Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Shiner Nursing And Rehabilitation Center Inc during CMS and state inspections, most recent first.
A dietary manager who was not a CDM served as the person overseeing food and nutrition services and was still in school for certification. During observation, she did not follow label directions for a whipped topping container and stored it in the refrigerator instead of the freezer. A resident with moderate cognitive impairment and recent significant wt loss received potato soup instead of the planned chicken and sausage gumbo, and the RD stated the substitution was not equivalent in protein and should have been documented on the substitution log.
Food preferences and diet orders were not consistently honored for two residents. One resident with cognitive impairment and recent wt loss was served loaded potato soup instead of the planned chicken and sausage gumbo, then later received fried foods despite documented dislikes and digestive intolerance. Another resident with dysphagia had a Negotiated Risk Agreement allowing regular foods, but her tray ticket still showed a mechanical soft diet, causing confusion when she requested a regular tray.
Kitchen Food Storage and Labeling Deficiencies: The kitchen had black circular spots inside the ice machine, whipped topping stored in the reach-in refrigerator without being frozen as indicated by the label, raw protein stored next to fully cooked food in the freezer, one food product without a name on its label, and 3 unlabeled buckets of food products. The DM and RD acknowledged the storage and labeling issues and discussed the risk of contamination and improper food identification.
A facility failed to maintain infection control during care for two residents. During incontinent care for one resident with dementia, diabetes, and bowel/bladder incontinence, a CNA did not sanitize between her fingers when using sanitizer between glove changes. During wound care for another resident with two pressure ulcers on EBP, an LVN did not don a gown, then changed gloves after cleaning the wound but did not sanitize her hands before applying treatment and dressing.
A resident with severe cognitive impairment and incontinence was observed receiving perineal care while CNAs attempted to use a privacy curtain that did not fully close around the bed, leaving the resident visible to the roommate and potentially anyone entering the room. In a separate incident, an unlocked laptop on a medication cart in a hallway displayed confidential resident information, and the MDS nurse confirmed it had been left unlocked accidentally.
A resident’s quarterly MDS failed to include his colon cancer diagnosis, even though hospital records showed invasive colonic adenocarcinoma and staff confirmed he returned to the facility with stage 4 colon cancer and was receiving chemo for palliative purposes. The diagnosis was also missing from the care plan, and the DON, ADM, MDS nurse, and reimbursement consultant all confirmed the omission.
The facility failed to keep care plans current for two residents. One resident’s care plan did not reflect colon cancer or chemotherapy after re-admission, even though staff knew he had stage 4 colon cancer and went for chemo. Another resident had dysphagia and a negotiated risk agreement to eat regular foods despite a mechanical soft order, but the care plan and tray ticket still reflected the mechanical soft diet, leading to confusion when she requested a regular meal.
Incomplete Perineal Care During Incontinent Care: A CNA provided incontinent care to a resident who was always incontinent of bladder and frequently incontinent of bowel, but did not clean the lower abdomen or groin areas. The resident had diagnoses including dementia, schizophrenia, type 2 DM, HTN, and CKD, and the care plan called for pericare after each incontinent episode. The CNA said she was nervous and forgot, while the DON stated staff should clean the lower abdomen and groin areas during incontinent care to help ensure proper cleaning and prevent infection.
The facility failed to ensure physician orders were signed and implemented for two residents. One resident had significant weight loss and an RD recommendation for fortified supplements and weekly weights that remained unsigned by the physician, while another resident’s pharmacy review recommending an increase in Januvia and discontinuation of sliding scale insulin was signed by the MD but not clarified or updated in the chart, leaving the order at the prior dose. Staff reported ongoing delays in getting MD responses and unsigned recommendations returned.
Unlocked Medication Cart in Hallway: Medication cart #1, located outside the dining room in the entrance hallway, was found unlocked when it was left unattended. An MDS nurse confirmed the cart was unlocked, and the ADM stated medication carts should be locked when left unattended. The cart contained narcotics in a separate locked container inside the cart.
A resident’s medical record was incomplete because his colon cancer diagnosis was not reflected on the admission record, MDS, or care plan, even though hospital records showed invasive colonic adenocarcinoma and staff knew he was going to chemotherapy. The resident said he had chemotherapy for colon cancer, and the MDS nurse, reimbursement consultant, DON, ADM, and CNAs all acknowledged the diagnosis and its impact on his condition were known but not documented in the key record sources.
