Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pflugerville Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe dementia was mistreated during morning med pass when a CMA forcefully pulled down her chin to give meds while she was still asleep and then threw a blanket over her head before leaving the room. Camera footage and a family complaint described the resident struggling to remove the blanket, while staff interviews and the DON/ADM acknowledged the actions did not meet facility standards and were considered abuse.
A resident with severe cognitive impairment and multiple chronic diagnoses had scheduled morning meds documented as given by CMAs even though family reported the resident did not receive them in the room on multiple mornings. Interviews with RNs, LVNs, the DON, the ADM, and CMAs showed staff knew meds should be administered before MAR documentation and that missed or delayed doses should be reported, but no one documented that the resident was asleep, refused, or otherwise did not receive the meds as recorded.
Unlocked Medication Cart Left Unattended: A nursing medication cart containing residents' prescription drugs, OTC meds, narcotics in a locked box, syringes, and other supplies was observed unattended and unlocked in a hallway. RN A stated she had been trained in medication storage and knew the cart should be locked when not in use, but left it unlocked while responding to the doorbell and calling leadership. The DON, ADM, and facility policy all stated medication carts must be locked when not in use and not left unattended.
Surveyors found that the facility did not complete required quarterly assessments or review and revise care plans for a large group of residents for more than three months. MDS records showed that quarterly care plans had not been updated for dozens of residents since the prior quarter. The DON and MDS Case Manager reported that the IDT was expected to reassess residents and update care plans quarterly, and that a Social Worker was responsible for coordinating these meetings, but the facility had been without a Social Worker for most of the year. The ADM stated he expected the IDT to follow RAI Manual requirements for quarterly care plan meetings, which had not occurred.
A resident with a history of mental health and behavioral issues reported to the DON that she received a bruise from a CNA after a shower. The DON did not observe bruising and failed to report the allegation to the ADM as required by policy. The ADM only learned of the allegation days later through the resident's responsible party and a nurse, resulting in a delayed investigation of the abuse allegation.
A resident with a history of end-stage renal disease and communication barriers was injured in a facility van when her wheelchair was not properly secured, causing it to tilt backward and her to hit her head. Despite the injury and subsequent hospital visit, the incident was not reported to the State Agency within the required timeframe. Interviews revealed the van driver was unsure of the incident details, and the facility's administrator did not consider it reportable.
A resident with multiple health conditions was at risk due to a nurse's failure to follow infection control protocols during blood glucose monitoring. The nurse did not perform hand hygiene or wear gloves, despite handling equipment and the resident's blood. The resident expressed concerns about the lack of glove use, and the nurse admitted to the oversight, citing haste as the reason. The DON confirmed the breach of protocol, emphasizing the importance of adherence to infection control policies.
A facility failed to monitor a diabetic resident's glucose levels or A1C for five months after admission, despite a high glucose reading of 318. The resident, recently discontinued from diabetes medications, did not receive necessary follow-up lab work. Interviews with the NP, MD, and DON highlighted a lack of communication and absence of a policy for diabetic care.
A facility failed to address a pharmacist's recommendation to update the diagnosis for Seroquel XR, prescribed for a resident with generalized anxiety disorder, which is not CMS-approved for this medication. The resident had multiple diagnoses, including major depressive disorder and PTSD. The facility lacked formal procedures for timely follow-up on pharmacy recommendations, relying on informal monitoring, which could risk unreviewed pharmacy consultations.
The facility failed to date two multi-use vials of Tuberculin, Purified Protein Derivative, Diluted Aplisol in the medication storage room. During an observation, the vials were found opened and accessed without being dated or initialed, which was confirmed by RN C and the DON. The facility's policy requires multi-dose vials to be dated and initialed when opened, and the manufacturer's package insert states that Aplisol vials should be discarded if used for more than 30 days.
The facility failed to store, prepare, and serve food according to professional standards, leading to potential risks of foodborne illness. Observations revealed improperly covered and dated food items, and inadequate handwashing and sanitization practices by staff. Despite established policies and training, these deficiencies were not addressed, as confirmed by the Dietary Manager, RD, and Administrator.
