Eagle Pass Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Eagle Pass Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 25, 2025

  Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision , The facility failed to supervise Resident #1 who eloped from the facility on 09/07/24 through an unlocked door and sustained a fall with no injury in the course of the elopement. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/24/25. The non-compliance began on 09/07/24 and ended on 09/09/24. […]

• Actual harm, isolatedF684Feb 10, 2024

  Based on interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received timely treatment and care that was eventually diagnosed with a laceration to the left foot. On 7/28/23, Resident #1 was found to have blood on her left foot when transferring to bed around 4 PM by NA AC. NA AD was aware of the injury prior to the end of her shift at 2 PM but did not report to a charge nurse. Resident #1 was left without care to her foot from the time NA AD noticed it bleeding (time undetermined) until 4 PM when NA AC noticed the foot bleeding. […]

• Actual harm, isolatedF726Feb 10, 2024

  Based on observation, interview, and record review, the facility failed to ensure that all nursing staff have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 of 4 residents (Residents #1 and #3) reviewed for reportable incidents. The facility failed to complete in-service training to all direct care staff after four reportable incidents occurred involving Resident #1 and #3. Resident #1 had a fractured 5th toe. […]

• No harm, potential for more than minimal, patternF641Jul 23, 2026

  Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected thestatus of the residents for 3 of 6 residents (Resident #1, #2 and #3) reviewed for MDS assessments. 1.The facility failed to ensure Resident #1s cardiac pacemaker was reflected as an active diagnosis on the quarterly MDS assessment dated [DATE]. 2. The facility failed to ensure Resident #2's use of an opioid medication was reflected in the quarterly MDS assessment dated [DATE]. 3. The facility failed to ensure Resident #3's anxiety was reflected as an active diagnosis on the quarterly MDS assessment dated [DATE]. […]

• No harm, potential for more than minimal, patternF812May 21, 2025

  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 observed for kitchen sanitation. 1. The facility failed to ensure a tray of prepared and poured glasses of thicken beverages were dated. 2. The facility failed to ensure opened jar of jalapenos dated 05/05/2025 were refrigerated. 3. The facility failed to ensure a large opened plastic container of vanilla cream icing with lid open to air and partially used was sealed properly. 4. The facility failed to ensure half used bottle of salad dressing was refrigerated. 5. The facility failed to ensure a beverage container in the dining room with water was dated with prepared date. […]