Surveyors identified multiple deficiencies in food service sanitation and equipment maintenance, including leaking and soiled refrigeration units, an inoperable vent hood, stained kitchen floors, and unsanitary conditions such as rusty drying racks and dust-covered filters. Staff interviews confirmed that these issues had been ongoing and reported but not resolved, with the DON newly aware of the extent of the problems.
Surveyors found that the dining room's eight ceiling air conditioning vents were soiled with a black substance and rust, and the return vent was covered with dust. The Maintenance Director confirmed the vents had not been cleaned since the previous year, and there was no set cleaning schedule. Both the Maintenance Director and DON acknowledged the importance of keeping vents clean for residents and staff.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, over 42 days. This was due to staffing shortages and competition for nursing staff, as confirmed by interviews and record reviews. Efforts to fill shifts with interim staff and regional nurses were made, but a permanent solution was not secured.
The facility failed to ensure proper documentation of DNR orders for three residents, resulting in incomplete OOH DNR forms. A resident's form lacked the physician's printed name, while two others were missing required second signatures. These deficiencies could lead to confusion about the residents' end-of-life wishes.
The facility failed to maintain proper pharmaceutical services, including incomplete glucometer logs, expired supplies, and improper storage of loose pills. A resident with gastrointestinal issues did not receive the correct dose of omeprazole, and the administration of polyethylene glycol was inaccurately documented. These deficiencies highlight lapses in medication handling and administration procedures.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds, central ports, and indwelling catheters, as well as improperly stored clean items, posing a risk for infection spread. A resident with a draining wound, another with a central port, and a third with a catheter did not have EBP in place until after surveyor observations. Additionally, a name tag was found in a box of clean spoons on a medication cart, indicating improper storage practices.
A facility failed to implement a comprehensive care plan for a resident with a chronic wound, omitting enhanced barrier precautions (EBP) necessary to prevent infections. The resident, with Alzheimer's and other conditions, had a significant change in condition with a skin tear and a full-thickness wound. Despite a wound care order, there was no EBP order, and staff were observed not using PPE. The DON was unaware of the wound, indicating a lapse in communication and care planning.
A resident with a history of heart and vascular conditions did not receive knee-high compression socks as ordered, leading to swelling in her legs and feet. Despite the care plan and provider orders, the resident was observed without the prescribed socks on multiple occasions. Staff acknowledged the oversight and eventually located the socks in a locked storage area.
Two residents were found with potentially hazardous materials in their rooms, including medicated chest rub, hairspray, and beer, without staff knowledge or proper orders. One resident had moderate cognitive impairment, increasing the risk of misuse, while the other had intact cognition but was not monitored for alcohol use. The facility's policy prohibited such items without specific orders, and staff oversight was lacking.
The facility failed to post oxygen warning signs for two residents requiring oxygen therapy, despite the presence of oxygen tanks and concentrators in their rooms. This oversight was confirmed by staff interviews and contradicted the facility's policy on oxygen administration, which mandates 'No Smoking' signs to prevent safety risks.
The facility failed to ensure that pharmacist medication regimen review recommendations were reviewed by the attending physician for two residents. A pharmacist recommended a gradual dose reduction for a resident's quetiapine fumarate, but the physician did not review it timely. Another resident's Zoloft dose reduction recommendation was ignored by the physician, with the DON acknowledging delays in addressing such recommendations.
A facility failed to accurately document the application of compression stockings for a resident with peripheral vascular disease. Despite documentation indicating the stockings were applied, observations and resident statements confirmed they were not. The resident experienced swollen legs and feet, and the ADON was unsure why the stockings were not reapplied after a shower, highlighting a lapse in documentation and care procedures.
Dietary Manager Lacked Required Qualifications and Meal Substitutions Were Not Properly Managed
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietician, based on observation, interview, and record review. The Dietary Manager did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. During interview, she stated she was not a Certified Dietary Manager and was attending school to become one, having started work at the facility in October 2025 and school in January 2026. The ADM also stated the Dietary Manager did not have to be certified if she was in school. Resident #5 was a [AGE]-year-old female with a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Her nutritional risk assessment reflected a significant weight loss of 9.1% (14.2 pounds) in 1 month, with the RD noting the loss may have been related to hospitalizations in February and that the resident was also at risk for weight fluctuations related to bilateral lower extremity edema and diuretic therapy. The resident’s nutritional interventions included house shakes twice daily and weekly weights for 4 weeks. Her weight summary before 02/03/2026 showed stable weight from November 2025 through January 2026. During observation, the Dietary Manager did not follow food storage directions for a container of whipped topping in the reach-in refrigerator; she stated she had not read the label and was unaware that the product should be frozen to use the listed discard date. During lunch service, Resident #5 received potato soup instead of the chicken and sausage gumbo listed on the tray ticket, and she stated she did not want the potato soup because she had already had potato soup as the soup of the day. The tray ticket showed the meal was to include soup, entree, starch, salad, bread, dessert, condiment, and beverage, and the menu substitution for that day listed ham and cheese sandwich as the meat substitution. The ADM stated the loaded baked potato soup was intended to meet protein requirements, while the RD stated the Dietary Manager should have contacted her before substituting it because it did not provide as much protein as the chicken and sausage gumbo and should have been documented on the substitution log.