A CNA failed to perform hand hygiene during glove changes while providing catheter care to a resident with severe cognitive impairment and multiple health conditions. Observations and interviews revealed inconsistencies in understanding and implementing hand hygiene protocols, despite facility policies requiring hand hygiene before and after glove use.
A facility failed to provide an accurate PASRR Level 1 Screening for a resident with bipolar disorder, resulting in a deficiency. The resident's screening incorrectly indicated no mental illness, despite documented diagnoses. Interviews revealed that staff did not update the screening due to misinterpretation of guidelines, potentially affecting the resident's access to necessary services.
Abuse During Medication Administration and Blanket Incident
Penalty
Summary
The facility failed to ensure a resident with severe cognitive impairment was free from abuse and mistreatment when a CMA forcefully handled her during morning medication administration and then left her with a blanket over her head. The resident was an 86-year-old female with vascular dementia, depression, anxiety disorder, atherosclerotic heart disease, and a need for assistance with personal care. Her care plan directed staff to converse with her during care, use her preferred name, identify themselves, face her when speaking, make eye contact, and provide cues, reorientation, and supervision as needed. Her MDS reflected a BIMS score of 2, indicating severe cognitive impairment. Camera footage showed the CMA applying force to the resident’s chin while pulling it down to administer medications while the resident was not fully awake. The footage also showed the CMA throwing a blanket over the resident’s head, walking away, and leaving the room without removing the blanket from the resident’s face or checking on her. The resident struggled to remove the blanket herself and was left uncovered from the waist down with the bed inclined. A complaint letter described the resident as being in a deep sleep, being tapped and pushed to wake her, and having her jaw forcefully manipulated during the medication attempt. The resident’s family member reviewed the video and reported that the resident appeared upset and could not communicate except by mumbling. The family member stated the resident seemed lethargic at the facility compared with another facility. Interviews with staff showed awareness that forcing medication or throwing a blanket on a resident’s head would be considered abuse, and the DON and ADM both acknowledged that the CMA’s actions did not meet the facility’s standards of care. The facility record also included a policy for administering medication to sleeping or confused residents that called for gentle awakening, allowing time, assessing readiness, documenting, and returning later if the resident was sleeping soundly and the medication was not time sensitive.
Medication Administration Documented Before Actual Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring accurate acquiring, receiving, dispensing, and administering of medications. For one resident with diagnoses including atherosclerotic heart disease, vascular dementia, depression, anxiety disorder, and need for assistance with personal care, the record showed severe cognitive impairment with a BIMS score of 2. The resident’s care plan directed staff to converse with the resident during care, use the resident’s preferred name, identify themselves at each interaction, face the resident when speaking, make eye contact, and provide cues, reorientation, and supervision as needed. A family complaint stated that on three mornings the resident did not receive morning medications in the room. The complaint noted that on one morning a med tech took the resident’s blood pressure shortly after 7:00 a.m. but the family member did not see medications given. A CMA statement said that on one of the mornings the resident was in bed at the time of medication administration and the medication was not administered while the resident was asleep or disturbed because of prior behavioral disruptions when awakened. An undated note from another CMA stated that she went into the room to pass medication, found the resident asleep, tried to wake her by rubbing her shoulder and patting her head, and then tried to open her mouth by pressing down on her chin. The MAR audit showed that scheduled 7:00 a.m. medications, including sertraline, docusate sodium, omeprazole, Depakote Sprinkles, carvedilol, polyethylene glycol, and lorazepam, were documented as administered on the three dates in question by CMA A and CMA H. The documentation times matched the administration times, but nursing progress notes did not indicate that the resident did not receive medications on those days. Interviews with RN, LVN, DON, ADM, and CMAs reflected that medications should be administered before documentation, that missed or delayed medications should be reported to the nurse, and that no one had been notified that the resident’s medications were administered late or not administered. The DON stated the resident’s RP contacted her about the missed medications, and the ADM stated there were no witnesses to the administrations. The facility’s medication administration policy required signing the MAR after medication was administered and documenting refusals or adverse side effects.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that a nursing medication cart was locked and only accessible to authorized persons for 1 of 8 medication carts reviewed for pharmacy services. During observation of the 400 hallway, a nursing medication cart was found along the wall unattended and unlocked. The cart contained residents' prescription drugs, over-the-counter medications, narcotics in a locked box, syringes, and other supplies. No residents, visitors, or staff were near the cart, and all resident room doors on the hallway were closed. During interview, RN A stated she had been trained in medication storage and that medication carts should be locked any time staff walk away from them. RN A stated she was responsible for locking the cart, but left it unlocked while responding to the doorbell to let surveyors in and calling leadership to report that State had entered the building. The DON and ADM both stated the cart should be locked when not in use and that the nurse in possession of the keys was responsible for locking it. The facility policy titled, Medication Carts and Supplies for Administering Meds, stated the medication cart is locked at all times when not in use and should not be left unlocked or unattended in resident care areas.
