Central Texas Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or no later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures for 1 of 3 residents (Resident #1) reviewed for neglect. The facility failed to report an allegation of neglect involving Resident #1 to the State Reporting Agency (HHSC) within 24 hours of CNA D not providing adequate care.…

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 ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 3 residents (Resident #1) reviewed for ADL care. The facility failed to ensure Resident #1 was provided with timely incontinent care by facility staff. This failure could place residents at risk for discomfort, skin breakdown, and urinary tract infections.Findings include: Record review of Resident #1 face sheet, dated 1/16/2026, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: unspecified dementia (significant memory and thinking problems), unspecified convulsions (experiencing sudden, involuntary muscle spasms or full body shaking), chronic obstructive pulmonary disease (progressive lung disease). Resident #1 expired in the facility on 1/3/2026. Record review of Resident #1's Significant Change in Status…

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 drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 1 of 3 medication carts (Hall 400 nurse medication cart) reviewed for medication storage. The facility failed to ensure the nurses cart #1 for the 400 Hall did not contain nebulizers and inhalers that were opened and not labeled with the open date. This failure could place residents at risk of adverse medication reactions. Findings included: Observation on 05/28/25 at 11:30 AM revealed the nurse's medication cart #1 for the 400 Hall had the following opened medications with no open date labeled: 1. Advair diskus inhaler 2. Advair HFA 3. Albuterol Sulfate HFA 4. 2 boxes Ipratropium Bromide and albuterol sulfate inhalation solution Interview on 05/28/25 at 11:31 AM with RN B, she said once inhalers, nasal spray, and nebulizers are opened they need to be dated with open dates. She said it…

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 2 of 2 residents (Resident #52, Resident #161) reviewed for incontinent care. CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #52 and Resident #161. CNA A failed to follow Enhanced Barrier Precautions (EBP) while performing incontinent care for Resident #161. These failures could place residents at risk for cross contamination and the spread of infection. Finding included: Resident #52 Record review of Resident #52's facility face sheet, dated May 29th, 2025, revealed Resident #52 was a [AGE] year-old female admitted to the facility on [DATE]. Medical diagnoses included Huntington's Disease (disease affects a person's movements, thinking ability and mental health)…

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 interviews and record reviews the facility failed to ensure the residents had the right to participate in his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 5 residents (Resident #14) reviewed. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #14 prior to administering increased dose of Seroquel, a psychotropic medication, (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed. Findings included: Record review…

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 interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that could be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes for hospice services for Resident #1. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Record review of Resident #1's electronic face sheet 05/29/2025 revealed [AGE] year-old female admitted [DATE] and diagnoses included Congestive heart failure (CHF), (condition where the heart is unable to pump blood effectively), Dementia (a group of symptoms affecting memory, thinking, and social abilities that interfere with daily…

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 interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 15 residents (Resident #22 and Resident #31) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #22 prior to administering Buspirone, an anxiolytic (antianxiety medication) used to treat anxiety. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #31 prior to administering Aripiprazole, an antipsychotic medication used to treat psychosis. This failure could place residents at risk of…

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 develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 15 residents (Residents #22 and Resident #56) reviewed for care plans. The facility failed to ensure that Resident #22 had a care plan in place for the use of psychotropic medications. The facility failed to ensure that Resident #56 had a care plan in place for his orthotic flexion gloves (therapy gloves used to help the resident curl his fingers into a fist) or his PEG tube (percutaneous endoscopic gastrostomy - tube inserted into the stomach used for nutrition due to swallowing difficulties). These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #22 Review of Resident #22's admission…

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 residents had the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 1 resident (Resident #2) reviewed for restraints. The facility failed to ensure Resident #2 had documented, ongoing monitoring of her lap belt use and that she used her lap belt for the least amount of time possible. This failure could place the resident at risk of unnecessarily inhibiting the resident's freedom of movement, and the possibility of skin breakdown if not released from the lap belt at regular intervals. The findings included: Review of Resident #2's admission Record dated 4/17/24 revealed she was [AGE] year-old female originally admitted to the facility on [DATE] with a most recent admission date of 8/1/20. She had diagnoses which included cerebral palsy (congenital disorder of movement, muscle tone, or posture), generalized…

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 provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 (medication cart in secure unit) of 3 medication carts reviewed for pharmacy services, in that: The medication cart used for the secure unit had an insulin pen that had expired as indicated by the manufacturers recommendations. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an observation and interview on 04/16/24 at 11:44 AM the medication cart in the secure unit was inspected with LVN A present. In the top drawer of the medication cart was one insulin pen that was dated 03/06/24. LVN A said the insulin pen was good for 28 days once they were opened. LVN A said she believed it was the night shift staff that were supposed to monitor the medication cart and inspect for expired or undated medications. LVN A said if a resident received an expired insulin, it might not…

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 all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments for the facilities only medication room reviewed for labeling/storage of drugs and biologicals. The facility failed to provide separately locked, permanently affixed compartments for the storage of controlled drugs. These failures could place the facility at risk of drug diversion and access to medications. Findings included: Observation of the facility medication room with LVN B on 04/16/2024 at 03:32 pm revealed a narcotic lock box in the locked medication refrigerator. The Narcotic lock box was not secured to the fridge. The box contained four boxes of lorazepam 2mg/ml. An interview with LVN B on 04/16/2024 at 03:34 pm, stated the lock box was normally glued to the bottom of the fridge but it had gotten dislodged at some point. LVN B was unsure how long the box had been loose in the fridge. LVN B states she was off for a week and when she last worked the box was affixed to the fridge. An…

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 interviews and records reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (Resident #3) of 5 residents reviewed for base-line care plans. The facility failed to ensure Resident #3 had a baseline care plan developed within 48-hours after admission with goals and interventions. The non-compliance was identified as PNC. The noncompliance began on 11/30/2023 and ended on 12/26/2023 when the comprehensive care plan was developed. The facility had corrected the noncompliance before the survey began. This failure could place newly admitted residents at risk of not receiving individualized care and continuity of services. Findings included: Record review of Resident #3's Face Sheet, dated 01/23/2024, revealed Resident #3 was a [AGE] year-old female who was admitted into the nursing facility on 11/28/2023. 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.

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 four (Resident #2, Resident #12, Resident #39, and Resident # 44) of 23 residents reviewed for infection control. 1. The facility failed to ensure CNA A changed her gloves after they became contaminated during incontinent care while assisting Resident #44 and Resident #39. 2. The facility failed to ensure CNA B changed her gloves after they became contaminated during incontinent care while assisting Resident #12. 3. The facility failed to ensure CNA C changed her gloves after they became contaminated during incontinent care while assisting Resident #12. 4. The facility failed to ensure CNA D changed her gloves after they became contaminated during incontinent care while assisting Resident #2. 5. The facility failed to ensure CNA E…

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.