Food Preferences and Diet Orders Not Honored
Penalty
Summary
The facility failed to ensure Resident #5 received food that matched her preferences and provided equal nutritive value when her Tuesday lunch tray was altered from the planned chicken and sausage gumbo to loaded potato soup. Resident #5, a female with a BIMS score of 09/15 and recent significant weight loss noted by the RD, told staff she did not want potato soup because she had already had potato soup as the soup of the day. Her tray ticket reflected a preference of no sausage and listed the meal components, including the gumbo entree, but the meal observed on the tray consisted of 2 bowls of potato soup instead of the ordered entree. The record showed the facility’s lunch menu for that meal included chicken and sausage gumbo, and the menu substitution for the meat item was ham and cheese sandwich. The ADM stated the loaded baked potato soup recipe should meet protein requirements because it contained bacon, cheese, milk, and sour cream, but the RD later stated she would not have agreed that loaded potato soup was an adequate substitution for chicken and sausage gumbo and would have added chicken because the soup did not provide as much protein as the original entree. The facility’s diet manual and substitution policy required substitutions of equal value and indicated meat servings should be provided at lunch according to calorie level. The facility also failed to honor Resident #5’s food dislikes on Friday lunch when her tray included fried okra, fried fish, and hushpuppies even though her tray ticket reflected she disliked fried-breaded foods and she reported fried foods affected her digestion after gallbladder removal. LVN I confirmed she was not supposed to have fried foods on her tray but could not explain why they remained on it. In addition, the facility failed to update Resident #16’s tray ticket to reflect her Negotiated Risk Agreement allowing a regular diet instead of the mechanically soft diet shown on her order summary and tray ticket; when she requested a regular tray, nursing staff had to return to the kitchen because the ticket still showed mechanical soft, and the Dietary Manager stated she was allowed a regular diet because she had the right to request it.
Kitchen Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation and interview, the ice machine had black circular spots on the inside above the ice. The DM confirmed the spots were present, stated they did not look like mold, and was able to wipe them off with an unnamed substance on a paper towel. She stated she cleaned the inside of the ice machine once a week by placing a plastic bag on top of the ice and cleaning the inside, and said it was important to keep the ice machine clean because residents could drink whatever contaminants were in the ice machine. In the reach-in refrigerator in the food preparation area, containers of whipped topping were observed with a date of 03/03/2026 and a use-by date of 07/06/2027. The container also stated that when frozen, the use-by date was 06 July 2027. The DM stated she was not aware that the product needed to be frozen for that discard date to apply. In the reach-in freezer, raw protein foods were stored next to fully cooked food products. The DM and [NAME] J stated raw protein foods should not be stored near fully cooked foods because blood leaking from raw protein packages could contaminate the fully cooked food products. There was also a food product observed without a name on its label, and the DM stated food products needed to have the name of the food product so staff would know what it was. In addition, three buckets of food products in the food preparation area were observed without labels. [NAME] J identified the buckets as cornmeal, flour, and sugar, and stated they were not labeled. The DM stated she oversaw the kitchen to ensure everything was in order, and also stated that when she was off work, things became unorganized with food storage.
