Shiner Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 1 of 6 residents (Resident #3) reviewed for medical records. The facility failed to ensure Resident #3's admission record, care plan, and MDS assessment included his diagnosis of colon cancer since 12/04/2025. These failures could place residents at risk for inaccurate medical records. The findings included:Record review of Resident #3's admission record, dated 03/17/2026, reflected a [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with diagnoses to include dementia (decline in cognitive functions (memory, reasoning, and thinking) which interferes with daily life) and gastrointestinal hemorrhage (GI bleeding). Colon cancer was not reflected as a diagnosis on his admission record. Record review of Resident #3's hospital documentation with admit date [DATE] reflected Resident #3 had 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.

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 for 1 of 1 kitchen reviewed, in that: 1. The ice machine in the kitchen was leaking. 2. The double door standing refrigerator was leaking water from the mechanism at the top, with containers of food in standing water at the bottom of the unit. 3. The silver refrigerator had an accumulation of ice inside the walls. The lid, base, and inside seal were visibly soiled with a black substance. 4. The white deep freezer had an accumulation of ice inside the walls. The lid, base, and inside seal were visibly soiled with a black substance. 5. 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. 6. The vent hood over the stove was inoperable. These deficient practices could place residents at risk for cross-contamination and foodborne illnesses. The findings were: 1.…

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 a safe, functional, and sanitary environment for 1 of 1 dining room reviewed, in that: The dining room air conditioning vents were visibly soiled. This deficient practice could result in residents living, staff working, and families visiting in an unclean and unpleasant environment. The findings were: Observation on 05/16/2025 at 12:00 p.m. revealed the facility dining room had eight air conditioning vents in the ceiling. Further observation revealed each vent was soiled with a black substance and with rust. Further observation revealed the return vent was covered with dust. During an interview with the Maintenance Director on 05/16/2025 at 2:20 p.m., the Maintenance Director confirmed that the eight air conditioning vents in facility dining room were rusty and soiled, and confirmed the return vent in the dining room was covered with dust. The Maintenance Director stated the Housekeeping Department was responsible for cleaning the return vent and that she was responsible for cleaning the ceiling air…

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 use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 42 days (5/11/24, 6/4/24, 6/5/24, 6/6/24, 6/7/24, 6/8/24, 6/10/24/, 6/12/24, 6/13/24, 6/14/24, 6/17/24, 6/18/24, 6/21/24. 6/22/24. 6/25/24, 6/27/24, 6/28/24, 6/29/24,7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/15/24, 7/16/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23,24, 7/24/24, 7/27/24, 7/28/24, 8/1/24, 8/2/24 and 8/12/24) of 184 days reviewed for nursing services. The facility had no RN coverage for 5/11/24, 6/4/24, 6/5/24, 6/6/24, 6/7/24, 6/8/24, 6/10/24/, 6/12/24, 6/13/24, 6/14/24, 6/17/24, 6/18/24, 6/21/24. 6/22/24. 6/25/24, 6/27/24, 6/28/24, 6/29/24,7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/9/24, 7/10/24, 7/11/24, 7/12/24, 7/13/24, 7/15/24, 7/16/24, 7/17/24, 7/18/24, 7/19/24, 7/20/24, 7/21/24, 7/22/24, 7/23,24, 7/24/24, 7/27/24, 7/28/24, 8/1/24, 8/2/24 and 8/12/24 for a total of 42 days from May 11, 2024 through August 12, 2024. This failure could result in residents 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure the residents had the right to formulate an advanced directive and determine the choice to recieve or not recieve CPR (cardiopulmonary resuscitation) for 3 (Resident #5, Resident #25, Resident #40) of 8 residents reviewed for accuracy and completeness of clinical records. 1 The facility failed ensure Resident #5's OOH DNR was not missing the physicians printed name. 2 The facility failed to ensure Resident #25's OOH DNR was signed a 2nd time by the resident representative. 3. The facility failed to ensure Resident #40's OOH DNR was signed a 2nd time by the resident. This failure could affect any residents who have medical records and could result in misinformation about professional care provided. Findings included: 1. Record review of Resident #5's admission Record, dated [DATE], revealed a [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of non-ST elevation myocardial infarction (type of heart…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 medication carts (medication A hall cart, medication B hall cart, and medication C hall cart) and 1 of 1 medication storage room reviewed for medications and pharmacy services, in that 1. The facility failed to maintain glucometer logs. 2. The facility failed to ensure expired supplies were discarded. 3. The facility failed to ensure loose pills were not stored in the medication cart. 4.) The facility failed to ensure staff administered Resident #39's omeprazole (antacid) and the ordered dose of polyethylene glycol (laxative). This failure could place residents at risk for not receiving therapeutic effects of treatments. The findings included: 1. During an observation and interview on [DATE] at 2:29 p.m. Nursing medication cart for the…