Failure to Complete Quarterly Assessments and Update IDT Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and maintain comprehensive care plans in accordance with federal requirements. Record review showed that for 67 of 105 residents reviewed, quarterly assessments and corresponding care plan reviews and revisions had not been completed within the required three‑month interval. Minimum Data Set (MDS) records dated within the review period revealed that these residents had not had an updated quarterly care plan for longer than three months, with quarterly care plans not updated since August 2025. The deficiency relates to the requirement at 42 CFR 483.21(b) that comprehensive care plans be developed within 7 days of the comprehensive assessment and then reviewed and revised by the interdisciplinary team (IDT) after each assessment, including both comprehensive and quarterly assessments. During interviews, the DON stated she expected the IDT to complete a new care plan for each newly admitted resident within 14 days of admission and to reassess each resident on a quarterly basis, and identified the Social Worker as responsible for coordinating quarterly care plan meetings. The DON acknowledged that the facility did not have a Social Worker at the time and confirmed that the 67 residents’ quarterly care plans had not been updated since August 2025. The MDS Case Manager confirmed that the IDT was expected to meet quarterly to initiate and complete quarterly care plan assessments and reiterated that the Social Worker was responsible for coordinating these meetings, noting that the facility had been without a Social Worker for most of 2025. The Administrator stated he expected the IDT to follow the RAI Manual regarding the frequency of care plan meetings and confirmed that care plan meetings should be held on a quarterly basis. Reference to the CMS RAI Manual and Appendix PP documented that, although quarterly MDS assessments do not require Care Area Assessments, the resident’s care plan must be reviewed and revised by the IDT after each assessment.
Failure to Timely Report Alleged Abuse to Administrator
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but no later than two hours, as required by facility policy. After a resident reported to the DON that she had received a bruise from a staff member following a shower, the DON did not report this allegation to the Administrator (ADM) as required. The DON stated that the resident showed her arm and said, 'look at this bruise, she did it,' but the DON did not observe any bruising and did not follow up or report the allegation, assuming the ADM had overheard the comment. The ADM only became aware of the allegation about a week later, after the resident's responsible party (RP) reported it to a nurse, who then notified the ADM. The resident involved had a history of major depressive disorder, anxiety disorder, and impulse disorder, and was care planned for risks related to skin impairment, resistiveness to care, and potential for physical aggression. The resident's care plan included interventions such as weekly skin inspections and having two staff present during showers. Despite these interventions, the resident reported being pinched by a CNA during a shower, which was not her scheduled shower day. Multiple staff interviews confirmed that the resident made a statement about a bruise after her shower, but the initial report was not escalated according to policy. Documentation and interviews revealed that the resident's report of abuse was not communicated to the ADM until several days after the incident, delaying the initiation of an investigation. The facility's policy required immediate reporting of all alleged violations to the ADM, but this was not followed. The delay in reporting could have resulted in a failure to protect the resident from further harm and did not comply with the facility's established procedures for handling allegations of abuse.
