Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ballinger Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of hip fracture, stroke, dementia, osteoporosis, severe cognitive impairment, and dependence for transfers was observed being transferred by two CNAs who, despite applying a gait belt, hooked their arms under the resident’s arms and one also grabbed the seat of the resident’s pants during a pivot transfer. The DOR stated this method did not meet the facility’s expectations for a two-person gait belt transfer, which required both staff to control the resident using the gait belt only, and confirmed that hooking under the arms or using the seat of the pants was not appropriate. Facility in-service materials and written policy directed staff to use a gait belt and, when two staff were needed, to grasp the gait belt on each side to safely stand and turn the resident, but this procedure was not followed during the observed event.
The facility did not have a qualified full-time DON or an eligible interim DON for an extended period after the previous DON left. The Administrator reported that an RNC was overseeing nursing services and was available by phone, but acknowledged that the RNC did not meet DON requirements because they were not present in the facility 8 hours a day. The facility also lacked a written policy for DON requirements and relied on state regulations for guidance, and the Administrator believed there had been no negative resident outcomes during this time.
The facility failed to post required oxygen-in-use signage outside the rooms of two residents receiving oxygen therapy via nasal cannula. Both residents had documented diagnoses requiring oxygen, active care plans referencing oxygen therapy, and physician orders for oxygen at 2–5 L/min PRN or 2 L/min every shift, with observations confirming oxygen concentrators in use. Despite this, no oxygen signs were posted on their doors, contrary to facility policy and the stated expectations of the ADON and Administrator that such signage be used for safety and no-smoking precautions.
Surveyors identified that three dual-occupancy rooms lacked full visual privacy because the central ceiling-to-floor curtains stopped short of the wall and the side curtains for each bed left significant gaps, preventing complete separation between roommates. An interview with the Administrator confirmed that rooms without full visual privacy curtains could not provide privacy when requested and that there was no existing policy addressing privacy curtains.
A resident with a g-tube and multiple comorbidities did not receive g-tube medications according to professional standards or facility policy when the ADON administered crushed medications using excessive water volumes, failed to perform hand hygiene before care, and did not change visibly soiled gloves. The ADON placed a syringe plunger on an unclean bedside surface outside the clean field and reused it without cleaning, and did not fully dissolve certain medications, discarding undissolved portions so the resident did not receive full ordered doses. Facility policies required hand hygiene before resident contact and limited water flushes to 5–15 ml between medications, and the RNC later acknowledged expectations for proper infection control and g-tube procedures but could not locate specific g-tube medication training for staff.
A resident with dementia and CHF, care planned and assessed for oxygen therapy, had an order for PRN oxygen at 2–5 LPM via nasal cannula for SOB. Review of the resident’s January eTAR showed that nursing staff did not document oxygen administration, including oxygen use, pulse, respiratory rate, and time completed, on the eTAR, even though some information was recorded only in the vital signs section. The ADON and Administrator both stated that treatments were expected to be documented on the eTAR, and the facility’s documentation policy required complete and accurate documentation on all appropriate clinical record sheets.
A resident with an uninhibited neuropathic bladder, colostomy, and indwelling Foley catheter was care-planned for Enhanced Barrier Precautions (EBP), requiring gown and gloves for high-contact care such as catheter care. During an observed catheter change, an LVN performed hand hygiene and wore gloves but did not don a gown, despite EBP signage outside the room and gowns available in the room. The LVN later acknowledged she had been trained on EBP, knew a gown was required, and stated she forgot due to being distracted. The ADON and Administrator confirmed staff were expected to use appropriate PPE for this resident’s catheter care and that failure to do so could spread infections.
The facility failed to follow professional standards for food safety and infection control. Chicken was improperly thawed, and a staff member wore a face mask incorrectly while preparing food. Food storage was inadequate, with exposed chicken and dry milk on the floor. Hair restraint practices were not followed, and thermometer cleaning was insufficient, leading to cross-contamination. The facility's policies on thawing, storage, and infection control were not adhered to.
A nurse in an LTC facility failed to perform hand hygiene between glove changes during medication administration and wound care for two residents, leading to potential infection control issues. The nurse placed wound care supplies on a porous towel on the floor and did not adhere to the facility's infection control policies, which require hand hygiene and the use of non-porous barriers.