Infection Control Lapses During Incontinent Care and Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 2 residents reviewed for infection control. For Resident #3, whose record showed diagnoses including dementia, schizophrenia, hyperlipidemia, major depressive disorder, type 2 diabetes mellitus, hypertension, and chronic kidney disease, the quarterly MDS indicated a BIMS score of 15 and that the resident was always incontinent of bladder and frequently incontinent of bowel. The care plan directed staff to provide pericare after each incontinent episode. During observation of incontinent care, CNA C did not sanitize between her fingers when using sanitizer between glove changes while providing care for Resident #3. In interview, CNA C stated she did not sanitize between her fingers, said she was nervous and forgot, and stated she had received infection control training within the year. For Resident #7, whose record showed diagnoses including hyperlipidemia, COPD, major depressive disorder, and neoplasm of uncertain behavior of skin, the quarterly MDS indicated a BIMS score of 15 and that the resident had two pressure ulcers. The care plan identified enhanced barrier precautions due to wounds and directed staff to use gown and gloves during high-contact care activities. During observation of wound care, LVN D did not gown up before entering the room and providing care, despite a sign and protective equipment being present by the door. After cleaning the wound, LVN D changed gloves but did not sanitize her hands before applying the treatment and dressing. In interview, LVN D stated she forgot the resident was on enhanced barrier precautions, said the precautions were new to her, and stated she had dipped her fingers in sanitizer but did not sanitize her whole hands between glove changes.
Privacy and Confidentiality Failures During Care and on an Unlocked Medication Cart
Penalty
Summary
Resident #8, who had diagnoses including end stage renal disease, major depressive disorder, hyperlipidemia, anxiety disorder, and dependence on renal dialysis, was observed receiving perineal care while CNAs A and B attempted to pull the privacy curtain around the bed. The curtain was too short in width to go around the bed completely, and Resident #8 could be seen by the roommate and could have been seen by someone opening the room door. Record review showed the resident had a BIMS score of 5, indicating severe cognitive impairment, and was incontinent of bladder and frequently incontinent of bowel. The care plan directed staff to provide pericare after each incontinent episode. The facility also failed to protect resident information when a computer screen on a medication cart located outside the dining room and in the entrance hallway was left unlocked and unsupervised with confidential resident information visible. A COTA confirmed the screen was unlocked and displayed confidential information, and the MDS nurse stated she had left it unlocked accidentally and that it needed to be locked for HIPAA reasons. The ADM stated the laptop on the medication cart needed to be locked and noted the MDS nurse did not typically work on the floor and may have forgotten.
MDS Assessment Omitted Colon Cancer Diagnosis
Penalty
Summary
The facility failed to ensure Resident #3’s quarterly MDS assessment accurately reflected his status by omitting his diagnosis of colon cancer. Record review showed the resident was initially admitted and later re-admitted with diagnoses including GI bleeding, and hospital documentation reflected invasive colonic adenocarcinoma. However, the quarterly MDS dated 12/08/2025 listed a BIMS score of 15 out of 15 and did not include colon cancer as a diagnosis, and the care plan also did not mention colon cancer. During interviews, the resident stated he went to chemotherapy because he had colon cancer. The MDS Nurse and Reimbursement Consultant stated the resident returned to the facility with stage 4 colon cancer and was currently receiving chemotherapy for palliative purposes. They explained that diagnoses were reviewed from pertinent medical records and added to the MDS assessments and face sheets, and confirmed colon cancer was not reflected on the MDS. The DON and ADM also verified the diagnosis was missing from the MDS assessment, stating it needed to be included because the resident had colon cancer and staff needed to be aware of it.
Care Plans Not Updated for Cancer Treatment and Negotiated Diet Risk
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents with identified needs. For one resident, the record showed a re-admission with diagnoses including dementia and GI hemorrhage, and hospital documentation reflected invasive colonic adenocarcinoma. The resident’s quarterly MDS did not reflect colon cancer as a diagnosis, and the care plan did not mention the cancer or that the resident was going to chemotherapy after re-admission. During interviews, the resident stated he went to chemotherapy because he had colon cancer, and facility staff acknowledged the diagnosis should have been reflected in the care plan so nursing staff would be aware of it and any related treatment needs. For another resident, the admission record reflected dysphagia and the MDS showed a mechanically altered diet. The resident also had a Negotiated Risk Agreement stating she preferred to eat regular foods even though she was at risk for aspiration. However, the care plan did not address the Negotiated Risk Agreement and did not state that she was allowed to eat a regular diet instead of the prescribed mechanical soft diet. The order summary still reflected a mechanical soft diet, and the care plan only noted that the resident had a diet order other than regular and was at risk for unplanned weight loss or gain. During observation and interview, the resident received a mechanically soft lunch tray, then requested a regular diet meal. Nursing staff had to check with the kitchen, which said it was okay to give her a regular diet tray, while staff at the time were not aware that the tray ticket still reflected mechanical soft. Facility staff acknowledged the resident had a Negotiated Risk Agreement because she chose to eat regular foods, and the MDS nurse stated that this should have been in the care plan so staff would know it was okay for her to have a regular diet because it was her preference and her right.
