Deficiencies (last 3 years)
Deficiencies (over 3 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
357% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 24, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care plans and fall prevention measures.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, including measurable objectives and timeframes. Staff did not follow fall interventions, specifically failing to keep Resident #1's bed in the lowest position, which could increase the risk of injury from falls.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Report Facts
Residents reviewed for care plans: 6
Resident #1 BIMS score: 3
Date of Resident #1 MDS assessment: Oct 4, 2025
Date of Resident #1 physician's order for low bed: Nov 29, 2022
Date of Resident #1 physician's order for fall precautions at all times: Nov 3, 2025
Date of Resident #1 fall with subdural hematoma: Oct 31, 2025
Date of revised care plan for Resident #1: Nov 3, 2025
Date of intervention low bed: Oct 23, 2025
Date of care plan indicating high fall risk: Feb 10, 2022
Date of observation and interview: Nov 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Nurse assigned to Resident #1 who acknowledged bed was not in lowest position and staff responsibility for fall prevention |
| DON | Director of Nursing | Stated staff training on fall prevention and responsibility for keeping beds in low position |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 18, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, accommodation of resident needs, accuracy of assessments, PASRR coordination, accident hazard prevention, pharmaceutical services, and medication storage and labeling.
Findings
The facility was found deficient in several areas including failure to treat residents with dignity, failure to ensure call lights were accessible, inaccurate clinical record documentation, failure to coordinate PASRR assessments for residents with mental illness, inadequate fall prevention measures, inaccurate medication reconciliation for controlled substances, and improper labeling and storage of medications and biologicals.
Deficiencies (7)
Failure to ensure resident's right to be treated with respect and dignity; resident referred to as a feeder.
Failure to ensure call lights were within reach for residents #12 and #31.
Failure to maintain accurate clinical records; Resident #5's MDS assessment inaccurately recorded insulin injection days.
Failure to coordinate PASRR assessments for residents #4 and #15 with mental illness diagnoses.
Failure to provide fall mats for Resident #12 as per care plan.
Failure to ensure accurate medication reconciliation for controlled substance Norco for Resident #31.
Failure to ensure all drugs and biologicals were properly labeled and stored; expired supplies found and insulin pens not dated.
Report Facts
Residents reviewed: 8
Residents reviewed: 6
Residents reviewed: 6
Residents reviewed: 4
Residents reviewed: 2
Residents reviewed: 5
Insulin injection days: 25
Medication doses remaining: 16
Medication doses available: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Named in dignity and respect deficiency for using the term 'feeder' | |
| DON | Director of Nursing | Interviewed regarding dignity and respect, call light accessibility, PASRR coordination, and fall prevention |
| CNA C | Interviewed regarding call light accessibility and fall mat placement | |
| MDS Coordinator | Interviewed regarding accuracy of assessments and PASRR referrals | |
| Medication Aide | Interviewed regarding medication reconciliation for controlled substances | |
| LVN A | Interviewed regarding insulin pen labeling and medication cart observations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 4, 2025
Visit Reason
The inspection was conducted to investigate deficiencies related to the facility's failure to develop and implement a comprehensive person-centered care plan for Resident #3, specifically regarding timely revision of the care plan following multiple falls.
Complaint Details
The investigation was complaint-related focusing on Resident #3's care plan updates following multiple falls. The complaint was substantiated as the facility did not update the care plan timely after falls, potentially risking resident safety.
Findings
The facility failed to update Resident #3's care plan in a timely manner after four falls occurring on 4/6/25, 4/17/25, 4/20/25, and 4/30/25. Interviews with staff revealed lapses in updating care plans due to staffing schedules, and the care plan did not reflect all falls or interventions until late May 2025. The facility acknowledged the importance of timely care plan updates to ensure resident safety and prevent further falls.
Deficiencies (2)
Failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for Resident #3.
Failed to revise Resident #3's care plan in a timely manner to reflect falls on four occasions.
Report Facts
Falls: 4
Residents reviewed for care plan revision: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | MDS Nurse | Responsible for updating care plans; acknowledged care plan was not updated timely after falls. |
| DOR | Director of Rehabilitation | Provided details on care plan updates and interventions for Resident #3. |
| DON | Director of Nursing | Responsible for ensuring care plans were updated; involved in updating Resident #3's care plan. |
| Administrator | Facility Administrator | Oversaw care plan update process and expected timely updates after falls. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 18, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure to timely report abuse, improper discharge without documentation, incomplete care plans, failure to provide appropriate treatment and care, and medication errors.