A nurse's treatment cart on Hall 4 was left unlocked and unsupervised for about 10 minutes, containing ointments, nail clippers, dressings, and saline bottles. RN A was unaware of leaving the cart unlocked while attending to a resident. The DON and Administrator confirmed the expectation for carts to be locked to prevent unauthorized access, as per facility policy.
Improper Two-Person Transfer Technique and Failure to Follow Gait Belt Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received adequate supervision and proper assistance devices during transfers, resulting in an unsafe transfer technique by two CNAs. The resident was an elderly female with a history of left hip fracture, stroke, dementia with agitation, osteoporosis, severe cognitive impairment (BIMS score 1/15), signs of delirium, and a pattern of rejecting care on some days. Her MDS and care plan documented that she was dependent on staff for chair-to-bed transfers and required two staff for bed mobility. During an observed transfer from bed, CNA A and CNA B assisted the resident to sit at the edge of the bed, placed a gait belt, and then each CNA hooked her arms under the resident’s arms; CNA A additionally grabbed the seat of the resident’s pants and CNA B grabbed the back of the gait belt before performing a pivot transfer. The Director of Rehabilitation (DOR) stated that the facility’s expectation for a two-person gait belt transfer was for the resident to be positioned between the two staff, with both staff using their hands on the gait belt to assist the resident to stand and control movement, and that hooking arms under a resident’s arms was not appropriate. The DOR described the resident as impulsive following a prior stroke, cognitively impaired with rapid onset of sundowning, and physically fragile due to weight loss, though still able to bear weight, stand, transfer, and walk short distances with encouragement but with poor balance. CNA A later stated she usually transferred residents by the seat of their pants, and the DOR indicated this was not a safe practice. CNA B initially denied but then admitted hooking her arms under the resident’s arms and acknowledged it was not the correct way to transfer. Facility in-service training and written policy on transfers specified the use of a gait belt and, when two staff were required, both were to grasp the gait belt to stand and turn the resident, which was not followed during the observed transfer.
Failure to Maintain a Qualified Full-Time DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the full-time Director of Nursing (DON) and did not have a qualified full-time or interim DON from 12/27/2025 through 02/19/2026. Interview and record review showed that the previous DON’s last day was 12/27/2025, and the Administrator reported that an RNC was acting as the interim DON, overseeing the facility and being readily available by phone as needed. However, the Administrator acknowledged that the RNC did not qualify as an interim DON because the RNC was not in the facility 8 hours a day, as required. The Administrator also stated that the facility did not have a policy outlining DON requirements and instead relied on state regulations for guidance, and believed residents had not experienced negative outcomes because the RNC had been overseeing the facility and nursing staff were available. The surveyors determined that this failure could place all residents at risk of not receiving necessary care and services. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency was identified at the facility level based on staffing and leadership requirements for nursing services.
Failure to Post Oxygen-in-Use Signage for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards by not posting required oxygen signage outside the rooms of two residents receiving oxygen therapy. One resident with dementia and heart failure had a care plan indicating oxygen therapy related to shortness of breath due to congestive heart failure, and an MDS assessment and physician order for oxygen via nasal cannula at 2–5 L/min PRN for shortness of breath. During observation, this resident was in bed with oxygen in use via nasal cannula connected to a concentrator set at 2 L/min, and there was no oxygen sign posted outside the room, despite facility policy requiring a “No smoking – Oxygen in use” sign on the patient’s door when appropriate. Another resident with chronic respiratory failure with hypoxia had a care plan indicating oxygen therapy related to chronic respiratory failure, an MDS assessment documenting oxygen therapy, and a physician order for oxygen at 2 L/min via nasal cannula every shift. Observation showed this resident in bed with oxygen in use via nasal cannula connected to a concentrator set at 2 L/min, again without an oxygen sign posted outside the room. In interviews, the ADON and the Administrator both stated that it was the facility’s expectation that oxygen signs be posted outside rooms where oxygen was being used for safety reasons, including to prevent smoking in those rooms. The facility’s written policy on nasal cannula oxygen therapy also directed staff to post a “No smoking – Oxygen in use” sign on the patient’s door when appropriate.
