Inspection Reports for Pflugerville Nursing and Rehabilitation Center
104 Rex Kerwin Ct, Pflugerville, TX 78660, United States, TX, 78660
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
151% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 25, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse and neglect of Resident #1, specifically concerning a delayed report of an alleged pinching incident by a CNA.
Complaint Details
The complaint involved Resident #1 reporting being pinched by CNA C during a shower. The DON did not report the allegation immediately to the ADM as required. The ADM was informed about a week later by the Resident's Responsible Party (RP) and RN B. CNA C was suspended pending investigation. The allegation was found unconfirmed due to witnesses present during the shower.
Findings
The facility failed to ensure that the Director of Nursing (DON) reported allegations of abuse immediately, within 2 hours, to the Administrator (ADM) after Resident #1 reported being pinched by a CNA. The ADM investigated and found the allegation unconfirmed due to witnesses present during the shower. The facility conducted staff in-service training on abuse and neglect policies.
Deficiencies (1)
Failure to timely report suspected abuse to the Administrator within 2 hours as required.
Report Facts
Residents Affected: 3
Residents Affected: 1
Date of survey completed: Jun 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in abuse allegation involving pinching Resident #1 |
| RN A | Registered Nurse | Observed mark on Resident #1 and interviewed regarding abuse reporting |
| RN B | Registered Nurse | Received call from Resident #1's Responsible Party and reported allegation to ADM |
| CNA D | Certified Nursing Assistant | Interviewed about Resident #1 care and abuse reporting |
| CNA E | Certified Nursing Assistant | Observed shower and interviewed about abuse allegation |
| DON | Director of Nursing | Failed to report abuse allegation timely to ADM |
| ADM | Administrator | Abuse coordinator, received abuse report and conducted investigation |
Inspection Report
Routine
Deficiencies: 9
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, activities, medication storage, food and nutrition services, infection control, and pest control at Pflugerville Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate assistance with activities of daily living (ADLs) for residents, inadequate activities programming, unsecured medication storage, insufficiently trained dietary staff, improper food preparation and sanitation practices, failure to properly dispose of garbage, and ineffective infection prevention and pest control programs.
Deficiencies (9)
Failure to provide care and assistance to perform activities of daily living for residents who are unable, including inadequate nail and oral care for three residents.
Failure to provide an ongoing activities program to support residents' choice of activities, including failure to provide in-room activities for Resident #15.
Failure to ensure medication carts were locked and medications secure, allowing potential unauthorized access.
Failure to employ dietary staff with appropriate competencies and skills, including allowing an untrained dietary aide to cook unsupervised and expired food handler certificate.
Failure to prepare food by methods that conserve nutritive value, including lack of recipe for pureeing sausage and unmeasured water added.
Failure to store, prepare, and distribute food in accordance with professional standards, including improper hand hygiene and failure to wear hair nets and beard guards by dietary staff.
Failure to properly dispose of garbage and refuse, including overflowing garbage near food prep areas and presence of roaches.
Failure to maintain an infection prevention and control program, including failure to sanitize nasal spray medication and use of soiled gloves during peri care.
Failure to maintain an effective pest control program, with observed cockroaches in kitchen and dining areas.
Report Facts
Residents reviewed for ADL abilities: 7
Residents reviewed for activities: 5
Sausage patties pureed: 28
Food handler certificate expiration date: May 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in finding for using soiled gloves during peri care on Resident #35. | |
| MA B | Named in finding for failure to sanitize nasal spray medication before and after use on Resident #68. | |
| Dietary Aide E | Dietary Aide / Cook in Training | Named in findings for untrained cooking, expired food handler certificate, improper food preparation, and failure to wear hair net. |
| Dietary Manager | Named in findings for supervising dietary staff, training deficiencies, and food safety oversight. | |
| Dietary [NAME] C | Named in finding for improper glove use during food preparation. | |
| Dietary [NAME] D | Named in finding for improper glove use and hand hygiene during food preparation. | |
| Dietary Aide F | Named in finding for failure to wear beard guard during food preparation. | |
| Administrator | Named in interview regarding pest control and activity program oversight. | |
| Maintenance Supervisor | Named in interview regarding pest control program and response. | |
| IP | Infection Preventionist | Named in interview regarding infection control program supervision. |
| ADM | Administrator | Named in interview regarding nail care expectations. |
| DON | Director of Nursing | Named in interview regarding nail care expectations and infection control. |
| CNA B | Named in interview regarding nail care responsibilities. | |
| Activity Director | Named in findings regarding failure to provide activities and documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 1, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an incident involving a resident's injury during transport and failure to maintain proper infection control practices.
