Five Points of Pflugerville

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident's right to be free from misappropriation of resident property for one of five residents (Resident #1) reviewed for misappropriation. The facility failed to prevent a diversion of Resident #1's blister packet of 30 pills of the medication Gabapentin Oral Capsule, 100 MG for Peripheral Neuropathy. Resident #1's medication was taken from the facility by RN A on 07/03/2026 and was confiscated by the local PD during a routine traffic stop. This failure could place residents at risk for decreased quality of life, unrelieved pain, and misappropriation of property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the maintenance for comfortable sound levels for 4 of 8 residents (Resident #40, Resident #52, Resident #62, Resident #67) reviewed for homelike environment. The facility failed to ensure that Resident #40, Resident #52, Resident #62, and Resident #67 resided in an environment free from excessive noise levels. This failure placed residents at risk for becoming agitated and disturbed.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals) for 3 of 14 residents (Resident #8, Resident #35 and Resident #61) to meet the needs of the resident, in that:The facility failed to administer Resident # 8's pain medication on time for 34 administrations. The facility failed to administer Resident #35's Parkinson's medication on time as schedule for 34 administrations. The facility failed to ensure LVN E did not document Resident #61's medications in the MAR as being administered before resident took his medications. These failures placed Residents at risk for uncontrolled pain, tremors, decrease quality of life and hospitalization.3. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure storage of medications used in the facility were in accordance with currently accepted professional principles and included the appropriate expiration dates to preserve their integrity for the stored medications, and to store medications properly to prevent deterioration for one medications (400-hall Nurse and Medication aide cart) carts out of four reviewed for medications storage for three (Resident #s 57, #62 and # 100) of 8 residents review in that:1. The facility failed to ensure an expired OTC medication belonging to Resident #57 was removed from the 400-hall nurse's cart after it was opened and used.2. The facility failed to label Resident #62's insulin pen with the opened date after it was opened and being used on the 400-hall nurse's cart.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for three of three days reviewed for menu adherence. The facility failed to serve the lunch menu as planned on 5/12/2026 and on 5/13/2026. CK M failed to use a large enough scoop for oatmeal during breakfast on 5/14/2026 and failed to serve orange juice to Resident #95. These failures placed residents at risk for decreased intake, weight loss, and nutritional inadequacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food did not look or taste good and that it was frequently cold from 1 of 1 kitchen. The test tray of the lunch meal on 05/13/2026 was lukewarm, unappetizing in appearance (no condiments provided, and no beans observed in charro beans) the chicken fajita tasted heavily salted, and the tray lacked meal items described on the menu without a substitution (guacamole 5/13/26). [...]

Inspectors wroteBased 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 one of one kitchens reviewed for sanitation. The facility failed to ensure all food items were dated with an open date on 5/14/2026. The facility failed to ensure all food items were properly covered, labeled and dated on 5/12/2026 and on 5/14/2026. CK N failed to ensure that the temperature of fried chicken was checked before serving lunch on 5/12/2026. CK N failed to ensure that the pureed enchiladas were at least 135 when serving lunch on 5/12/2026. The facility failed to ensure that the thermometer was sanitized between testing each food item. These failures placed resides at risk for foodborne illness.

Inspectors wroteBased 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 and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #2, Resident #3, Resident #74) reviewed for infection prevention.1. The facility failed to ensure Treatment Nurse labeled Resident #74's wound dressing on 05/12/2026.2. The facility failed to ensure CNA J properly performed perineal care for Resident #2 with foley catheter on 05/12/2026.3. The facility failed to ensure Resident #2's catheter drainage bag was positioned correctly and not laying on the floor on 05/13/2026.4. [...]