Complaint Details
The complaint investigation focused on allegations of abuse reporting failures, improper resident discharge and denial of return, incomplete care planning, inadequate treatment, and medication errors. The abuse allegation was not reported within required timeframes. Resident #4 was discharged without proper documentation and denied re-admission despite medical clearance. Resident #3's care plan and treatment for a cardiac pacemaker were incomplete and inadequate. Resident #2 had insulin doses held without physician orders, risking blood sugar spikes.
Findings
The facility failed to timely report an allegation of abuse involving a resident falling from bed, failed to document the basis for a resident's discharge and improperly denied re-admission, had incomplete and inadequate care plans for a resident's cardiac pacemaker, and failed to administer prescribed insulin medication correctly for another resident.
Deficiencies (5)
Failure to timely report an allegation of abuse to the State Survey Agency within 24 hours for Resident #1 who fell from bed.
Failure to document the bases for Resident #4's discharge and denial of re-admission despite medical clearance.
Incomplete care plan for Resident #3's cardiac pacemaker lacking name, serial number, and recent cardiac physician appointment.
Failure to provide appropriate treatment and care according to orders and resident preferences for Resident #3 related to cardiac pacemaker management.
Failure to ensure Resident #2 received prescribed insulin Glargine medication as ordered, with multiple doses held without physician orders.
Report Facts
Deficiencies cited: 5
Missed insulin doses: 4
BIMS score: 6
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Notified DON of Resident #1's fall; held insulin Glargine for Resident #2 without physician order. |
| DON | Director of Nursing | Interviewed regarding abuse reporting and medication administration policies. |
| Administrator | Facility Administrator | Interviewed regarding abuse reporting and Resident #4's discharge and re-admission. |
Inspection Report
Routine
Deficiencies: 4
Date: Apr 4, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident safety, food service safety, clinical record accuracy, infection control, and maintenance of resident equipment.
Findings
The facility was found deficient in several areas including failure to promptly repair resident equipment, improper food storage practices, inaccurate clinical records regarding hospice status, and failure to maintain proper infection control signage for residents on enhanced barrier precautions.
Deficiencies (4)
Failure to provide a safe, functional, and comfortable environment due to delayed repair of Resident #4's electric bed footrest.
Improper food storage with meat products stored above other food items in the kitchen freezer.
Failure to maintain accurate clinical records for Resident #4 regarding hospice discharge status.
Failure to maintain infection prevention and control program by not posting enhanced barrier precaution signs on Resident #4's door until the last day of the survey.
Report Facts
Residents affected: 1
Residents affected: 34
Residents affected: 1
Residents affected: 1
Employee signatures: 17
Employee signatures: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN K | Hospice RN | Met with Resident #4 to discuss discharge planning from hospice |
| CNA B | Entered maintenance work order for Resident #4's bed | |
| CNA F | Interviewed regarding Resident #4's bed complaints and hospice status | |
| MA D | Interviewed regarding Resident #4's bed complaints | |
| ADON | Assistant Director of Nursing | Placed maintenance work order for Resident #4's bed |
| Maintenance Director | Responsible for maintenance work orders and bed repair | |
| Administrator | Provided statements on maintenance and infection control policies | |
| Dietary Manager | Responsible for food storage in the kitchen | |
| Dietician | Interviewed regarding food storage training | |
| LVN A | Licensed Vocational Nurse | Interviewed regarding hospice care and infection control |
| DON | Director of Nursing | Interviewed regarding hospice discharge and infection control signage |
| MDS Coordinator | Responsible for updating care plans | |
| CNA C | Interviewed regarding hospice status and infection control signage |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 16, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to update care plans after resident falls and failure to conduct neurological assessments following unwitnessed falls.
Complaint Details
The complaint investigation found substantiated failures related to updating care plans after falls and completing/documenting neurological assessments as per facility protocol.
Findings
The facility failed to ensure care plans were updated after falls for three residents and failed to complete required neurological assessments for two residents following unwitnessed falls. Additionally, resident medical records were not accurately maintained, including missing neurological assessment documentation.
Deficiencies (3)
Failure to ensure comprehensive care plans were reviewed and revised after each assessment for 3 of 5 residents, specifically after falls on 7/19/24, 8/17/24, 8/18/24, and 8/30/24.
Failure to conduct neurological assessments as required by facility protocol for 72 hours after an unwitnessed fall with laceration on 08/18/24 for Resident #3.
Failure to accurately document neurological assessments in medical records for Resident #4 following a fall on 8/30/24.