Failure to Report Resident Injury Due to Improper Wheelchair Securing
Penalty
Summary
The facility failed to report an incident involving a resident who was not properly secured in the facility's van, resulting in the resident sustaining a head injury. The incident occurred when the van driver failed to ensure the resident's wheelchair was properly strapped, causing the wheelchair to tilt backward and the resident to hit her head on a metal grate. Despite the resident complaining of a headache and being sent to the hospital for a CT scan, the facility did not report the incident to the State Agency within the required 24-hour timeframe. The resident involved was an elderly female with a history of end-stage renal disease, type 2 diabetes mellitus, and encephalopathy, which increased her risk for miscommunication due to language barriers. On the day of the incident, the resident was being transported to a dialysis appointment when the van driver accelerated from a stoplight, causing the unsecured wheelchair to tilt. The resident sustained a right parietal scalp contusion, as confirmed by a CT scan, and was subsequently sent to the emergency room for further evaluation. Interviews with the van driver and other residents present during the incident revealed that the resident's wheelchair was not properly secured, with the front wheels not strapped. The van driver admitted to not being sure of what happened and was later suspended for failing to report the incident. The facility's administrator, who was responsible for reporting such incidents, did not consider the event reportable, despite the facility's policy requiring immediate reporting of any allegations involving abuse or neglect.
Infection Control Lapse During Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the context of blood glucose monitoring for a resident. During an observation, RN A was seen entering a resident's room without performing hand hygiene and proceeded to check the resident's blood glucose without wearing gloves. The resident, a male with end-stage renal disease, type 2 diabetes mellitus, and other health conditions, was at risk due to this lapse in protocol. RN A used ungloved hands to handle the glucometer, test strip, lancet, and gauze, and did not perform hand hygiene after the procedure, potentially exposing the resident to infection. The resident expressed concern during an interview, noting that staff often checked his blood glucose without wearing gloves, which made him uneasy about potential contamination. RN A admitted to not following proper procedures, acknowledging the importance of wearing gloves to prevent infection transmission. She cited being in a hurry as the reason for her oversight, which she recognized as inappropriate. The Director of Nursing (DON) confirmed that RN A's actions were not in line with the facility's infection control policies. The DON emphasized the importance of following established procedures, including hand hygiene and the use of gloves when handling bodily fluids. The facility's policies on hand hygiene and infection prevention were reviewed, highlighting the requirement for staff to perform hand hygiene and use personal protective equipment as part of standard precautions to prevent the spread of infections.
Failure to Monitor Glucose Levels in Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with type II diabetes, as they did not monitor the resident's glucose levels or A1C for five months following admission. The resident was admitted with a diagnosis of type II diabetes and had recently been discontinued from diabetes medications, Metformin and Trulicity, at the hospital. Despite having a high glucose level of 318 recorded in April, no further lab work was conducted, and the resident's glucose levels were not checked during their stay at the facility. Interviews with the resident's nurse practitioner (NP), medical doctor (MD), and the Director of Nursing (DON) revealed a lack of communication and follow-up regarding the resident's high glucose reading. The NP stated that glucose levels should be checked regularly, and the A1C should be monitored every three months. The MD acknowledged the high glucose reading but did not order further tests, attributing the reading to possible dietary intake. The DON confirmed that labs should be conducted every 3-4 months for diabetic residents not on medication and noted the absence of a policy for lab work or diabetic care.
Failure to Address Pharmacist's Recommendation for Seroquel XR
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the use of Seroquel XR. The licensed pharmacist recommended updating the diagnosis for Seroquel XR, as the current diagnosis of generalized anxiety disorder was not CMS-approved for this antipsychotic medication. However, the facility did not implement this recommendation or provide a rationale for not doing so. The resident involved was a female with multiple diagnoses, including Guillain-Barre syndrome, major depressive disorder, PTSD, and generalized anxiety disorder, among others. Her cognitive assessment indicated intact cognition, and she required varying levels of assistance for activities of daily living. The facility also lacked policies and procedures to address the timeframes for medication regimen reviews. The Director of Nursing (DON) admitted there were no written timeframes for following up on pharmacy recommendations, and the process relied on informal monitoring. The facility's policy stated that the consultant pharmacist should communicate recommendations within 10 working days, but there was no formal tracking or monitoring to ensure these recommendations were acted upon. This oversight could potentially place residents at risk of not having their pharmacy consultations reviewed or recommendations implemented.