Inspectors wroteBased on interviews, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for 1 of 8 (Resident #24) residents observed for dignity. The facility failed to ensure Resident #24 had her chin and neck hair trimmed. These failures could place residents at risk of experiencing humiliation, degradation, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 1 (Resident #24) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure the MDS dated [DATE] was updated to reflect all of Resident #24's current functional abilities. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a significant medication error for 1 of 1 (Resident # 74) resident reviewed for pharmacy services. The facility failed to ensure Resident # 74 received scheduled medication within the ordered liberalized time range: 07:00am-09:00am, 11:30am-2:00pm, 6:30pm-10:30pmThis deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization. Findings Included:Record review of Resident #74's undated face sheet reflected a 65-year female was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 2 of 8 residents (Resident #32 and Resident #50) reviewed for dietary services. 1. The facility failed to ensure Resident #32 received his prescribed diet of pureed texture. 2. The facility failed to ensure Resident #50 received his prescribed diet of mechanical soft texture. These failures placed residents at risk of choking, aspiration (inhaling food), and diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from verbal abuse for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to prevent [CNA B], from verbally abusing Resident #1 on 11/23/2025 at 3:15 PM. This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to distribute and serve food in accordance with professional standards on only the 500 Hall. Staff were observed moving from one resident to another without using hand hygiene between meals. The failure places residents at risk of cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medical records were accurately documented for four(Resident #1, Resident #2, Resident #3, and Resident #4) of six residents reviewed for accurate medical records. The facility failed to have documentation that they provided care to Resident #1 from 10pm to 6am from [DATE] - [DATE]. Resident #1 was on hospice and found deceased around 6am and there was no information of what care was to be provided during rounds or that Resident #1 was having a change of condition that required intervention. The facility failed to have documentation that they provided care to Residents #2, #3, and #4 from 10p to 6a from [DATE] - [DATE]. These failures could place residents at risk of not receiving timely care and services, accidents, harm, and death.

Inspectors wroteBased on interviews and record review, the facility failed to properly discharge and include all other necessary information, including a copy of the resident's discharge summary, and any other documentation, to ensure a safe and effective transition of care for 1 of 7 residents (Resident #1) reviewed for transfer and discharge requirements. 1. The facility failed to provide all necessary information and/or documentation for a safe and effective transition to the resident, responsible party (RP), and ombudsman for Resident #1. 2. The facility failed to document a discharge summary or plan for a safe discharge for Resident #1. This failure could place residents at risk of not receiving the necessary care and services when discharged to meet their physical and psychological needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 (Resident #47, Resident #59, and Resident #70) of 8 residents reviewed for care plans. The facility failed to ensure Resident #47's, #59's, and #70's care plan was revised to reflect the change of activity level. This failure placed residents at risk of not having their needs reviewed and revised when needed to ensure appropriate care is being provided.

Inspectors wroteBased on observations, 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 three of eight residents (Resident#20, Resident #77, and Resident #56 ) reviewed for ADL care. 1. The facility failed to ensure Resident #20's and Resident # 77's nails were cleaned, trimmed, and did not have any rough edges. 2. The facility failed to ensure Resident # 56 was free of facial hair on 3/17/25-3/19/25. These failures could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure DM wore a beard guard while in the kitchen. This failure could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased 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 6 (Resident # 7, Resident #17, Resident #33, Resident #36, Resident #44, and Resident #51) of 9 residents reviewed for infection control. 1. The facility failed to ensure Student Nurse A sanitized or washed her hands prior to touching contaminated surfaces (her shirt, wheelchair arm rest, and clothes of other residents) prior to touching Resident #33, Resident #44, Resident #7, and Resident #36's food. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 (Resident #15, Resident #50, and Resident #52) of 15 resident reviewed for dignity. The facility failed to ensure Resident #52 received their meal with other residents at their table. The facility failed to ensure that Resident #15 and Resident # 50 received their meal during the dining room meal pass while other dining room residents were receiving their lunch meals. This failure could place residents at risk of diminished dignity and affect their quality of life.

Inspectors wroteBased on observation, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 10 residents (Resident #239) reviewed for comprehensive care plans. The facility failed to implement Resident # 239's care plan instructions of having fall mat in place beside bed. This failure could place residents at risk for not receiving proper care and services due to care plans instructions not being implemented.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide, based on comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging interaction in the community for 3 of 8 residents ( Resident #47, Resident #59, and Resident # 70) reviewed for activities. 1. The facility failed to provide Residents #47 and #70 one-on-one activities three times per week during the months of January, February, and March of 2025. 2. The facility failed to provide Resident #59 one -on- one during the month of January, February and March of 2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #63) of 5 residents reviewed for quality of care. The facility failed to obtain Resident # 63's meal preferences. The facility failed to implement and monitor RD recommendations of snacks with protein and Med Pass 2.0 2 oz. BID for Resident # 63. These failures could place residents at risk of weight loss and decreased health status.

