Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Silver Pines Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with significant cognitive and physical impairments did not receive required in-room or 1:1 activities for an extended period, despite documented care plans and staff awareness of their needs. Activity participation records, staff interviews, and resident feedback confirmed the absence of individualized activities, and the facility lacked a policy on activity programming and documentation.
Staff failed to follow infection control protocols during perineal care and when using reusable medical equipment. A CNA handled clean supplies with soiled gloves and left contaminated items at a resident's bedside, while a medication aide did not sanitize a blood pressure monitor between two residents. These actions did not comply with facility policies and were identified through direct observation and staff interviews.
A resident with multiple cardiac and mobility issues was admitted without a baseline care plan being completed within 48 hours, as required by facility policy. Staff interviews confirmed that the admitting nurse was responsible for this task, and the DON was to review and sign off, but the process was not followed, leaving the resident at risk of not receiving appropriate care.
Three residents with respiratory conditions did not have their nebulizer masks and tubing stored in protective bags when not in use, as required by physician orders and professional standards. Staff confirmed the equipment was left exposed and not sanitized or stored properly, and facility policy did not address this requirement.
A medication cart was found to contain a staff member's personal handbag alongside resident medications, in violation of facility policy. The medication aide admitted to placing the item in the cart, and the nurse in charge confirmed that personal belongings are not allowed in medication carts to prevent contamination. The DON stated that staff are expected to check carts daily to ensure only medications and related supplies are present.
A dietary staff member failed to change gloves and perform hand hygiene after touching contaminated items, such as a bread bag and a piece of paper, before handling bread and using a puree processor. This lapse in food safety protocol was observed and confirmed by interviews with dietary and administrative staff, all of whom acknowledged the expectation for proper glove use and handwashing between tasks.
The facility failed to maintain a safe and homelike environment in several rooms by not cutting and capping toilet mounting bolts and not painting repaired drywall. The Maintenance Director, responsible for these tasks, acknowledged the oversight, and the Administrator confirmed the expectation for proper maintenance. The facility's policies require sufficient maintenance personnel, which was not met in this case.
A resident with a positive PASARR Level I screening for mental illness did not receive the required Level II evaluation. The resident had a history of intracerebral hemorrhage, hemiplegia, hemiparesis, and bipolar disorder, with active diagnoses of anxiety, depression, and bipolar disorder. The Assessment Nurse was responsible for ensuring the evaluation was completed, but it was not done, and the facility lacked a PASARR policy.
The facility failed to maintain food safety standards, with uncovered and unlabeled food items in the kitchen and a visitor entering without proper hair and beard coverings. This posed potential health risks to residents.
An AD and a CNA I failed to perform hand hygiene between assisting two residents each during a lunch meal service, violating the facility's infection control policy. This oversight was acknowledged by both staff members and confirmed by the DON and Administrator, highlighting a risk of cross-contamination.
The facility failed to maintain an effective pest control program, resulting in multiple flies being present in the dining room during meal services. Staff, including the AD, CNA I, and DON, observed flies around residents' food, acknowledging the potential for contamination. Despite noticing the issue, there was no formal reporting or existing pest control policy, and the pest control log showed no prior reports of flies in the past year.
A resident with complex medical conditions, including COPD and heart failure, experienced increased confusion and a fall, yet the facility failed to update the care plan to reflect changes in health and physician orders. Despite observations of confusion and disrobing behavior, the care plan was not adjusted, leading to a deficiency in care planning.
Two residents experienced a lack of dignity and hygiene care in the facility. One resident was found exposed after a fall, with staff failing to protect his privacy. Another resident had long, untrimmed fingernails, with no documentation of refusals for care. The facility did not adhere to its policy on maintaining resident dignity.
A facility failed to complete and submit a Discharge MDS Assessment for a resident with Alzheimer's Disease and Vascular Dementia who was discharged to hospice care. The Assessment Nurse, DON, and Administrator acknowledged the oversight, which could lead to billing issues. The facility's policy requires an OBRA discharge assessment within 14 days, which was not adhered to.
A facility failed to update a resident's care plan following significant changes in condition, including increased confusion and a fall. The resident, with multiple health issues, was not provided with updated interventions for a UTI and related behaviors. Observations showed the resident experienced confusion and disrobing, yet staff did not protect the resident's dignity during care. Interviews revealed that the care plan was not adjusted as required by facility policy.
A resident with edema was not provided with the prescribed compression socks as per physician orders, leading to untreated swelling. Despite the resident's acknowledgment of needing the socks, observations showed she was wearing non-skid socks instead. Nursing staff admitted to not following the care plan, citing being busy as the reason for the oversight.