Failure to Date Multi-Use Vials in Medication Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to professional principles, specifically in the medication storage room. During an observation, two multi-use vials of Tuberculin, Purified Protein Derivative, Diluted Aplisol were found opened and accessed without being dated or initialed. This oversight was confirmed during an interview with RN C, who acknowledged that all multi-use vials and bottles should be dated when opened, as the nurse opening the vial is responsible for this task. The RN also noted that medications are only effective for a specific time once opened, and expired medications may not have the desired effect. The Director of Nursing (DON) reiterated that multi-dose vials should be dated upon opening, as they have a certain shelf-life. The DON expressed that it did not meet her expectations that the vials were opened and not dated, emphasizing that expired medications could have decreased strength or potency. The facility's policy on expiration dating and expired medications requires multi-dose vials to be dated and initialed when opened. According to the manufacturer's package insert, Aplisol vials should be discarded if used for more than 30 days, highlighting the importance of proper labeling to ensure safety and efficacy.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. During an inspection, it was noted that the reach-in refrigerator contained several items that were not properly covered, dated, or discarded when expired. Specifically, an opened container of tartar sauce and mayonnaise were found with only a received date, and a plastic meal tray with shredded cheese and bacon was uncovered. The Dietary Manager acknowledged these issues, stating that staff were instructed to label, date, cover, and discard items according to the use-by date, but these practices were not consistently followed. Additionally, the facility did not ensure proper handwashing and sanitization procedures were followed. An employee, identified as CK L, was observed washing a food processor without using sanitizer and then proceeded to handle food without washing her hands. The Dietary Manager confirmed that the process for using the three-compartment sink was to wash, rinse, and sanitize dishes, and that staff, including CK L, had been trained on these procedures. However, the employee did not adhere to these protocols, potentially placing residents at risk of foodborne illness. Interviews with the Dietary Manager, Registered Dietitian (RD), and Administrator revealed that there were established policies for food storage, handwashing, and dish sanitization, but these were not consistently implemented. The RD and Administrator both emphasized the importance of following these procedures to prevent contamination and protect residents. Despite training and monitoring efforts, the facility's failure to comply with these standards was evident, as reflected in the kitchen's sanitation audit and the facility's policies.
Inadequate Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) who did not perform hand hygiene when changing gloves during catheter care for a resident. The resident, an elderly male with severe cognitive impairment and multiple health conditions, including dementia and chronic kidney disease, had an indwelling catheter. During an observation, the CNA was seen changing gloves multiple times without performing hand hygiene, which is a critical step in preventing the spread of infections. Interviews with the CNA, Director of Nursing (DON), and Infection Preventionist revealed inconsistencies in understanding and implementing hand hygiene protocols. The CNA admitted to possibly missing hand hygiene during glove changes, while the Infection Preventionist believed that performing hand hygiene with 3 out of 5 glove changes was adequate. The facility's policies and training materials indicated that hand hygiene should be performed before donning and after removing gloves, but there was a lack of clarity and adherence to these guidelines, as noted by the DON and Administrator.
Inaccurate PASRR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that a resident with mental health disorders received an accurate Preadmission Screening and Resident Review (PASRR) Level 1 Screening. This deficiency was identified for one of the four residents reviewed for PASRR, specifically a female resident diagnosed with bipolar disorder, type 2 diabetes mellitus, hypertension, and Bell's Palsy. Despite having a diagnosis of bipolar disorder, the resident's PASRR Level 1 Screening incorrectly indicated that there was no evidence of mental illness. This oversight was discovered during a review of the resident's face sheet, MDS assessment, comprehensive care plan, and consultation notes from an acute care hospital stay. Interviews with facility staff revealed a lack of proper coordination and communication regarding the PASRR process. Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) acknowledged the inaccuracies in the PASRR screening and the potential for residents not receiving necessary services due to these errors. The staff responsible for PASRRs did not update the screening to reflect the resident's mental illness diagnosis, citing guidelines that they believed disqualified the resident due to the absence of an inpatient psychiatric or rehabilitation stay. The Administrator confirmed that the MDS nurses were responsible for completing and monitoring PASRRs, and expressed an expectation for accuracy and timeliness in the process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pflugerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Five Points Of Pflugerville | 1.1 mi | ★★★★★ | 16 | 0 |
| Avir At Park Bend | 5 mi | ★★★★★ | 8 | 0 |
| Gracy Woods Ii Living Center | 5.1 mi | ★★★★★ | 0 | 0 |
| Gracy Woods Nursing Center | 5.2 mi | — | 20 | 0 |
| Trinity Care Center | 5.2 mi | ★★★★★ | 9 | 0 |
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