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 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 and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #25, Resident #26, Resident #43) of 16 residents and 1 (Hall A Medication cart) of 3 medication carts observed for infection control. 1. The facility failed to initiate enhanced barrier precautions for Resident #25, #26 and #43 who all required enhanced barrier precautions. 2. The facility failed to ensure an employee's name tag was not stored in a box of clean disposable wooden spoons used to mix crushed medications with food. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #25 Record review of Resident #25's admission Record, dated 12/13/24, revealed an [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses 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 observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #25) reviewed for comprehensive care plans: The facility failed to ensure Resident #25's care plan reflected that she had a chronic wound and was on enhanced barrier precautions. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings included: Record review of Resident #25's admission Record, dated 12/13/24, revealed an [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of Alzheimer's disease, chronic kidney disease stage…

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 observations, interviews and record reviews, 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 for 1 (Resident #5) of 8 residents reviewed for quality of care. The facility failed to follow provider orders and care plan interventions by not placing knee high compression socks on Resident #5 for edema (swelling caused by too much fluid trapped in the body's tissues). This failure could prevent the resident from receiving treatments and worsening of edema. Findings included: Record review of Resident #5's admission Record, dated 12/13/24, revealed a [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of non-ST elevation myocardial infarction (type of heart attack that occurs when a coronary artery is partially blocked, reducing blood flow to the heart muscle), hypertensive heart disease without heart failure (group of heart…

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 the resident environment remains as free of accident hazards as is possible for 2 (Resident #5 and Resident #40) of 8 residents reviewed for environment, in that: 1. The facility failed to ensure Resident #5 did not have medicated chest rub and a bottle of hair spray on a dresser in her room. 2. The facility failed to ensure Resident #40 did not have a beer in his room without staff's knowledge of it. This deficient practice could result in residents encountering potentially hazardous materials. The findings were: Record review of Resident #5's admission Record, dated 12/13/24, revealed a [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of non-ST elevation myocardial infarction (type of heart attack that occurs when a coronary artery is partially blocked, reducing blood flow to the heart muscle), hypertensive heart disease without heart failure (group of heart conditions that are caused by long-term…

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, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 2 of 6 (Resident #25 and Resident #34) residents reviewed for respiratory care. The facility failed to ensure Resident #25 and Resident #34 had an oxygen sign posted on their door to alert they had an oxygen tank and concentrator in their room. This deficient practice could place residents at risk for an increase in respiratory complications and make other unaware oxygen is in use. The findings included: Record review of Resident #25's admission Record, dated 12/13/24, revealed an [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of Alzheimer's disease, chronic kidney disease stage 3, and seizures. Record review of Resident #25's significant change MDS assessment, dated 12/4/24, revealed the resident's cognition was severely…

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 residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and what, if any, action has been taken to address them, for 2 of 4 residents (Residents #4 and #16) reviewed for pharmacy services. The facility failed to ensure the pharmacist's recommendations to Residents' #4's and #16's physician were reviewed by the physician for medication regimen review. This failure could place residents at risk for significant health status declines and could place residents on psychoactive medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life. Findings include: Resident #4 Record review of Resident #4's admission Record, dated 12/13/24, revealed a [AGE] year-old female admitted on [DATE] with diagnoses of dementia, chronic atrial fibrillation, and psychotic disorder with delusions due to know physiological condition, and major depressive disorder.…