Complaint Details
The complaint investigation was substantiated. The facility failed to report an incident on 09/23/2024 where Resident #1's wheelchair tilted backward in the van causing a head injury. The Van Driver failed to ensure the resident was properly strapped. The incident was not reported to the State Agency. Additionally, RN A failed to perform hand hygiene and wear gloves during blood glucose monitoring of Resident #2, placing residents at risk of infection.
Findings
The facility failed to ensure timely reporting of an incident where a resident's wheelchair tilted backward in the facility's van causing a head injury, and the incident was not reported to the State Agency. Additionally, the facility failed to maintain an infection prevention and control program, as evidenced by a nurse not performing hand hygiene or wearing gloves during blood glucose monitoring of a resident.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities related to a resident's injury during transport in the facility's van.
Failure to maintain an infection prevention and control program, including failure of RN A to perform hand hygiene and wear gloves while checking a resident's blood glucose.
Report Facts
Date of incident: Sep 23, 2024
Date of survey completion: Oct 1, 2024
Years Van Driver employed: 2
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Failed to perform hand hygiene and wear gloves while checking Resident #2's blood glucose. |
| Administrator | Administrator and Abuse and Neglect Coordinator | Conducted investigation of the van incident, suspended Van Driver, and provided staff in-service on abuse and neglect. |
| Van Driver | Failed to properly strap Resident #1 in the van, causing wheelchair to tilt backward and resident to hit head; suspended after incident. | |
| Maintenance Director | Maintenance Director | Responsible for monthly van checks and training on securing wheelchairs. |
| DON | Director of Nursing | In-serviced RN A on infection control and hand hygiene after observing failure to follow protocol. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 17, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate treatment and care to Resident #1, specifically related to monitoring glucose levels and managing diabetes care.
Complaint Details
The complaint investigation found that Resident #1's glucose level was never checked during the stay despite a high glucose reading of 318 in April 2024. The nurse practitioner expected follow-up labs to be ordered, the physician acknowledged notification of the high reading but did not order further checks, and the director of nursing stated there was no policy on lab work for diabetic residents and nurses failed to notify the NP.
Findings
The facility failed to check Resident #1's glucose level or A1C for five months despite a diagnosis of type II diabetes and recent discontinuation of diabetic medications. This failure could place residents at risk of harm, including hospitalization. Interviews with the resident's nurse practitioner, physician, and director of nursing confirmed lapses in lab work and communication regarding high glucose levels.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically failure to monitor glucose levels and A1C for Resident #1 with type II diabetes.
Report Facts
Glucose level: 318
A1C value: 5.4
Date of hospital discharge: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner | Interviewed regarding diabetic care and lab monitoring for Resident #1 | |
| Medical Doctor | Interviewed regarding Resident #1's glucose monitoring and A1C testing | |
| Director of Nursing | Interviewed about facility policies and nursing responsibilities related to diabetic care |
Inspection Report
Routine
Deficiencies: 6
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including activities of daily living assistance, podiatry care, fall prevention, nursing competencies, psychotropic medication use, and medication administration.
Findings
The facility failed to ensure residents received necessary assistance with activities of daily living such as nail care and feeding, failed to provide podiatry care as ordered or requested, failed to maintain fall mats as ordered, failed to ensure the Director of Nursing was competent in PICC line removal procedures, failed to implement gradual dose reductions for psychotropic medications, and had a medication error rate exceeding 5%.
Deficiencies (6)
Failed to ensure residents unable to perform activities of daily living received necessary assistance with grooming and feeding, including nail care for Residents #210 and #213 and feeding assistance for Resident #10.
Failed to ensure Residents #72 and #82 received podiatry care as ordered or requested, placing them at risk for untreated podiatry issues.