Incomplete Perineal Care During Incontinent Care
Penalty
Summary
Incontinent care was not provided in accordance with appropriate treatment and service practices for Resident #3. During observation on 03/19/2026 at 12:35 p.m., CNA C provided incontinent care but did not clean the resident’s lower abdomen area or the left and right groin areas. During interview later that day, CNA C stated she did not clean those areas because she was nervous and forgot, and she reported receiving incontinent care training within the year. Resident #3’s record showed an admission date of 08/18/2023 and a readmission date of 12/04/2025, with diagnoses including dementia, schizophrenia, hyperlipidemia, major depressive disorder, type 2 diabetes mellitus, hypertension, and chronic kidney disease. The quarterly MDS indicated a BIMS score of 15, showing the resident was cognitively intact, and that the resident was always incontinent of bladder and frequently incontinent of bowel. The care plan directed staff to provide pericare after each incontinent episode. The DON stated staff should clean residents’ lower abdomen area and the left and right groin areas during incontinent care to ensure proper cleaning and prevent infection, and the facility policy on perineal care directed wiping across the pubis area and continuing care to the scrotum and inner thigh.
Unsigned Physician Orders and Delayed Review of RD and Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure physician, physician assistant, nurse practitioner, or clinical nurse specialist orders were in place for the immediate care and needs of 2 residents reviewed for physician services. For Resident #5, the quarterly MDS dated 02/27/2026 reflected a BIMS score of 09 out of 15, indicating moderate cognitive impairment. The RD’s Nutritional Risk Assessment, also dated 02/27/2026, documented a significant weight loss of 9.1% (14.2 pounds) in 1 month, with possible contributing factors including recent hospitalizations, fluid fluctuations related to BLE edema, and diuretic therapy. The RD recommended house shakes BID and weekly weights for 4 weeks, but the communication between the dietitian and attending physician showed Dr. K had not signed the diet recommendations. For Resident #3, the record reflected diagnoses including dementia and Type 2 diabetes, and the quarterly MDS dated 12/08/2025 showed a BIMS score of 15 out of 15. The pharmacist’s Medication Regimen Review dated 02/25/2026 recommended increasing Januvia to 100 mg and attempting to discontinue sliding scale insulin to reduce needle sticks and medication burden. Dr. K signed the medication regimen review on 03/09/2026, but the facility had not updated the resident’s orders by 03/19/2026, and Januvia remained ordered at 50 mg daily. During interview, the DON and Compliance Nurse stated pharmacy and RD recommendations were emailed to the DON or MDS Nurse to send to the doctor for signature, and the signed orders were then returned for entry into the medical record. They stated there had been many unsigned orders and that Resident #3’s orders were not updated because Dr. K had been called for clarification on his note and had not responded. The Compliance Nurse stated responses should take less than 3 days, and the MDS Nurse and RD both described ongoing problems with physician response times and getting recommendations signed. The facility policies reflected that physician orders must be signed and dated, that the physician must supervise each resident’s medical care, and that nutrition and drug regimen recommendations should be signed and returned by the physician.
Unlocked Medication Cart in Hallway
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 3 medication carts reviewed, specifically medication cart #1. During observation and interview on 03/17/2026 at 11:46 AM, medication cart #1, located right outside the dining room in the facility's entrance hallway, was found unlocked with the button used to open the cart popped out. No residents or visitors were present at the time. COTA F walked by the cart and then got MDS Nurse E, who confirmed the cart was unlocked and stated that the narcotics inside medication cart #1 were kept in another container that was locked inside the cart. MDS Nurse E said it was important for medication carts to be locked so no medication could be taken out by someone who did not know what they were doing. During interview on 03/17/2026 at 4 PM, the ADM stated medication carts should be locked when left unattended and said MDS Nurse E did not typically work on the floor so she may have forgotten. Record review of the facility's policy, Medication Storage in the Facility, dated 03/2025, stated medications and biologicals are stored safely, securely, and properly.