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, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident # 5) of 8 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to ensure nursing staff did not document they put on compression stocking on Resident #5 when they did not put them on. This failure could affect any residents who have medical records and could result in misinformation about professional care provided. Findings included: 1. Record review of Resident #5's admission Record, dated 12/13/24, revealed a [AGE] year-old female admitted on [DATE], and readmitted on [DATE] with diagnoses of non-ST elevation myocardial infarction (type of heart attack that occurs when a coronary artery is partially blocked, reducing blood flow to the heart muscle), hypertensive heart disease without heart failure (group of heart conditions 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 observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for 2 of 2 residents (Residents #5 & #31) reviewed for assistance with ADL care, in that: 1. The facility failed to prevent Resident # 5 from missing 2 of 13 scheduled showers between 09/29/23 - 10/26/23. 2. The facility failed to prevent Resident #31 from missing 9 of 11 scheduled showers between 10/01/23 and 10/26/23. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. The findings included: 1. Record review of Resident #5's face sheet dated 10/27/2023 reflected a [AGE] year-old male admitted on [DATE] with a primary diagnosis of chronic kidney disease, stage 3 unspecified (a condition where the…

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 for 1 of 1 facility reviewed for food storage sanitation in that: 1. The facility failed to maintain the cleanliness of the ice maker found within the kitchen. 2. The facility failed to remove past dated items from the dry food storage. 3. The facility failed to remove past dated items from a combined resident/staff refrigerator within the medication storage room. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation and interview on 10/24/23 beginning at 10:59 AM revealed an ice maker in the kitchen with a dark grey substance built up inside the unit. The DM stated the MS came to clean the unit on a recurring basis. The DM stated she was not sure what the substance was and stated she was not previously aware of the substances' presence. The DM stated it was her expectation that the ice maker be clean and the substance reflected…

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 2 of 6 staff (MA F & LVN A) reviewed for infection control, in that: 1. MA F did not sanitize her hands prior to administering eye drops to Resident #37. 2. LVN A did not sanitize her hands prior to administering insulin to Resident #45, removed gloves from a box, and placed them in her pocket to use. These deficient practices could place residents at-risk for infections. The findings included: 1. During an observation on 10/26/23 at 10:16 a.m. MA F planned to administer eye drops to Resident #37. MA F sanitized her hands at the medication cart. MA F carried the medication into the room and closed the door with her bare hands. Without sanitizing her hands, MA F went to the resident's bedside tabled, grabbed a pair of gloves, put on the gloves. MA F then pulled down the resident's lower eyelid, with her gloved hands, and…

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 residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #27) reviewed for dialysis in that: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #27. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs. The findings were: Record review of Resident #27's face sheet, dated 10/26/23 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with, hyperlipidemia (elevated cholesterol), cognitive communication deficit, end stage renal disease (condition in which the kidneys cease functioning on a permanent basis), type 2 diabetes mellites, and dependence on renal dialysis. Record review of Resident #27's most recent…

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 an irregularity noted by the pharmacist was acted upon for 3 (Residents #3, #12, & #36) of 5 residents reviewed for pharmacy review in that: 1. The facility failed to implement or provide reasoning for not implementing the recommendation by the licensed pharmacist to add a maximum daily dose of acetaminophen to the routine acetaminophen prescription order for Resident #12. 2. The facility failed to implement or provide reasoning for not implementing the recommendation by the licensed pharmacist to update the diagnosis for Risperdal for Resident #3. 3. The facility failed to implement or provide reasoning for not implementing the recommendation by the licensed pharmacist to order an A1C lab test (test result reflects your average blood sugar level for the past two to three months) because one was not done in the past 6 months for Resident #36. This failure could place resident as risk of not having their pharmacy consultations reviewed or…

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 maintain medical records that were complete and accurate on 1 (Residents #3) of 13 residents reviewed for resident records. The facility failed to ensure Residents #3 had a consent and diagnosis for risperidone (an antipsychotic used to treat certain mental/mood disorders) filled out correctly. This failure could place residents at risk of involuntary receiving psychotropic medication and not consenting to dosage changes. Findings included: 2. Record review of Resident # 3's face sheet, dated 10/27/2023, reflected a [AGE] year-old female admitted on [DATE] with a diagnosis which included dementia (a slow, progressive decline in mental function including memory, thinking, judgment, and the ability to learn), psychotic disorder (affect brain function by altering thoughts, beliefs or perceptions) with delusions, delusional disorder (is characterized by one or more firmly held false beliefs that persist for at least 1 month), and altered mental status (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.