Failure to Provide Full Visual Privacy in Dual-Occupancy Rooms
Penalty
Summary
Surveyors found that the facility failed to ensure full visual privacy in three dual-occupancy rooms (Rooms 5, 18, and 21) during a review of 30 such rooms. Observations showed that each of these rooms had an A and B bed separated by a single ceiling-to-floor curtain that divided the center of the room but stopped approximately 12 inches from the wall, leaving a gap. In addition, each bed had its own side curtain, but these side curtains left gaps of approximately 18 inches and 30 inches, preventing total visual privacy for the residents in those beds. During an interview, the Administrator acknowledged that if a resident room did not have a full visual privacy curtain, it would not provide privacy when a resident requested it, and also stated that the facility did not have a policy regarding privacy curtains. The report states that this failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being.
Improper G-Tube Medication Administration and Infection Control by ADON
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services provided via gastrostomy tube (g-tube) were delivered according to professional standards and facility policy for one resident. The resident was an elderly female with a g-tube for nutrition, hydration, and medications, and had multiple diagnoses including cerebral palsy, anxiety disorder, intellectual disability, convulsions, and dementia. Her MDS showed severely impaired cognition and total dependence on staff for all ADLs, and her care plan identified a surgical abdominal site related to peg-tube placement with a goal to remain free from infection. Physician orders specified continuous enteral feeding with a defined formula and rate, free water at a prescribed rate and duration, and multiple medications to be administered via the g-tube. During an observed medication administration via g-tube, the ADON began care by donning gloves without performing hand hygiene, contrary to the facility’s infection control policy that requires hand hygiene before direct resident contact and before assisting with meals. The ADON prepared the medications by separating and crushing them, then attached a 60 cc syringe to the g-tube, checked placement, and instilled 60 cc of water before giving medications. She then used more than 30 cc of water for each medication, exceeding the facility’s enteral tube medication administration policy, which directs staff to flush the tube with only 5–15 ml of water after each medication. During the process, the resident coughed, causing medication to spill from the syringe and spatter around the resident. In response to the spatter, the ADON used the syringe plunger to cover the syringe, placed the plunger on an unclean part of the bedside table outside the established clean field, and then reused the plunger without cleaning it. Her gloves became visibly soiled with medication, yet she did not remove them, perform hand hygiene, or change gloves before continuing care. Additionally, the ADON did not fully dissolve certain medications (Dilantin chewable and omeprazole magnesium), leaving a significant amount of medication residue in the cups, which she discarded into the trash. As a result, the resident did not receive the full doses of all ordered medications. In interviews, the ADON acknowledged she should have washed her hands and changed gloves and stated she had not received facility training on g-tube medication administration, while the RNC confirmed expectations for hand hygiene and adherence to g-tube procedures and reported he could not locate any facility training or in-services specific to g-tube medication administration.
Incomplete eTAR Documentation for PRN Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving PRN oxygen therapy. The resident, an older adult admitted with dementia and heart failure, had a care plan indicating oxygen therapy related to shortness of breath due to CHF, with interventions including reassurance, assistance via call system, and staying with the resident during episodes of respiratory distress. The resident’s MDS assessment documented oxygen therapy under Section O for special treatments and procedures. However, review of the resident’s eTAR for January 2026 showed an order for oxygen at 2–5 LPM via nasal cannula as needed for shortness of breath, but the eTAR lacked documentation of oxygen administration, including oxygen use, pulse, respiratory rate, and time completed. During interviews, the ADON stated that nurses were expected to document the resident’s oxygen status on the eTAR and not solely in the vital signs section, explaining that without eTAR documentation they would not know if the resident was using oxygen more regularly or needed it more than PRN. The Administrator confirmed that nursing staff were expected to document residents’ treatments on the corresponding eTAR and acknowledged that, in this case, documentation was present only under vital signs and not on the eTAR. The Administrator further stated that if a treatment was not documented, they would not be able to determine if the treatment was completed. The facility’s documentation policy stated that the facility would maintain complete and accurate documentation for each resident on all appropriate clinical record sheets, which was not followed in this instance.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper implementation of its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for a resident with an indwelling urinary catheter and colostomy. The resident, admitted with an uninhibited neuropathic bladder and identified on the care plan as requiring EBP due to the presence of a colostomy and Foley catheter, had care instructions stating that gloves and a gown should be donned for high-contact activities such as linen changes, resident hygiene, and catheter care. Facility policy on EBP, as well as signage posted outside the resident’s room, directed staff to perform hand hygiene and wear both gown and gloves during high-contact care for residents with indwelling medical devices, including urinary catheters. On the observed date and time, an LVN entered the resident’s room to change the urinary catheter, performed hand hygiene, and donned gloves but did not put on a gown, despite gowns being readily available in a nearby plastic dresser and the posted EBP instructions outside the room. The LVN later acknowledged in an interview that she was supposed to use a gown when changing the catheter, stated she had been trained on EBP, and attributed the omission to being distracted. She also stated that not wearing a gown could lead to infection or cross contamination. The ADON and the Administrator both confirmed that the expectation was for nursing staff to use appropriate PPE, including EBP, when providing catheter care to this resident and that failure to do so could spread infections to and from the resident.