A resident with severe cognitive impairment was found with mouthwash and hand sanitizer in their room, contrary to facility policy. Staff interviews revealed a lack of awareness and enforcement of safety protocols regarding hazardous substances, highlighting a lapse in supervision and adherence to safety measures.
Failure to Provide Required In-Room Activities for Residents with Special Needs
Penalty
Summary
The facility failed to provide an ongoing activities program tailored to the needs and preferences of two residents who required in-room or 1:1 activities due to their physical and cognitive limitations. Both residents had documented care plans and assessments indicating their dependence on staff for emotional, intellectual, physical, and social needs, with specific interventions requiring individualized activities. Despite these documented needs, neither resident received in-room activities during a specified period, as confirmed by activity participation records and staff interviews. One resident, a female with severe cognitive impairment, vascular dementia, anxiety, and hemiplegia, was noted to have a care plan requiring 1:1 bedside activities and modifications for communication deficits. Observations showed her in bed with minimal or no stimulation, and activity records confirmed a lack of in-room activities for nearly two weeks. The other resident, a male with moderate cognitive impairment, multiple sclerosis, anxiety, and schizoaffective disorder, also had a care plan specifying a need for 1:1 in-room activities based on his preferences. He reported feeling lonely and expressed a desire for more frequent visits from activity staff, which were not provided during the same period. Interviews with the Activity Director and Activity Assistant revealed that both were aware of the residents' needs and the expectation to provide in-room activities, especially when the Activity Director was absent. However, the Activity Assistant did not visit the residents as instructed, and there was a lack of documentation and monitoring of activity provision. The facility also lacked a policy on activity programming and documentation, as confirmed by the Administrator.
Infection Control Lapses in Perineal Care and Equipment Sanitization
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three residents, as evidenced by direct observations and staff interviews. In one instance, a certified nursing assistant (CNA) provided perineal care to a resident with severe cognitive impairment and incontinence, but handled a packet of wet wipes with soiled gloves during the cleaning process. The contaminated wipe packet was then saved at the resident's bedside, contrary to infection control protocols and the facility's own policy, which requires changing gloves if soiled and proper handling of supplies to prevent cross-contamination. Additionally, a medication aide (MA) was observed taking blood pressure readings for two residents with hypertension and other comorbidities, using the same blood pressure monitor without sanitizing it between uses. The aide did not clean the equipment until prompted by the investigator, despite acknowledging the importance of sanitizing medical equipment to prevent the spread of infection. The aide stated that she had received general infection control training but had not attended any in-services specifically focused on sanitizing medical equipment. Record reviews confirmed that the facility had policies in place for perineal care and infection prevention, including requirements for hand hygiene, glove use, and cleaning of reusable equipment. However, the observed practices by staff did not align with these policies, resulting in lapses that could facilitate the transmission of communicable diseases among residents. The deficiencies were identified through a combination of observation, interview, and review of facility records.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. The resident, a male with chronic diastolic heart failure, atherosclerotic heart disease, paroxysmal atrial fibrillation, and difficulty walking, was admitted with multiple care needs, including assistance with activities of daily living, risk for pressure ulcers, and shortness of breath when lying flat. Despite these needs, review of the electronic medical record showed that a baseline care plan was not completed as required. Interviews with the Director of Nurses and an LVN confirmed that it was the responsibility of the admitting nurse to complete the baseline care plan using an admission checklist, and that the DON was to review and sign off on the plan. Both staff members acknowledged that the absence of a baseline care plan could result in residents not receiving appropriate care, such as proper transfers or hygiene assistance. The facility's policy required the baseline care plan to be developed within 48 hours, but this was not done for the resident in question.
Failure to Properly Store and Sanitize Nebulizer Equipment
Penalty
Summary
Surveyors found that the facility failed to provide safe and appropriate respiratory care for three residents who required nebulizer treatments. Observations revealed that the nebulizer masks and tubing for these residents were left exposed on bedside tables and were not stored in protective bags when not in use, contrary to professional standards and physician orders. Interviews with staff, including an LVN and the DON, confirmed that the equipment should have been sanitized and stored in protective bags to prevent contamination, but this was not done. The facility's policy on oxygen safety did not specify the need for storing nebulizer equipment in protective bags, and staff acknowledged non-compliance with expected procedures. The residents involved had significant medical histories, including dementia, COPD, chronic respiratory failure, and dependence on supplemental oxygen. Their care plans and physician orders specifically required regular cleaning and proper storage of nebulizer equipment. Despite these orders, the equipment was not handled according to protocol, as confirmed by both direct observation and staff interviews. This lapse in practice was identified as a deficiency in providing care consistent with professional standards for residents needing respiratory support.
