Pflugerville Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 4, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse and neglect for 3 of 24 residents (Residents #91, 81, and 92) reviewed for abuse/neglect. The facility failed to take sufficient protective measures after Resident #91 assaulted Resident #81 on 08/27/22 which resulted in Resident #91 assaulting and injuring Resident #92. On 11/30/22 at 5:30 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/04/22, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. […]

• No harm, potential for more than minimal, widespreadF657Feb 6, 2026

  Based on interviews and record reviews the facility failed to ensure a comprehensive care plan was developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 67 of 105 (1, 2, 3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25, 26,27,28,29,30, 31, 32, 33, 34, 35, 36, 37, 38, 39,40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 ) residents reviewed for IDT meetings/ care plans in that:The facility failed to complete a quarterly assessment for Residents 1, 2, 3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25, 26,27,28,29,30, 31, 32, 33, 34, 35, 36,… […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2022

  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 one of one kitchen reviewed for sanitation and food storage. The facility failed to ensure all food items were properly stored, labeled, dated, and discarded prior to their use-by or best-by dates and that all kitchen staff wore effective hair restraints while in the kitchen. These failures could place the residents at risk of foodborne illness. Findings included: Observation and interview on [DATE] at 6:50 a.m. revealed CK J was in the kitchen without a hair restraint. CK J was observed placing a steam pan in the service line. CK J stated hairnets were required in the kitchen. […]

• No harm, potential for more than minimal, patternF677Apr 3, 2025

  Based on observations, interviews, and record review the facility failed to ensure residents were given the appropriate services to maintain activities of daily living (ADLs) for three of seven residents (Resident #67, Resident #18, and Resident #2) reviewed for ADL abilities. Resident #67 had dirty, jagged fingernails and flaky, dry skin on legs. Resident #18 had long, jagged fingernails. Resident #2 had long, jagged fingernails, chipped nail polish and unbrushed teeth. This deficient practice could place residents who required assistance at risk of or not receiving care and services to meet their needs and avoid ADL decline. Findings included: Resident #67 Review of Resident #67's face sheet, dated 04/02/2025, reflected an [AGE] year-old female admitted to the facility on . […]

• No harm, potential for more than minimal, patternF812Apr 3, 2025

  Based 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. 1. The facility failed to ensure Dietary [NAME] C, Dietary [NAME] D and Dietary Aide E used proper hand hygiene during food preparation. 2. The facility failed to ensure Dietary Aide E wear a hair net and Dietary Aide F wear a beard guard when standing over the oven and the food prep table. These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings included: 1. Observation on 03/31/2025 at 9: 20 AM Dietary [NAME] C was wearing gloves in the kitchen. She was standing by the stove preparing lunch. […]