effectiveness of dialysis treatment.
Infection Control Lapses in Equipment Sanitization and Linen Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving multiple residents. In the first incident, a registered nurse (RN) did not disinfect a reusable blood pressure cuff between checks on three residents. This oversight occurred during a morning medication pass, where the RN admitted to forgetting to sanitize the cuff, despite acknowledging the risk of cross-contamination and infection spread. The facility's policy mandates that resident equipment be cleaned with an EPA-approved disinfectant between uses, which was not adhered to in this case. In the second incident, a certified nursing assistant (CNA) failed to change soiled bed linen after providing incontinence care to a resident. During the care, a bowel movement was observed on the bed linen, but the CNA did not replace the soiled linen, instead repositioning the resident onto it. The CNA later admitted that she was aware of the requirement to change soiled linen to prevent infection spread but forgot to do so in this instance. The facility's policy emphasizes the importance of infection control and preventing cross-contamination, which was not followed in this situation. Interviews with the staff involved and the Director of Nursing (DON) confirmed that the facility had trained staff on the importance of sanitizing equipment and changing soiled linens. However, the lapses in practice by the RN and CNA indicate a failure to consistently implement these infection control measures, potentially placing residents at risk of infection or illness.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in critical areas such as the kitchen, dining room, and resident rooms. Observations revealed multiple instances of flies landing on food preparation surfaces, trash cans, and food items like Splenda and sour cream packets. The presence of flies was also noted in resident rooms, with one resident observed swatting flies near their mouth, indicating a pervasive issue throughout the facility. Interviews with facility staff, including the Dietary Manager and Environmental Services (EVS) Manager, highlighted a lack of awareness and communication regarding the fly problem. The Dietary Manager acknowledged the presence of flies for several months and mentioned pest control treatments for drain flies, but was unaware of specific issues like flies on the bread rack. The EVS Manager was not informed of the fly issue and stated that pest control measures, such as bug traps, were in place but had not received complaints about flies in the kitchen or other areas. The Maintenance Director and Pest Control Service Supervisor provided additional insights into the facility's pest control measures. The Maintenance Director described the installation of aerators and UV lights with sticky traps to deter flies, but noted limitations in the types of chemicals that could be used. The Pest Control Service Supervisor confirmed the presence of fly lights and ongoing treatments, attributing the fly issue to environmental factors like dry conditions and high traffic areas. Despite these measures, the facility's pest control reports from June to August 2024 consistently documented fly issues, indicating an ongoing problem that had not been effectively resolved.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and exploitation of residents, specifically in the case of a resident who required extensive assistance for transfers. The incident involved a hospitality aide (HA) who was not certified and was not authorized to perform resident transfers. The HA attempted to transfer the resident without assistance, resulting in the resident sustaining a fracture of the left femur. The resident required surgical intervention and was to remain non-weight bearing with a brace on the left leg following the incident. The resident, who had a history of cerebral infarction, dysphagia, and hemiplegia, required substantial assistance with transfers as indicated in her care plan. Despite this, the HA, whose certification had expired, attempted to transfer the resident alone when the certified nurse aide (CNA) was on break. During the transfer, the resident's knee buckled, and a loud pop was heard, leading to the injury. The HA was not supposed to perform such tasks and should have called for assistance from a nurse or another staff member. The facility's Director of Nursing (DON) and Administrator were aware of the incident but initially decided not to report it to the state agency, as they believed the fall was witnessed and the injury's origin was known. However, upon review, it was determined that the incident should have been reported as an allegation of neglect due to the serious injury. The facility's failure to report the incident within the required timeframe and to ensure that only authorized personnel performed resident transfers contributed to the deficiency.
Failure in Medication Management on Nurses Cart Hall 3
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of each resident, specifically in the management of medications on Nurses Cart Hall 3. During an observation and record review, it was found that the blister pack for a resident's controlled medication, Acetamin-codeine 300-30 mg tablet, had two broken blister seals with the pills still inside. RN J, who was responsible for the cart, was unaware of when or how the seals were broken and did not notice the issue during the narcotics count at shift change. This oversight could lead to potential drug diversion and the resident not receiving the intended therapeutic benefit. The Director of Nursing (DON) stated that any medication with a broken seal should be discarded and not kept in the blister pack, as it poses a risk for drug diversion and infection control issues. The facility's policy on medication storage requires that medications in containers without secure closures be immediately removed from inventory and disposed of according to procedures. However, the policy was not followed in this instance, as the broken blister pack was not addressed appropriately. The DON also mentioned that the ADONs and the DON were supposed to check the carts weekly, indicating a lapse in the facility's adherence to its own procedures.
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Illustrative
What surveyors actually found near you
We read the 44 citations issued within 25 miles in the last 12 months — including the 7 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
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Nursing homes near Mineral Wells
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mineral Wells Nursing & Rehabilitation | 0.2 mi | ★★★★★ | 0 | 0 |
| Avir At Keeneland | 19.6 mi | ★★★★★ | 0 | 0 |
| Avir At Weatherford | 19.9 mi | ★★★★★ | 12 | 2 |
| Peach Tree Place | 20.4 mi | ★★★★★ | 8 | 5 |
| College Park Rehabilitation And Care Center | 21.3 mi | ★★★★★ | 0 | 0 |
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