Personal Belongings Found in Medication Cart with Resident Medications
Penalty
Summary
A deficiency was identified when a medication cart on the 200 Hall, operated by a medication aide, was found to contain a personal handbag in the bottom drawer alongside resident medications. The medication aide acknowledged during the survey that placing personal belongings in the medication cart was against facility policy and immediately removed the item. The nurse in charge confirmed that personal items should be stored in designated staff areas and not in medication carts, as they could introduce contaminants and are not permitted according to facility procedures. The Director of Nursing stated that nursing staff are expected to check medication carts daily to ensure only resident medications and related supplies are present, and that personal belongings should not be stored in the carts. Facility policy requires medication carts to be used exclusively for the storage and administration of medications and related supplies, and to be kept clean and orderly. The presence of a personal item in the medication cart was a direct violation of these established procedures.
Failure to Change Gloves and Maintain Hand Hygiene During Food Preparation
Penalty
Summary
A deficiency was identified when a dietary staff member failed to follow proper glove-changing and hand hygiene protocols during food preparation in the facility's kitchen. The staff member, while wearing gloves, touched a piece of paper and the outside of a bread bag, both of which were considered contaminated, and then proceeded to handle bread and place it into a puree processor without changing gloves. During this process, the staff member's gloved fingers also came into contact with the inside of the puree processor and the pureed bread, further increasing the risk of contamination. At no point during these tasks did the staff member change gloves or wash hands, despite having been in-serviced on hand hygiene practices. Interviews with the dietary staff member, the Dietary Manager, and the Administrator confirmed that the expectation was for staff to change gloves and wash hands between tasks or after touching contaminated items. All acknowledged that the bread bag and paper were considered contaminated and that failure to follow hand hygiene protocols could result in the spread of germs to food. Review of the facility's handwashing policy also reflected the importance of good handwashing practices to minimize the risk of infection and foodborne illness among residents.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, orderly, and comfortable homelike environment in five of twelve rooms reviewed in the secure unit. Specifically, the facility did not cut down and cap the mounting bolts that secure the toilet's base to the floor in several rooms, including rooms 451, 460, and 463. This oversight left the bolts exposed, uncut, and uncapped, which could potentially lead to safety hazards for the residents. Additionally, room [ROOM NUMBER]'s bathroom walls were not painted after drywall repairs, leaving the repairs visible and not matching the rest of the bathroom's paint color. Interviews with the Maintenance Director and the Administrator revealed that the Maintenance Director was responsible for all building maintenance, including patches, painting, and toilets, but had no additional staff to assist. The Maintenance Director acknowledged that the walls should have been painted after the drywall was patched and that the toilet mounting bolts should have been cut and covered. The Administrator confirmed the expectation that the facility be maintained in a safe and homelike manner and agreed that the maintenance tasks were not completed as required. The facility's General Housekeeping Policies indicated that sufficient maintenance personnel should be provided to maintain the facility, but this was not adhered to in this instance.
Failure to Complete PASARR Level II Evaluation for Resident
Penalty
Summary
The facility failed to ensure that a resident with a positive PASARR Level I screening for mental illness received the necessary PASARR Level II evaluation. The resident, a female with a history of nontraumatic intracerebral hemorrhage, hemiplegia, hemiparesis, and bipolar disorder, was admitted to the facility with active diagnoses of anxiety disorder, depression, and bipolar disorder. Despite these conditions, the required PASARR Level II assessment was not completed, which could have determined the need for additional mental health services. Interviews with facility staff, including the Assessment Nurse, Director of Nursing (DON), and Administrator, revealed that the responsibility for completing the PASARR Level II assessment fell on the Assessment Nurse. However, the assessment was not conducted, and the facility lacked a PASARR policy to guide this process. The failure to complete the PASARR Level II evaluation was acknowledged by the staff, who recognized the potential risk of residents not receiving necessary mental health services due to this oversight.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During a survey, it was noted that various food items in the walk-in refrigerator were not properly covered or labeled. Specifically, leftover chicken, pureed fruit, pureed bread pudding, and boiled eggs were found without proper coverings or labels. Additionally, trays of fruit and a container of brown sugar were not labeled or dated. In the dry storage area, several opened packets of gravy and seasoning mixes were found with smeared or missing dates, indicating a lack of proper food storage practices. Furthermore, the facility did not enforce its policy on hair and beard coverings in the kitchen. A visitor with long hair and a beard entered the kitchen without wearing a hair net or beard guard, despite walking near food preparation areas and clean dishes. The visitor was identified as someone who frequently entered the kitchen to collect food scraps for personal use, yet he did not comply with the facility's sanitation policies. The Dietary Manager acknowledged the visitor's non-compliance and the potential contamination risks associated with his presence in the kitchen. Interviews with the Dietary Aide and Dietary Manager revealed that there was an expectation for all food to be labeled, dated, and covered, and for anyone entering the kitchen to wear appropriate hair and beard coverings. The Dietary Manager confirmed that the visitor was not a contractor and should not have been allowed in the kitchen. The Administrator reiterated these expectations and acknowledged the potential health risks posed by these deficiencies, including the possibility of foodborne illnesses among residents.