Report Facts
Residents reviewed for care plans: 5
Falls dates: 4
Neurological assessments completed: 4
Frequency of neuro checks: 72
Neuro check frequency intervals: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Mentioned in relation to observations and interviews about falls and neurological assessments | |
| RN C | Provided information about neurological assessments and fall observations | |
| DON | Director of Nursing | Responsible for ensuring care plans and neurological assessments were updated and completed |
| AIT | Interviewed regarding responsibilities for care plan and neurological assessment compliance | |
| RN D | Completed neurological assessment for Resident #4 and documented it | |
| LVN B | Mentioned in relation to Resident #4's fall and neurological assessments | |
| RN E | Mentioned in progress notes and attempted interview |
Inspection Report
Complaint Investigation
Deficiencies: 14
Date: Jun 7, 2024
Visit Reason
Investigation of alleged abuse and neglect involving Resident #11 who sustained skin tears, bruising, and a left-hand fracture after care by CNA A.
Complaint Details
The complaint investigation was triggered by allegations of abuse and neglect involving Resident #11 who sustained injuries after care by CNA A. An Immediate Jeopardy was identified on 6/5/24 and removed on 6/7/24 after corrective actions. The facility failed to timely report the incident to the state and failed to suspend CNA A pending investigation.
Findings
The facility failed to ensure Resident #11 was free from abuse and neglect, failed to suspend CNA A pending investigation, and failed to timely report the incident to the state. An Immediate Jeopardy was identified and removed after corrective actions including termination of CNA A, staff education, and audits. Additional deficiencies included incomplete wound care documentation and improper insulin administration.
Deficiencies (14)
Failure to protect Resident #11 from abuse and neglect resulting in skin tears, bruising, and a left-hand fracture.
Failure to timely report suspected abuse and neglect to the state within required timeframe.
Failure to develop and implement policies and procedures to prevent abuse, neglect, and exploitation.
Failure to develop accurate PASARR screening for Resident #29 with mental health disorders.
Failure to develop comprehensive person-centered care plans for Residents #23, #27, and #39 including code status and psychotropic medication monitoring.
Failure to provide wound care according to orders and facility policy for Resident #11 and Resident #34, including failure to date and initial dressings and incomplete wound assessments.
Failure to provide respiratory care consistent with professional standards for Resident #6, including failure to change oxygen tubing weekly as ordered.
Failure to provide pharmaceutical services according to policy, including improper insulin administration by LVN C to Resident #26 (intramuscular instead of subcutaneous).
Failure to implement gradual dose reductions and obtain informed consent for psychotropic medications for Residents #12, #14, and #20.
Failure to ensure medication cart was clean and free of loose pills, debris, and unlabeled medications.
Failure to maintain infection prevention and control program; LVN C contaminated hands after washing by touching paper towel dispenser before wound care.
Failure to maintain all essential equipment in safe operating condition; dishwasher not reaching required wash temperature and vent hood not inspected and cleaned timely.
Failure to procure food from approved sources and store, prepare, distribute, and serve food safely; expired food in dry storage, freezer not maintaining freezing temperatures, unlabeled food items, and unclean ice maker.
Failure to provide rooms with minimum 80 square feet per resident in 20 of 46 resident rooms.