Failed to ensure Residents #12 and #77 had fall mats in place according to physician orders and care plans.
Failed to ensure the Director of Nursing was competent in PICC line removal for Resident #212, including proper documentation and measurement of catheter length.
Failed to ensure Resident #31 had a preexisting mental illness warranting psychotropic drugs and failed to provide gradual dose reductions for Cymbalta and Zyprexa.
Medication error rate of 10.71% involving administration errors for Residents #38 and #44, including wrong medication formulations given.
Report Facts
Medication error rate: 10.71
Fall risk score: 19
BIMS score: 6
BIMS score: 7
BIMS score: 5
BIMS score: 12
BIMS score: 15
BIMS score: 3
BIMS score: 3
Medication dosage: 30
Medication dosage: 60
Medication dosage: 5
Medication dosage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN M | Licensed Vocational Nurse | Documented PICC line removal note for Resident #212 |
| DON | Director of Nursing | Removed PICC line for Resident #212 and interviewed about competency and procedure |
| RPh A | Pharmacist | Reviewed medication regimen and discussed psychotropic medication use for Resident #31 |
| MA H | Medication Aide | Administered medications with errors to Residents #38 and #44 |
| Administrator | Facility Administrator | Interviewed regarding expectations for medication error rates and psychotropic medication management |
Inspection Report
Routine
Deficiencies: 10
Date: Feb 16, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including inaccurate PASRR screening for mental illness, inadequate assistance with activities of daily living, failure to provide podiatry care, lack of fall mats as ordered, nursing competency in PICC line removal, unnecessary psychotropic drug use without gradual dose reduction, medication administration errors, improper labeling and storage of medications, food safety violations, and failure to perform hand hygiene during catheter care.
Deficiencies (10)
Failed to ensure accurate PASRR Level 1 Screening for mental illness diagnosis for Resident #94.
Failed to provide necessary assistance with activities of daily living including nail care and feeding for Residents #210, #213, and #10.
Failed to ensure Residents #72 and #82 received podiatry care as ordered and needed.
Failed to ensure fall mats were in place as ordered for Residents #12 and #77.
Failed to ensure the Director of Nursing was competent in PICC line removal procedure for Resident #212.
Failed to ensure Resident #31 had a preexisting mental illness warranting psychotropic drugs and failed to provide gradual dose reduction for psychotropic medications.
Medication administration errors occurred including wrong medication given to Residents #38 and #44.
Failed to date multi-dose vials of Tuberculin Purified Protein Derivative (Aplisol) when opened.
Failed to ensure proper food storage, labeling, and sanitation in the kitchen; failed to ensure hand hygiene and proper sanitizing of dishes by kitchen staff.
Failed to ensure CNA performed hand hygiene when changing gloves during catheter care for Resident #85.
Report Facts
Medication error rate: 10.71
Fall risk score: 19
BIMS score: 14
BIMS score: 6
BIMS score: 7
BIMS score: 5
BIMS score: 12
BIMS score: 15
BIMS score: 4
BIMS score: 9
Medication dose: 300
Medication dose: 60
Medication dose: 5
Medication dose: 10
Medication dose: 324
Medication dose: 325
Medication dose: 600
Medication dose: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN D | Licensed Vocational Nurse | Interviewed regarding PASRR screenings |
| LVN E | Licensed Vocational Nurse | Interviewed regarding PASRR screenings and Resident #94 mental illness diagnosis |
| DON | Director of Nursing | Interviewed regarding PASRR, nail care, podiatry, PICC line removal, psychotropic medications, hand hygiene |
| Administrator | Facility Administrator | Interviewed regarding PASRR, nail care, podiatry, PICC line removal, psychotropic medications, medication error rate, food safety, hand hygiene |
| CNA K | Certified Nursing Assistant | Interviewed and observed regarding nail care for Residents #210 and #213 |
| CNA J | Certified Nursing Assistant | Interviewed and observed regarding nail care for Resident #213 |
| Treatment Nurse | Interviewed regarding podiatry care for Resident #82 | |
| SW | Social Worker | Interviewed regarding podiatry care process and Resident #82 podiatry needs |
| RPh A | Pharmacist | Interviewed regarding psychotropic medications and gradual dose reductions |
| MA H | Medication Aide | Observed and interviewed regarding medication administration errors |
| RN C | Registered Nurse | Interviewed regarding medication vial dating |
| CK L | Cook | Observed and interviewed regarding food sanitation and hand hygiene |
| CNA I | Certified Nursing Assistant | Observed and interviewed regarding catheter care and hand hygiene |
| Infection Preventionist | Interviewed regarding hand hygiene expectations |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 6, 2023
Visit Reason
The inspection was conducted to assess compliance with meal service regulations, specifically to ensure residents received meals at regular times in accordance with their needs, preferences, and requests.