Medical Record Missing Colon Cancer Diagnosis
Penalty
Summary
The facility failed to maintain Resident #3’s medical records in a complete and accurately documented manner when his diagnosis of colon cancer was not included on his admission record, quarterly MDS assessment, or care plan. Resident #3’s admission record listed diagnoses including dementia and gastrointestinal hemorrhage, but did not reflect colon cancer, even though hospital documentation showed he had invasive colonic adenocarcinoma. His quarterly MDS assessment dated 12/08/2025 showed a BIMS score of 15 out of 15 and also did not include colon cancer, and the undated care plan made no mention of colon cancer or chemotherapy. During interview, Resident #3 stated he had gone to chemotherapy because he had colon cancer. The MDS Nurse E and the Reimbursement Consultant stated Resident #3 returned to the facility with stage 4 colon cancer and that the diagnosis should have been added to the face sheet so it could carry over to the MDS assessment and care plan. The DON and ADM also stated the face sheet should have included colon cancer because he was going to chemotherapy. CNAs A, G, and H stated they knew Resident #3 had cancer and that he returned from chemotherapy weaker and needing more assistance on those days.
Multiple Food Service Sanitation and Equipment Deficiencies Identified
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations of unsanitary and poorly maintained kitchen equipment and areas. The ice machine in the kitchen was found to be leaking, with water pooling on the floor and wet towels surrounding the machine. The double door standing refrigerator was leaking water from the top mechanism, resulting in containers of food sitting in standing water at the bottom of the unit. Both the silver refrigerator and the white deep freezer had accumulations of ice inside the walls, and their lids, bases, and inside seals were visibly soiled with a black substance. Despite these issues, the temperatures of the refrigeration units were within the appropriate range. Further observations revealed that the kitchen floors were stained and soiled with food particles, two electrical outlets were visibly soiled, the kitchen drying racks were rusty, and the large return filter was covered with dust. The vent hood over the stove was inoperable, with its switch covered by blue tape and marked as not to be touched. Interviews with dietary staff confirmed that the ice machine had a recurring water leak due to a clogged drain, and the double door refrigerator had been leaking for an extended period. Staff also acknowledged the presence of accumulated ice and soiling in the refrigeration units, and that these issues had been reported to the Maintenance Director and Dietary Manager but remained unresolved. The Maintenance Director confirmed the ongoing issues with the kitchen equipment, including the need for a replacement part for the vent hood, a recurring clog in the ice machine drain, and a broken door gasket on the double door refrigerator. The Director of Nursing, who was new to the facility, confirmed the unsanitary conditions and stated she was previously unaware of these issues. The facility's policy and the FDA Food Code require food to be stored in clean, dry locations and equipment to be clean to sight and touch, which was not met in these instances.
Dining Room Air Conditioning Vents Found Soiled and Rusty
Penalty
Summary
Surveyors observed that the facility's dining room had eight ceiling air conditioning vents, all of which were visibly soiled with a black substance and rust. The return vent in the dining room was also covered with dust. The Maintenance Director confirmed these findings, stating that the Housekeeping Department was responsible for cleaning the return vent, while she was responsible for the ceiling vents. She reported that she occasionally wiped the vents and sprayed bleach on the black substance, but this was ineffective in removing it. She also noted that the vents were rusty and needed to be painted or replaced. There was no set schedule for cleaning the vents, and the last documented cleaning occurred in October or November of the previous year. The Maintenance Director acknowledged that the return vent cleaning was overdue. The DON also confirmed the vents were soiled and rusty, and the return vent was dusty, emphasizing the importance of clean vents for residents' access to unsoiled air. Review of the facility's policy indicated that preventive maintenance should be completed routinely and according to protocol, but this was not followed in this instance.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, over a period of 42 days between May 11, 2024, and August 12, 2024. This deficiency was identified through interviews and record reviews, including the CMS PBJ staffing data report and facility timesheets. The absence of RN coverage on specific dates was confirmed, indicating a lack of compliance with the required staffing regulations. Interviews with the current Director of Nursing (DON) and the previous administrator revealed that the facility faced challenges in maintaining RN coverage due to staffing shortages and competition for nursing staff. The current DON, who started on July 17, 2024, stated that her hours were not recorded on a timesheet as she is salaried. The previous administrator mentioned efforts to fill shifts with interim staff and regional nurses, but acknowledged the difficulty in securing a permanent DON or RN to meet the staffing requirements.
Deficiencies in DNR Documentation for Residents
Penalty
Summary
The facility failed to ensure that residents had the right to formulate an advance directive and determine their choice regarding CPR, as evidenced by deficiencies in the documentation of Out of Hospital (OOH) Do Not Resuscitate (DNR) orders for three residents. Resident #5's OOH DNR was missing the physician's printed name, which is a necessary component for the document's validity. This oversight occurred despite the resident's documented DNR status and the presence of a care plan that included DNR interventions. Resident #25's OOH DNR was incomplete as it lacked a second signature from the resident's representative at the bottom of the document, where all signatories are required to sign again. This resident had severe cognitive impairment, and the responsibility for ensuring the DNR's completeness fell to the representative. The facility's failure to ensure the document was fully executed could lead to confusion regarding the resident's end-of-life wishes. Similarly, Resident #40's OOH DNR was missing the resident's second signature at the bottom of the document. Despite being cognitively intact and having a care plan that included DNR interventions, the resident's DNR documentation was not properly completed. During an interview, facility staff acknowledged the oversight and the potential issues it could cause with external agencies not honoring the DNR due to incomplete documentation.