Inspectors wroteBased on observation, interview the facility failed to ensure medications and biologicals were stored in the medication refrigerator located in 1 of 1 medication room. The over-the-counter medication of Probiotics was stored in the locked refrigerator on the secure unit where food and open drink containers that belonged to staff were also being stored. This facility failure placed the facility's residents at risk of being administered contaminated medication and or supplements.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for one (1) of three (3) residents (Resident #51) reviewed for food allergies. The facility failed to honor Resident #51's food preference of large portions according to his care plan and meal ticket. This failure could place the residents at risk of not having their preference honored and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of six residents reviewed for quality of care. The facility failed to ensure Resident #1 was assessed by a nurse before CNA A got him off the floor after an unwitnessed fall on 01/14/25. This failure could place residents at risk of not receiving necessary medical care, harm, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to: - Ensure Resident #1 was transferred per her transfer status (hoyer lift with two-person assistance) on two occasions on [DATE]. On the first occasion, LVN A and CNA B lost their grip and Resident #1 slid to the ground. LVN A, CNA B, and CNA C transferred her from the ground to the bed without a hoyer lift. Approximately 24 hours later her legs were swollen, red, and warm to touch. She was transferred to the ER where she was diagnosed with two femur fractures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to: - Ensure Resident #1 was transferred per her transfer status (hoyer lift with two-person assistance) on two occasions on [DATE]. On the first occasion, LVN A and CNA B lost their grip and Resident #1 slid to the ground. LVN A, CNA B, and CNA C transferred her from the ground to the bed without a hoyer lift. Approximately 24 hours later her legs were swollen, red, and warm to touch. She was transferred to the ER where she was diagnosed with two femur fractures. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of three residents reviewed for quality of care. The facility failed to identify bruising and changes in skin for Resident #1 and Resident #2. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care, in that: The facility failed to ensure Resident #1's Eliquis (blood thinner) was held two days before a tooth extraction procedure, subsequently causing him to go without the procedure, leaving him in pain, and feeling frustrated and neglected. This failure placed residents at risk of frustration, uncontrolled pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to receives adequate supervision to prevent accidents for 2 of 8 residents (Residents #1 and 2) reviewed for falls. The facility failed to ensure Residents #1 and #2's care plan interventions related to falls and a fall risk assessment tool were implemented. Resident #1 fell on [DATE] and sustained a hip fracture requiring surgical intervention. This failure placed residents at risk of falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that Preadmission Screening and Resident Review (PASARR) federal requirements were met for 1 of 1 resident reviewed for delinquent PASARR processes. The facility failed to ensure Resident #1 received the services recommended by the PASARR department when they failed to order her wheelchair by the required deadline. This failure caused a delay in her Medicaid Entitled Service. This failure placed Resident #1 at risk of not achieving or maintaining her highest practicable level of physical functioning and could potentially result in increased disability.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights,that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment, for 6 of 16 residents (Residents #7, #8, #15, #17, #49, and #56) reviewed for care plans. 1. The facility failed to ensure Resident #7's bowel incontinence was reflected in her care plan. 2. The facility failed to ensure Resident #8's need for assistance with her activities of daily living was developed in her care plan. 3. The facility failed to ensure Resident #15's pain was reflected in his care plan. 4. The facility failed to ensure Resident #17's need for TED Hose was reflected in her care plan. 5. [...]

Inspectors wroteBased 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 for food procurement. The facility failed to ensure dietary staff who had facial hair wore restraints. The facility failed to ensure refrigerated food items were dated when opened or prepared in 1 of 1 refrigerator. The facility failed to ensure dried food goods were dated and sealed when opened in 1 of 1 pantry. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 residents out of 24 (Resident #7 and 10)residents reviewed for MDS assessments. 1. Facility failed to ensure Resident #7's quarterly MDS, dated [DATE], assessment accurately reflected she was on a mechanically altered diet. 2. Facility failed to ensure Resident #10's quarterly MDS, dated [DATE], accurately reflected her cognitive status related to her ability to communicate. These deficient practices could place residents at [NAME] of inadequate care.

Inspectors wroteBased on observation, 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 2 of 16 residents ( Residents #7 and #34) reviewed for assistance with ADL's. 1. Nursing staff failed to clean and file Resident #7's fingernails which were long and had a substance encrusted under them. 2. The facility staff failed to ensure Resident #34's fingernails were free of an encrusted substance under them. These deficient practices could place residents at risk of decreased self-esteem and dignity.

Inspectors wroteBased 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 and to help prevent the development and transmission of communicable disease and infection for 1 of 4 residents (Resident #8) reviewed for infection control. The facility failed to ensure CNA C performed hand hygiene and changed gloves before touching Resident #8's clean brief. This failures could place residents at-risk for infection.

Inspectors wroteCitation Text for Tag 0600, Regulation FF14 Based on interview and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for one (Resident #1) of six residents reviewed for pain, in that: Facility nursing staff failed to apply a fentanyl patch for pain on Resident #1 on 11/15/23 as ordered and he experienced pain. This failure could place residents at risk of experiencing pain and/or not getting therapeutic benefits of prescribed medications.