Failure in Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of an Activity Director (AD) and a Certified Nursing Assistant (CNA I) during a lunch meal service. Both staff members assisted two different unidentified residents each without performing proper hand hygiene between feedings. This lapse in protocol was observed on 05/21/24, where neither the AD nor the CNA I sanitized their hands between assisting the residents, which is a violation of the facility's infection control policy. Interviews conducted with the AD and CNA I revealed that they were aware of the requirement to sanitize between assisting residents but failed to do so due to forgetfulness. The Director of Nursing (DON) and the Administrator confirmed that the lack of hand hygiene could lead to cross-contamination and the spread of infections. The facility's policy, dated 05/13/23, mandates that all staff follow standard precautions, including hand hygiene, to prevent the transmission of communicable diseases.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of multiple flies in the dining room during resident meal services. On two separate occasions, flies were observed in and around residents' food, with staff members swatting them away as they assisted in feeding residents. The presence of flies was noted by various staff members, including the AD, CNA I, and the DON, who acknowledged the potential for contamination and infection control issues. Despite these observations, there was no prior documentation of the fly issue in the facility's pest control log, indicating a lack of formal reporting and response to the pest problem. Interviews with staff revealed that the issue of flies had been noticed but not officially reported. CNA I mentioned that she had seen flies frequently during meal services and had discussed it with other staff but never documented it in the pest control book. The DON and the Administrator both acknowledged the recent increase in flies, attributing it to heavy rain, but confirmed that there was no existing policy for pest control. The Administrator recognized the potential for contamination due to flies in residents' food but noted the absence of any prior reports in the pest control log over the past 12 months.
Failure to Update Care Plan for Resident with Changing Health Conditions
Penalty
Summary
The facility failed to update the care plan for Resident #57 in response to significant changes in health and behavior, as well as changes in physician orders. Despite the resident's complex medical history, including COPD, heart failure, diabetes, and a recent diagnosis of a UTI, the care plan did not reflect these changes. The resident experienced increased confusion and had a fall, yet the care plan was not adjusted to address these issues or the new antibiotic regimen prescribed by the nurse practitioner. Observations and interviews revealed that Resident #57 had a fall on 5/21/24, during which he was found face down on the floor with his brief around his ankles. Staff noted that the resident had become more confused, possibly due to his UTI or shingles outbreak. Despite these observations, the care plan was not updated to include interventions for his confusion or disrobing behavior, which were noted by staff as new developments. Interviews with staff, including the LVN and DON, indicated that the facility was aware of the resident's increased confusion and fall risk but did not take appropriate action to update the care plan. The facility's policy required care plans to be updated within seven days of a comprehensive MDS assessment, but this was not adhered to, leading to a deficiency in care planning for Resident #57.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to ensure the dignity and privacy of Resident #57, who was found on the floor after a fall with his brief around his ankles, exposing him. Despite the presence of three staff members in the room, no measures were taken to protect his dignity, such as closing the door, pulling curtains, or covering the resident. Resident #57, who has a history of dementia and was recently diagnosed with a UTI and shingles, was more confused than usual, which may have contributed to the incident. The facility's failure to address his confusion and disrobing behavior in the care plan was noted. Resident #66 was found with long, untrimmed fingernails, which could lead to skin breakdown and infection. Despite the facility's policy that aides should trim nails, it was unclear why Resident #66's nails were not maintained. The DON mentioned that Resident #66 would refuse nail trimming and showers, but no documentation of these refusals was found in the care plan or progress notes. This oversight in maintaining personal hygiene and dignity was a failure on the part of the facility. The facility's policy on promoting and maintaining resident dignity was not adhered to in these cases. Both residents were not provided with the necessary care and attention to ensure their dignity and respect, as outlined in the facility's policy. The lack of appropriate interventions and documentation for both residents highlights a deficiency in the facility's care practices.