Deficiencies in Food Safety and Infection Control Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. A bag of chicken was found thawing on the counter without running water, contrary to the facility's policy that requires thawing under running water or in a refrigerator. Additionally, a puddle of pink chicken juices was observed, indicating improper handling. A staff member, [NAME] B, was seen wearing a face mask incorrectly and coughing while preparing food, raising concerns about infection control. Further observations revealed that food storage practices were inadequate. A box of chicken was found with exposed chicken in the freezer, and a 50-pound bag of dry milk was left on the floor in the dry storage area. Spices were left open to the air, and the Dietary Manager (DM) admitted that they were not properly closed or wiped off after use. Hair restraint practices were also lacking, as a staff member's hair net was not fully covering her hair, and another staff member entered the kitchen without a hair net on. The facility's thermometer cleaning practices were also deficient. A staff member, [NAME] C, used a paper towel to clean the thermometer between dishes, which she acknowledged caused cross-contamination. The DM admitted to not addressing these issues with the staff to avoid making them feel scolded. The facility's policies on thawing foods, dry storage, and infection control were not followed, as evidenced by the observations and interviews conducted during the survey.
Inadequate Hand Hygiene Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN A during the care of two residents. RN A did not perform hand hygiene between glove changes while administering medication and changing the PEG tube dressing for a resident with cerebral palsy and gastrostomy status. This oversight occurred despite the nurse leaving the resident's room to obtain supplies, which should have prompted hand hygiene upon re-entry and before resuming care. In another instance, RN A did not adhere to proper hand hygiene protocols during wound care for a resident with a skin tear. The nurse placed wound care supplies on a porous towel on the floor, which was not a clean technique, and failed to perform hand hygiene between glove changes while cleaning and dressing the wound. This practice was contrary to the facility's infection control policy, which requires hand hygiene before and after glove use and the use of non-porous barriers for wound care supplies. Interviews with the DON, Regional RN Consultant, and the Administrator revealed that the facility's expectations for hand hygiene and infection control were not met. The DON and Regional RN Consultant emphasized the importance of hand hygiene and the use of non-porous barriers, while the Administrator acknowledged the infection control issue upon learning of the observations. The facility's policies clearly outlined the need for hand hygiene to prevent the transmission of infections, which was not followed in these instances.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, it was noted that a nurse's treatment cart on Hall 4 was left unlocked and unsupervised for approximately 10 minutes. The cart contained several ointments, nail clippers, dressings, and normal saline bottles. This incident occurred when RN A left the cart unattended while attending to a resident in their room. Interviews with RN A, the Director of Nursing (DON), and the Administrator revealed that it was expected for nursing staff to lock their medication carts when not in use. RN A admitted to being unaware that she had left the cart unlocked, stating it was an oversight. The DON and Administrator acknowledged the expectation for carts to be locked to prevent unauthorized access, with the Administrator suggesting that the oversight might have been due to staff nervousness during the surveyor's observation. The facility's policy, dated 2003, clearly indicated that medication carts must be locked when not in use or under direct supervision.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ballinger
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Central Texas Nursing & Rehabilitation | 0.2 mi | — | 2 | 0 |
| Winters Healthcare Residence | 14.3 mi | — | 0 | 0 |
| Bronte Health And Rehab Center | 21 mi | — | 11 | 0 |
| Holiday Hill Inc | 31.1 mi | — | 0 | 0 |
| Coleman Healthcare Center | 32.1 mi | — | 11 | 0 |
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