Report Facts
Residents affected: 1
Residents reviewed for PASARR: 8
Residents reviewed for care plans: 21
Residents reviewed for medication administration: 10
Residents reviewed for oxygen therapy: 3
Resident rooms reviewed: 46
Rooms not meeting minimum size: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in abuse and neglect incident involving Resident #11; not suspended pending investigation; contract terminated on 6/5/24. |
| LVN C | Licensed Vocational Nurse | Named in wound care deficiencies and improper insulin administration; failed to date and initial dressings; injected insulin intramuscularly instead of subcutaneously; contaminated hands during wound care. |
| DON | Director of Nursing | Interviewed regarding abuse incident, wound care, medication administration, staff education, and policies. |
| Administrator | Administrator | Interviewed regarding abuse incident, staff education, policies, and corrective actions. |
| LVN B | Licensed Vocational Nurse | Mentioned in wound care documentation and interview attempts. |
| LVN T | Licensed Vocational Nurse | Mentioned in wound care documentation and interview attempts. |
| PTA J | Physical Therapy Assistant | Received in-service training on abuse and combative resident protocols. |
| LVN F | Licensed Vocational Nurse | Received in-service training on abuse and neglect protocols. |
| CNA K | Certified Nursing Assistant | Agency CNA who received in-service training on abuse and combative resident protocols. |
| NA L | Nursing Assistant | Received in-service training on abuse and combative resident protocols. |
| CNA H | Certified Nursing Assistant | Received in-service training on abuse and neglect protocols. |
| COTA M | Certified Occupational Therapy Assistant | Received in-service training on abuse and neglect protocols. |
| LVN G | Licensed Vocational Nurse | Received in-service training on abuse and neglect protocols. |
| PTA N | Physical Therapy Assistant | Received in-service training on abuse and neglect protocols. |
| CNA O | Certified Nursing Assistant | Received in-service training on abuse and neglect protocols. |
| LVN P | Licensed Vocational Nurse | Received in-service training on abuse and neglect protocols. |
| LVN Q | Licensed Vocational Nurse | Received in-service training on abuse and neglect protocols. |
| CNA E | Certified Nursing Assistant | Received in-service training on abuse and neglect protocols. |
| SW | Social Worker | Received in-service training on abuse and neglect protocols. |
| ADON | Assistant Director of Nursing | Received in-service training on abuse and neglect protocols. |
| MS | Maintenance Supervisor | Interviewed regarding dishwasher and vent hood maintenance and cleaning. |
| DM | Dietary Manager | Interviewed regarding kitchen sanitation, food storage, and ice maker cleanliness. |
| Technician X | Contracted Dishwasher Technician | Interviewed regarding dishwasher operation and maintenance. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse, neglect, or injuries of unknown source involving Resident #11.
Complaint Details
The complaint investigation focused on Resident #11, who sustained injuries after care from CNA A. The facility failed to report the incident to the state reporting agency within the required 2-hour timeframe. The Director of Nursing (DON) stated the incident was initially treated as an injury of unknown origin rather than abuse, delaying the report until 4/2/24 after an x-ray showed a possible fracture. Interviews with CNA A and the Administrator confirmed the timeline and reporting failures.
Findings
The facility failed to report possible neglect or abuse of Resident #11 in a timely manner after the resident sustained injuries following care by a CNA. The investigation revealed multiple skin tears, bruising, swelling, and a possible fracture that was not reported immediately but only after new findings on 4/2/24. The facility also failed to ensure accurate PASARR screening for Resident #29, potentially placing residents at risk of not receiving needed assessments and specialized services.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or injuries of unknown source involving Resident #11.
Failure to ensure accurate PASARR screening for Resident #29 indicating mental illness and referral to state designated authority.
Report Facts
Residents reviewed for abuse and neglect: 9
Residents reviewed for PASRR: 8
Skin tears treated with steri-strips: 11
Days of antibiotic treatment ordered: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in the abuse/neglect finding related to Resident #11; described the incident and behavior of the resident during care. | |
| LVN B | Licensed Vocational Nurse | Documented initial skin tear treatment for Resident #11. |
| LVN C | Licensed Vocational Nurse | Documented skin tear assessments and treatments for Resident #11. |
| LVN R | Licensed Vocational Nurse | Documented X-ray results and treatment for Resident #11. |
| LVN S | Licensed Vocational Nurse | Documented discoloration and injury observations for Resident #11. |
| LVN T | Licensed Vocational Nurse | Documented left hand fracture with splint and edema for Resident #11. |
| DON | Director of Nursing | Interviewed regarding the incident, reporting timeline, and treatment decisions for Resident #11. |
| Administrator | Interviewed regarding awareness of the incident and reporting procedures. | |
| MDS Nurse | Interviewed regarding PASARR screening responsibility and assessment for Resident #29. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 24, 2024
Visit Reason
The inspection was conducted due to allegations of abuse and restraint involving Resident #1 and Resident #5, including the use of unauthorized physical restraints and verbal abuse by staff.
Complaint Details
The complaint investigation was substantiated with findings of abuse and neglect involving restraint and verbal abuse by RN A and other staff towards Residents #1 and #5. Multiple staff witnesses confirmed the allegations. Immediate Jeopardy was identified on 4/18/2024 and removed on 4/21/2024 after corrective actions.
Findings
The facility failed to immediately notify the physician and resident representative of a change in condition related to restraint and abuse of Resident #1. Resident #1 was restrained with a gait belt without physician orders or consents, and staff used profanity and verbal abuse towards residents. Multiple staff confirmed the abuse and restraint, and the facility identified an Immediate Jeopardy which was later removed. The facility also failed to ensure Resident #3 received timely incontinent care and failed to ensure nurse aide NA H was certified within four months of hire. Additionally, controlled substances were not properly secured on the medication cart.