Failure to Submit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete, encode, and submit a Discharge MDS Assessment for a resident who was discharged from the facility. The resident, a male with Alzheimer's Disease and Vascular Dementia, was admitted to hospice care and discharged at his family's request. Despite the requirement to complete a Discharge MDS Assessment within 14 days of discharge, the facility did not have any record of such an assessment being prepared, submitted, or accepted for this resident. Interviews with the Assessment Nurse, DON, and Administrator revealed a lack of clarity and adherence to the required timelines for MDS submissions. The Assessment Nurse acknowledged the oversight and the necessity of these assessments for billing and patient documentation. The DON and Administrator also recognized the failure to submit the Discharge MDS Assessment, which could lead to billing issues. The facility's policy mandates the completion of an OBRA discharge assessment within 14 days, which was not followed in this case.
Failure to Update Care Plan and Protect Resident Dignity
Penalty
Summary
The facility failed to update the care plan for Resident #57, who was admitted with multiple diagnoses including COPD, atrial fibrillation, heart failure, type 2 diabetes, and major depressive disorder. Despite a significant change in condition, including increased confusion and a fall, the care plan was not adjusted to reflect new physician orders or behaviors related to a UTI and antibiotic treatment. The resident's care plan did not include interventions for the recent diagnosis of a UTI, changes in antibiotic prescriptions, or the resident's confused behaviors. Observations and interviews revealed that Resident #57 experienced increased confusion and had a fall without injury, during which he was found face down on the floor with his brief around his ankles. The resident had been sent to the hospital previously for confusion and shaking, and upon return, continued to show signs of confusion. Despite these events, the care plan was not updated to address these changes, and staff did not take appropriate measures to protect the resident's dignity during care. Interviews with staff, including LVNs and the DON, indicated that the resident's confusion and disrobing behaviors were not adequately addressed in the care plan. The facility's policy required care plans to be updated within seven days of a comprehensive MDS assessment, but this was not followed. The Administrator acknowledged that interventions could have been added to address the resident's confusion and disrobing behaviors, and staff failed to protect the resident's dignity during care, as observed by the surveyor.
Failure to Follow Physician Orders for Edema Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with edema, as per physician orders and the comprehensive care plan. The resident, who had a history of hypertension and hemiplegia, was supposed to wear compression socks daily to manage edema. However, observations revealed that the resident was not wearing the prescribed compression socks on multiple occasions, despite having a physician's order to wear them from 7:00 AM to 7:00 PM. Interviews with the resident indicated that she did not refuse to wear the compression socks, and there was no documentation of any refusal in the medical records. The resident consistently pointed to her swollen feet and confirmed that she was not in pain but acknowledged the need for special socks to manage the swelling. Despite this, the resident was observed wearing non-skid socks instead of the prescribed compression socks, and her right leg was visibly swollen. The nursing staff, including LVN A, admitted to not following the physician's orders and failing to apply the compression socks as required. LVN A documented that the socks were applied without actually observing the resident, citing being busy as the reason for the oversight. The Director of Nurses and other staff members confirmed that there was no record of the resident refusing the compression socks, and the failure to apply them was acknowledged as a mistake by the staff involved.
Failure to Secure Hazardous Substances in Resident's Room
Penalty
Summary
The facility failed to ensure a safe environment for Resident #71 by not securely storing potentially hazardous substances, such as mouthwash and hand sanitizer, in his room. Resident #71, who was admitted with diagnoses including unspecified dementia and severe cognitive impairment, was found to have a large bottle of mouthwash and a bottle of hand sanitizer in his room. These items were observed despite the facility's policy that such substances should not be accessible to residents, particularly those with cognitive impairments. Interviews with staff revealed a lack of awareness and enforcement of the facility's policy regarding hazardous substances. A Hospitality Aide, who had been at the facility for two weeks, was unaware of any hazards in resident rooms and had not observed mouthwash or hand sanitizer. Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON) confirmed that residents, especially those with cognitive impairments, should not have access to these items. The facility's failure to prevent these items from being in Resident #71's room indicates a lapse in supervision and adherence to safety protocols.
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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 Bastrop
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bastrop Lost Pines Nursing And Rehabilitation Cent | 0.1 mi | ★★★★★ | 10 | 1 |
| Windsor Nursing And Rehabilitation Center Of Bastr | 0.3 mi | ★★★★★ | 1 | 0 |
| Towers Nursing Home | 14 mi | ★★★★★ | 3 | 0 |
| Elgin Nursing And Rehabilitation Center | 17.5 mi | ★★★★★ | 2 | 0 |
| Oakcrest Nursing And Rehabilitation Center | 22.8 mi | ★★★★★ | 8 | 0 |
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