Deficiencies in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by several deficiencies observed in the handling and administration of medications. The survey revealed that glucometer logs were not maintained properly, with missing entries for specific dates, and there was no clear identification of which glucometer was being tested. This lack of documentation and identification could lead to inaccuracies in blood glucose monitoring, as staff were not verifying if nightly controls were being conducted. Additionally, the facility did not ensure the removal of expired supplies, as observed with a box of IV alcohol caps that had passed its expiration date. Furthermore, loose pills were found stored in a medication cart, which is against the facility's policy due to the risk of contamination and medication errors. The Director of Nursing (DON) acknowledged that staff should not store pills ahead of time and emphasized the importance of following the Medication Administration Procedures. The report also highlighted a specific incident involving a resident with a history of gastrointestinal issues and other medical conditions. The resident did not receive the prescribed dose of omeprazole, and the administration of polyethylene glycol was inaccurately documented. The Licensed Vocational Nurse (LVN) involved failed to administer the correct medications initially and did not document the resident's refusal of the full dose of polyethylene glycol accurately. This oversight could potentially affect the resident's treatment for chronic gastrointestinal problems.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for three residents who required them. Resident #25, a female with Alzheimer's disease and a draining wound on her left leg, did not have EBP implemented until after the wound was observed to be draining. Similarly, Resident #26, who had a central port for dialysis, reported that staff never wore gowns during her care, and there was no order for EBP in her records. Resident #43, who had an indwelling catheter, also did not have EBP in place until after it was noted by the Director of Nursing (DON) that it should have been implemented. Additionally, the facility failed to ensure proper storage of clean items, as observed with a name tag being stored in a box of clean disposable wooden spoons on a medication cart. This incident was acknowledged by the Licensed Vocational Nurse (LVN) and the DON, who recognized the contamination risk and removed the box from the cart. The facility's policy on Enhanced Barrier Precautions and infection control measures was not adequately followed, leading to these deficiencies. The DON admitted to being unaware of the need for EBP for the residents in question until after the surveyor's observations. The facility's failure to implement EBP for residents with open wounds, central ports, and indwelling catheters, as well as the improper storage of clean items, posed a risk for the spread of infection and cross-contamination among residents.
Failure to Implement Comprehensive Care Plan for Resident with Chronic Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a chronic wound, which did not include measurable objectives and time frames to meet the resident's medical and nursing needs. The care plan did not reflect that the resident was on enhanced barrier precautions (EBP), which are necessary to prevent infections for residents with open wounds. This oversight was identified during a review of the resident's records and observations, where it was noted that the care plan lacked mention of EBP despite the resident having a chronic wound. The resident, who was admitted with Alzheimer's disease, chronic kidney disease stage 3, and seizures, had a significant change in condition with a skin tear and a full-thickness wound on her left lower leg. Despite the presence of a wound care order, there was no corresponding order for EBP, and staff were observed not using personal protective equipment (PPE) when interacting with the resident. The Director of Nursing (DON) was unaware of the resident's open draining wound until it was brought to attention, indicating a lapse in communication and care planning. This deficiency could place residents at risk of not receiving necessary care or services tailored to their specific needs.
Failure to Apply Compression Socks as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not follow provider orders and care plan interventions by failing to apply knee-high compression socks on a resident with edema. The resident, who had a history of non-ST elevation myocardial infarction, hypertensive heart disease, peripheral vascular disease, and chronic atrial fibrillation, was observed with swollen legs and feet and reported that staff had not applied her compression socks as requested. Observations and interviews revealed that the resident was wearing non-skid socks instead of the prescribed compression stockings. Despite the order for compression socks to be applied daily, the resident was found without them on multiple occasions. LVN A acknowledged the oversight and was observed searching for the compression socks, eventually finding them in a locked cart in the medication storage room. The ADON confirmed that the socks should have been worn during the day and removed at bedtime, and acknowledged that the resident would experience swelling without them.
