Querencia at Barton Creek

In the surveyor’s words

From the most serious findings on record at Querencia at Barton Creek, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Sep 5, 2025

  Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes for one (Resident #1) of nine residents reviewed for care plans. The facility failed to update Resident #1's care plan after a fall on 07/20/2025 with additional interventions to prevent another fall. The facility failed to update Resident #1's care plan after a physical therapy evaluation on 07/30/2025 determined Resident #1 should be transferred with two staff members. Resident #1 experienced a fall on 08/03/2025 and 48 hours later was diagnosed with a hip fracture from the fall and 24 hours later was in surgery for a full hip replacement. […]

• Immediate jeopardy, isolatedF689Sep 5, 2025

  Based on observations, interviews and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent avoidable accidents for 2 (Resident #1 and Resident #2) of 9 residents reviewed for quality of care. The facility failed to ensure CNA A used a gait belt when assisting Resident #1 with transfer on 08/03/2025 which resulted in Resident #1 falling and breaking her hip. The facility failed to ensure CNA A used two people assist with transfers as recommended on Resident #1's therapy evaluation on 07/30/2025, which determined Resident #1 should be transferred with two staff members. Resident #1 experienced a fall on 08/03/2025 and 48 hours later was diagnosed with a hip fracture from the fall. […]

• Actual harm, isolatedF684Sep 5, 2025

  Based on interviews and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 9 residents reviewed for quality of care. The facility failed to notice a change in condition after Resident #1 experienced a fall on 08/03/2025 and had visible signs of pain for 48 hours before being sent to the ER for a broken hip.The facility failed to complete post-fall assessments per policy for Resident #1 which caused Resident #1 to have an untreated hip fracture for up to 48 hours before outside medical attention was sought. […]

• No harm, potential for more than minimal, patternF880Dec 18, 2025

  Based 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 4 of 8 residents (Resident #11, Resident #13, Resident #19, and Resident #36) reviewed for infection control. 1. MA A did not conduct hand hygiene after preparing medications and prior to administering the medications for Resident #11, Resident #13, Resident #19, and Resident #36. 2. MA A did not sanitize the blood pressure cuff before or after assessing the blood pressure for Resident #11, Resident #13, Resident #19 and Resident #36 during medication pass. […]

• No harm, potential for more than minimal, patternF812Sep 20, 2024

  Based on observation, interviews, 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 2 kitchens. The facility failed to ensure staff (the cook) covered their facial hair with a hair restraint in the main kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 09/18/2024 at 9:57 a.m. revealed the [NAME] in the main kitchen at the serving line placing uncovered sauces on the serving table while not wearing a beard restraint properly. The [NAME] was observed to have his facial hair restraint down around his neck. […]