Findings
The facility failed to serve Resident #1 breakfast at the scheduled time of 7:30 AM, with the meal not delivered until 9:55 AM. This failure posed risks of weight loss, decreased quality of life, and feelings of unimportance for residents.
Deficiencies (1)
Failed to serve Resident #1 breakfast at the scheduled time of 7:30 AM, with the meal delayed until 9:55 AM.
Report Facts
Residents reviewed for frequency of meals: 3
BIMS score: 9
Scheduled breakfast time: 7.5
Actual breakfast time for Resident #1: 9.9167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Interviewed regarding missed meal delivery to Resident #1 | |
| DM | Dietary Manager who plated residents' food and was unsure why Resident #1's meal was missed | |
| DON | Director of Nursing who stated expectations for timely meal service and resident checks |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 5
Date: Dec 4, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident abuse and neglect involving Resident #91 assaulting Residents #81 and #92, resulting in injury.
Complaint Details
The complaint investigation was substantiated with findings of abuse and neglect involving Resident #91 assaulting Residents #81 and #92, resulting in injuries and immediate jeopardy status identified on 11/30/22.
Findings
The facility failed to protect residents from abuse and neglect, specifically failing to prevent Resident #91 from assaulting other residents and failing to provide adequate supervision and interventions. Additional deficiencies included failure to develop comprehensive care plans, failure to serve meals/snacks timely and appropriately, failure to maintain food safety standards, and failure to implement proper infection control practices.
Deficiencies (5)
Failed to protect residents from abuse and neglect, including failure to prevent Resident #91 from assaulting other residents and inadequate supervision.
Failed to develop and implement a comprehensive person-centered care plan to meet Resident #78's medical needs, including knee pain.
Failed to ensure meals and snacks were served at appropriate times and failed to provide suitable nourishing alternative meals and snacks, including failure to provide diabetic-friendly bedtime snacks.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including improper food labeling, dating, storage, and failure of kitchen staff to wear hair restraints.
Failed to establish and maintain an infection prevention and control program, including failure of CNA to change gloves and perform hand hygiene between tasks.
Report Facts
Residents reviewed for abuse/neglect: 24
Residents potentially affected by Resident #91: 26
Residents reviewed for care plans: 8
Residents reviewed for mealtime: 5
Residents reviewed for infection control: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN N | Licensed Vocational Nurse | Documented incident of Resident #91 pushing Resident #81 and involved in care |
| ADON A | Assistant Director of Nursing | Responded to incident involving Resident #91 and Resident #92, applied gauze, and coordinated care |
| CNA E | Certified Nursing Assistant | Assigned to one-to-one supervision of Resident #91 but did not maintain close supervision |
| CNA F | Certified Nursing Assistant | Witnessed assault by Resident #91 on Resident #92 and reported lack of training |
| CNA G | Certified Nursing Assistant | Involved in incident between Resident #91 and Resident #92 and failed to change gloves during care |
| LVN B | Licensed Vocational Nurse | Separated residents during assault, assigned one-to-one supervision, and provided care |
| DON | Director of Nursing | Oversaw investigation, assigned one-to-one supervision, and provided staff education |
| ADM | Administrator | Notified of immediate jeopardy and provided oversight of facility response |
| LD | Licensed Dietitian | Monitored kitchen sanitation and food storage, provided training on labeling and dating |
| DM | Dietary Manager | Responsible for kitchen operations and snack preparation |
| DA H | Dietary Aide | Observed with no hair restraint and responsible for food storage practices |
| CK J | Cook | Observed with no hair restraint and responsible for training dietary aides |
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