Failure to Prevent Hazardous Materials in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment for Resident #5 by allowing potentially hazardous materials in her room. Resident #5, a female with moderate cognitive impairment and a history of heart conditions, was found with a jar of medicated chest rub and a bottle of hairspray on her nightstand. The resident did not have an order to self-administer medications, and the presence of these items posed a risk due to her cognitive impairment. The Director of Nursing (DON) acknowledged that the resident should not have had these items, as they could be used incorrectly and cause harm. Resident #40, a male with intact cognition and a history of peripheral vascular disease and major depressive disorder, was found with an open beer can in his room. Although his care plan allowed for alcohol consumption at social functions, staff were unaware of the beer in his room. The resident claimed that staff knew about the beer, but interviews with staff members revealed they had never seen him with alcohol. The DON expressed concern about potential interactions between the beer and the resident's medications. The facility's policy prohibited medications and aerosol cans in resident rooms unless specifically ordered by a doctor. The DON admitted that the facility had overlooked assigning a new champion to monitor Resident #40 after the previous one left. Additionally, the facility had issues with visitors entering through side doors, which could have contributed to the presence of unauthorized items in resident rooms.
Failure to Post Oxygen Warning Signs for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents who required oxygen therapy, as evidenced by the absence of oxygen warning signs on their doors. Resident #25, a female with Alzheimer's disease, chronic kidney disease, and seizures, was observed with an oxygen concentrator and portable oxygen tank in her room without any signage indicating the presence of oxygen. Her care plan included the provision of oxygen as needed for dyspnea or low oxygen saturation, yet the necessary precautions were not in place. Similarly, Resident #34, a male with atrial fibrillation, sleep apnea, and influenza, was seen using oxygen therapy without any signs on his door to alert others of the oxygen use. His care plan also included oxygen therapy as ordered by the physician. Interviews with facility staff, including an LVN, the ADON, and the DON, confirmed that oxygen signs were required but not posted for residents using oxygen. The facility's policy on oxygen administration emphasized the importance of placing 'No Smoking' signs in areas where oxygen is administered and stored, to prevent the use of flames or sparks nearby. The lack of signage could lead to increased respiratory complications and unawareness of oxygen use, posing a safety risk to residents and staff.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the pharmacist's medication regimen review recommendations were reviewed by the attending physician for two residents. For Resident #4, the pharmacist recommended a gradual dose reduction of quetiapine fumarate, but the physician did not review this recommendation in a timely manner. The Director of Nursing (DON) was unsure if the provider had reviewed the recommendation, and it was later found that the provider had sent a form indicating the resident should continue with the same dose, but this form was not dated. For Resident #16, the pharmacist recommended a gradual dose reduction for Zoloft, but the physician had not addressed this recommendation as of the survey date. The DON revealed that the facility's medical records clerk delivered the pharmacy recommendations to the physician's office, but the physicians often ignored these recommendations. The DON acknowledged that the recommendation for Resident #16 had not been addressed, and it was only on the survey date that a signed form from the physician was provided, stating that the risk of clinical deterioration outweighed the benefit of the recommended change.
Failure to Accurately Document Compression Stocking Application
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the application of compression stockings. The resident, a female with a history of non-ST elevation myocardial infarction, hypertensive heart disease, peripheral vascular disease, and chronic atrial fibrillation, was supposed to have knee-high compression stockings applied as part of her care plan to manage her peripheral vascular disease. However, the nursing staff documented that the compression stockings were applied on specific days, despite the resident stating that they were not put on, and observations confirming that she was wearing regular ankle socks instead. The discrepancy was noted during observations and interviews, where the resident expressed that her legs and feet were swollen and that she had requested the compression stockings, but they were not applied. The facility's policy on documentation requires accurate and complete recording of care provided, which was not adhered to in this case. The Assistant Director of Nursing (ADON) was unsure why the compression stockings were not reapplied after the resident's shower, indicating a lapse in following the prescribed care plan and documentation procedures.
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What surveyors actually found near you
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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 Shiner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Yoakum Nursing And Rehabilitation Center | 9.3 mi | ★★★★★ | 5 | 0 |
| Shady Oak Nursing And Rehabilitation | 9.7 mi | ★★★★★ | 10 | 0 |
| Paradigm At Stevens | 9.9 mi | ★★★★★ | 3 | 0 |
| Hallettsville Nursing And Rehabilitation | 13 mi | ★★★★★ | 10 | 0 |
| Stevens Nursing And Rehabilitation Center Of Halle | 13.5 mi | ★★★★★ | 11 | 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.