Deficiencies (6)
Failure to notify physician and resident representative of change in condition related to restraint and abuse of Resident #1.
Failure to ensure Resident #1 was free from physical and verbal abuse, including unauthorized restraint with a gait belt and use of profanity by RN A.
Failure to provide incontinent care to Resident #3 when requested.
Failure to ensure nurse aide NA H was certified within four months of hire and was working without certification.
Failure to properly secure and label controlled substances on medication cart; pre-dispensing narcotics into medication cups without proper security.
Failure to develop and implement abuse policy that clearly defines restraint as abuse and ensure staff knowledge of reporting procedures.
Report Facts
Residents reviewed for abuse: 8
Staff in-serviced on abuse and neglect: 19
Staff roster count: 31
Medication dosages pre-dispensed: 4
Nurse aide hire date: Oct 11, 2022
Nurse aide training period: Nov 1, 2022
Nurse aide training period: Dec 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in multiple abuse and restraint findings involving Resident #1 and Resident #5. |
| DON | Director of Nursing | Interviewed regarding abuse, restraint, staff training, and notification procedures. |
| CNA B | Certified Nursing Assistant | Witnessed and reported restraint and abuse involving Resident #1. |
| CNA E | Certified Nursing Assistant | Witnessed and reported restraint and abuse involving Resident #1. |
| CNA D | Certified Nursing Assistant | Witnessed restraint use and reported fear of retaliation. |
| CNA N | Certified Nursing Assistant | Witnessed restraint use and reported to DON and Administrator. |
| CNA G | Certified Nursing Assistant | Witnessed restraint use and reported to DON. |
| CNA F | Certified Nursing Assistant | Witnessed restraint use and reported to DON. |
| LVN J | Licensed Vocational Nurse | Observed pre-dispensing controlled substances and interviewed about medication administration. |
| NA H | Nurse Aide | Worked without certification beyond four months; involved in neglect incident with Resident #3. |
| Medical Director | Medical Director | Interviewed regarding communication about restraints and abuse. |
| Administrator | Administrator | Abuse coordinator; interviewed about abuse reporting and investigation. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 20, 2023
Visit Reason
The inspection was conducted based on complaints and concerns related to care planning, pharmaceutical services, binding arbitration agreements, and infection prevention and control practices at Pleasanton North Nursing and Rehabilitation.
Complaint Details
The visit was complaint-related, triggered by concerns about care planning deficiencies, pharmaceutical service errors, arbitration agreement compliance, and infection control practices. Substantiation status is not explicitly stated.
Findings
The facility failed to develop and implement comprehensive person-centered care plans, provide accurate pharmaceutical services including medication storage and administration, ensure binding arbitration agreements included neutral arbitrator and venue provisions, and maintain proper infection prevention and control practices such as hand hygiene.
Deficiencies (4)
Failed to develop and implement a comprehensive person-centered care plan for Resident #22 that included measurable objectives and timeframes, specifically missing bowel and bladder continence interventions.
Failed to provide pharmaceutical services meeting residents' needs, including inaccurate narcotic log and unlabeled liquid lorazepam bottle for Resident #14, and failure to prime insulin pen prior to administration to Resident #35.
Failed to ensure binding arbitration agreements provided for selection of a neutral arbitrator and venue convenient to both parties for Residents #1, #14, and #22.
Failed to maintain infection prevention and control program; LVN A used bare hands to turn off sink faucet after handwashing before and after wound care for Resident #1.
Report Facts
Residents reviewed for care plans: 5
Residents reviewed for medication administration: 4
Residents affected by care plan deficiency: 1
Residents affected by pharmaceutical services deficiency: 2
Staff affected by pharmaceutical services deficiency: 1
Residents affected by arbitration agreement deficiency: 3
Residents affected by infection control deficiency: 1
Staff affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in medication administration and infection control deficiencies. |
| DON | Director of Nursing | Oversaw nursing care plans and commented on medication and infection control practices. |
| ADON | Assistant Director of Nursing | Oversaw revising and updating nursing sections of care plans. |
| Business Office Manager | Discussed admissions process and arbitration agreement handling. | |
| Director of Business Development | Responsible for admissions and arbitration agreement discussions with residents/families. | |
| Administrator | Provided information on arbitration agreement usage and facility policies. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 16, 2023
Visit Reason
The inspection was conducted as a routine annual survey of Pleasanton North Nursing and Rehabilitation to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were reported as unknown.
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