Ballinger Healthcare And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 resident (Resident #1) reviewed for accidents, hazards, supervision. CNA A and CNA B improperly transferred Resident #1 by hooking their arms under hers. The failure could place residents who required assistance during transfers at risk for injuries. The findings included:Review of Resident #1's admission Record, dated 4/14/26, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including fracture of the left hip, stroke, dementia with agitation, and osteoporosis. Review of Resident #1's Quarterly MDS Assessment, dated 3/20/26, revealed:She had a BIMS of 1 of 15 (indicating severe cognitive impairment) and showed signs of delirium including inattention and disorganized thinking.She rejected care 1 to 3 days of the previous 7.She was dependent on staff for chair to bed transfers. Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to ensure they employed had a full time or interim DON from 12/27/2025 through present (02/19/2026). This failure could place all residents at risk of not receiving necessary care and services. Findings included: During an interview on 02/19/2026 at 2:55 PM, the Administrator said the previous DON's last day at the facility was 12/27/2025. The Administrator said the interim DON was the RNC whom would oversee the facility and was readily available by phone as needed. The Administrator acknowledged stated the RNC did not qualify to be the interim DON due to the RNC not being in the facility 8 hours a day. The Administrator said they had interviewed some possible candidates for the DON position. The Administrator said he did not believe the residents had had had any negative outcomes due to no current DON. as He said the RNC had been overseeing the facility plus and they had nursing staff available. Interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #2 and #36) of 4 residents observed for oxygen management. The facility failed to ensure Resident #2 and Resident #36 had an oxygen signs posted outside their room. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and at risk of harm and exposure to a fire hazard if staff and visitors are not aware of oxygen present.Findings included: Record review of Resident #2's admission record dated 02/19/2026, revealed she was admitted to the facility on [DATE] with diagnoses of dementia and heart failure. The admission record indicated She was [AGE] years old. Record review of the current care plan for Resident #2, last reviewed/revised: dated 09/10/2025, revealed in part indicated: The resident has Oxygen Therapy related to SOB due to CHF. Provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure each room was designed or equipped to assure full visual privacy for 3 (Rooms 5, 18 and 21) of 30 dual occupancy rooms reviewed for privacy in the facility. The facility failed to ensure that dual occupancy rooms were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being. Findings included: During an observation on 02/17/2026 at 2:35 PM, resident rooms 5, 18 and 21 on halls A and B revealed that each room had dual occupancy with an A and B bed in each. The rooms had a single ceiling to floor curtain that divided the center of the room but stopped approximately 12 inches from the wall. Both A and B beds had a side curtain each but they each had a gap of 18 inches and 30 inches and were unable to allow for beds to have total visual privacy. Interview on 02/19/2026 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #27) of one resident observed for g-tube feedings.The facility failed to ensure the ADON administered medication and water to Resident #27 via her gastrostomy tube (g-tube) by following facility policy.The Facility failed to ensure the ADON performed hand hygiene and changed gloves while administering medication via g-tube.The facility failed to ensure the ADON cleaned the plunger after it came off established clean field area before using it again.These failures could place residents at risk for fluid overload, weight loss, aspiration pneumonia, abdominal discomfort, and risk for spread of infection.Findings included:Review of Resident #27 face sheet dated 02/19/26 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of gastronomy status (indicates that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 12 residents (Resident #2) reviewed, in that: The facility failed to ensure Resident #2's eTAR for the month of January 2026 were completed by the nursing staff and not left blank. This failure could place residents at risk of not receiving proper care and having their personal needs met.The findings included: Record review of Resident #2's admission record dated 02/19/2026, revealed she was admitted on [DATE] with diagnoses of dementia and heart failure. The admission record indicated she was [AGE] years old. Record review of care plan for Resident #2dated 09/10/2025, revealed The resident has Oxygen Therapy related to SOB due to CHF. Provide reassurance and allay anxiety: Have an agreed-on method for the resident to call for assistance (e.g., call light, bell). Stay with the resident during episodes of respiratory distress. Record review of Resident #2's MDS assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #9) of 3 residents reviewed for infection control. The facility failed to ensure LVN A used recommended PPE for Resident #9 who was on EBP precautions when changing her urinary catheter. This failure could place residents at risk of cross contamination and the spread of infection. Finding included: Record review of Resident #9's admission record dated 02/17/2026, indicated she was admitted [DATE], diagnosis included uninhibited neuropathic bladder (Usually due to damage to the brain from a stroke or brain tumor. This can cause reduced sensation of bladder fullness, low-capacity bladder, and urinary incontinence. The admission record indicated she was [AGE] years old. Record review of Resident #9's care plan dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure chicken was thawed under running water or in the refrigerator. 2. The facility failed to ensure staff appropriately cleaned and sanitized the thermometer prior testing food temperatures. 3. The facility failed to ensure sick staff wore an appropriate face mask. 4. The facility failed to ensure staff wore effective hair restraints. 5. The facility failed to ensure food was stored in a manner that was not opened to the air. These failures could place residents at risk for food borne illness and cross contamination. Findings include: Observation and interview on 11/19/24 at 9:53 a.m. revealed: A bag of chicken thawing on the counter of the industrial sink, it was not in running water. There was a bag of chicken thawing in running water immediately next to it. Upon moving the thawing bag of chicken, a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Residents #2 and #5) reviewed for infection control. 1. RN A failed to wash her hands or use hand sanitizer between glove changes during wound care for Resident #5. 2. RN A failed to wash her hands or use hand sanitizer between glove changes during medication administration and PEG tube dressing change for Resident #2. These failures could place resident's risk for cross contamination and the spread of infection. Finding include: 1. Record review of Resident #2's admission record, dated 11/20/2024, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included gastrostomy status (a surgical procedure for inserting a tube through the abdomen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 treatment carts (Hall 4 cart) reviewed for medication storage. The facility failed to ensure the nurses' treatment cart was not left unlocked and unsupervised for 10 minutes on hall 4. This failure could place residents at risk of loss, diversion or accidental ingestion of medications. The findings include: During an observation on 11/20/24 at 09:10 AM till 09:20 AM revealed RN A left the nurse's treatment cart unlocked and unattended for approximately 10 minutes while she entered a resident's room to attend to them. The cart contained several ointments, nail clippers, dressings and several other normal saline bottles. The cart was facing the hall. During an interview on 11/20/24 at 11:05 AM, RN A said she was not aware she left the treatment cart unlocked. RN A said she always was very…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for one medication cart (carts A and C) of four medication carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure treatment cart A was locked when unattended. The facility failed to ensure medication cart C was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation and interview on 09/20/2023 from 8:30 AM to 09:00 AM, revealed treatment cart A and medication cart C were found unlocked and unattended in front of the nurses station with no staff in sight. The Surveyor waited by the carts until the ADON came around the corner, from the dining room and stated that she had only walked away for a little bit. The ADON stated that she knew that she shouldn't have left the cart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.