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 Central Texas Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with terminal illness, severe cognitive impairment, and total incontinence, care-planned for q2h incontinence care and extensive assistance, was found late in the morning with dried feces on the buttocks and sheets, dried urine stains, dried food on clothing and bedding, and new skin issues after not being changed or repositioned since the start of the day shift. CNAs and the RN treatment nurse documented the resident’s condition and provided witness statements to the DON and Administrator, and the DON also observed dried stool and food on the resident and linens. Although these observations and statements constituted an allegation of neglect, the Administrator did not initially view the situation as neglect and did not further investigate at that time, and the incident was not reported to the state agency until several days later, exceeding the 24-hour reporting requirement in the facility’s abuse/neglect policy and HHSC guidelines.
A resident with severe cognitive impairment, total incontinence, and hospice care needs, whose care plan required q2h incontinence care and extensive ADL assistance, was found late in the morning with dried feces on the body and bedding, yellow urine stains on sheets, and dried food on clothing that had not been changed since a prior shower. Nursing and CNA staff reported that, although they started their shift early and knew the resident was incontinent, they only entered to change the resident hours later, citing that the resident was asleep and had reportedly been changed before shift change. The RN Treatment Nurse, DON, and Hospice Aide all observed the resident in a soiled state with new skin issues, confirming that routine turning, changing, and hygiene care were not provided as planned.
The facility failed to obtain informed consent for the administration of psychotropic medications to two residents, one with moderate cognitive impairment and another with severe cognitive impairment. The DON admitted responsibility for the oversight, which violated the facility's policy requiring consent before administering such medications.
The facility failed to develop comprehensive care plans for two residents, omitting critical details about psychotropic medications, PEG tube management, and therapy gloves, leading to potential gaps in individualized care.
The facility failed to document ongoing monitoring of a lap belt used by a resident with severe cognitive impairment and other medical conditions. Although the resident was frequently repositioned and checked for incontinent episodes, these actions were not documented as required, placing the resident at risk of complications.
The facility failed to ensure the accurate administering of medications, as an expired insulin pen was found in the medication cart of the secure unit. Staff did not notice the expired medication, and the ADON missed it during routine checks.
The facility failed to ensure all controlled drugs were stored in separately locked and permanently affixed compartments. A narcotic lock box containing lorazepam was found loose in the medication refrigerator. The DON and Administrator were unaware of the issue, and the facility's policy on storing Schedule II controlled medications was not followed.
Failure to Timely Report Alleged Neglect and Poor Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect involving Resident #1 to the State Reporting Agency (HHSC) within 24 hours, as required by regulation and the facility’s abuse/neglect policy. Resident #1 was an elderly male with unspecified dementia, unspecified convulsions, and COPD, who had a terminal prognosis, was on hospice for adult failure to thrive and senile degeneration of the brain, and had severe cognitive impairment with a BIMS score of 00. He was always incontinent of bowel and bladder and required substantial to maximum assistance for bed mobility and extensive assistance of two staff for toileting, with a care plan intervention for incontinence care every two hours. On 12/26/2025, multiple staff observed Resident #1 in a soiled and unkempt condition. The RN Treatment Nurse documented that around 11:15–11:30 AM she was alerted to skin concerns and found several raised blister-like areas on the right hip and buttock, redness to the coccyx, soiled sheets, dried bowel movement on both buttocks, a shirt with a dried yellow urine smell, and a large area of dried food on the back of the shirt. CNA D and CNA E each wrote witness statements describing that when they went to get the resident up for the day, they observed dried feces on his bottom that was difficult to clean, sheets stained with feces and food, and dried food stuck to his shirt, as well as wounds that they stated were not present when he last had a shower on 12/24/2025. The DON’s witness statement also described dried bowel movement on the sheets and dried food on the resident’s clothing and bed sheets. In interviews, CNA D and CNA E stated that their shift began at 6:00 AM, that they had looked in on the resident earlier but did not change or reposition him because he was asleep, and that the first time they attempted to change him that shift was around 11:00 AM, when the hospice aide arrived to provide a shower and the resident’s soiled condition and wounds were noted. The hospice aide reported that the resident was wearing the same shirt she had put on him at his shower two days earlier and that it was dirty with dried food, dried bowel movement, and yellow stains. The RN Treatment Nurse and DON both reported the condition and circumstances to the Administrator on 12/26/2025, and multiple witness statements were provided to him. The Administrator acknowledged receiving these statements, defined neglect as failure to provide goods or services, and stated he did not view the situation as neglect and did not conduct further investigation at that time. The incident, including the allegation of neglect involving Resident #1 and systemic skin concerns, was not reported to HHSC until 12/29/2025, beyond the 24-hour reporting requirement for allegations not involving serious bodily injury, despite the facility’s policy mirroring HHSC guidelines.
Failure to Provide Timely Incontinence and ADL Care Resulting in Prolonged Soiling
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance, including timely incontinence care, grooming, and hygiene, to a male resident with severe cognitive impairment and total bowel and bladder incontinence. The resident had dementia, convulsions, COPD, and was on hospice with a terminal prognosis and adult failure to thrive. His care plan documented an ADL self-care performance deficit and required staff assistance for bathing, bed mobility, dressing, toilet use, and incontinence care every two hours. On the morning in question, multiple staff members observed the resident with significant soiling and poor hygiene. The RN Treatment Nurse, called to the room around late morning due to skin concerns, found the resident lying on his right side with several raised blister-like areas on the right hip and buttock and redness to the coccyx. She also observed soiled sheets, dried feces on both buttocks, a shirt with a dried yellow urine smell, and a large area of dried food on the back of the shirt. Witness statements from CNAs assigned to the hall that morning described dried feces on the resident’s bottom and back, stained sheets with feces and food, and dried food stuck to his clothing, noting that these wounds and soiling were not present at his last shower two days earlier. Interviews with CNAs on the day shift revealed that although they began work at 6:00 AM, they only entered the resident’s room to change him for the first time around 11:00 AM, stating they had previously only looked in on him and did not disturb him because he was asleep and had reportedly been changed before shift change. The Hospice Aide, arriving around 11:00 AM to provide a shower, reported that the resident was still wearing the same shirt from his prior shower two days earlier, which was dirty with dried food, dried feces, and yellow stains. The DON and nursing staff acknowledged that the resident was found with dried urine and feces on his body and bedding and that the resident had not been turned or changed at routine intervals, despite his care plan requirement for incontinence care every two hours.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not obtain informed consent from two residents before administering psychotropic medications. Resident #22, who had moderate cognitive impairment and was receiving antipsychotic and antianxiety medications, did not have a care plan in place for these medications, and there was no consent documented for the use of Buspirone. Similarly, Resident #31, who had severe cognitive impairment and was receiving antipsychotic and antidepressant medications, did not have consent documented for the use of Aripiprazole. The Director of Nursing (DON) acknowledged that obtaining consents for psychotropic medications was her responsibility and admitted that the failure to ensure consents were obtained and placed in the residents' charts was her fault. The facility's policy required that consent be obtained before administering psychoactive medications, with a one-week grace period for obtaining consent for residents admitted while already on such medications. However, this policy was not followed in the cases of Resident #22 and Resident #31. The lack of informed consent for the administration of psychotropic medications to these residents indicates a significant oversight in the facility's processes for ensuring residents' rights to be informed and to participate in their treatment decisions. This failure could potentially place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party, as highlighted by the findings in the report.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, leading to deficiencies in their care. Resident #22, an elderly female with diagnoses including psychotic disorder with hallucinations, dementia, and anxiety disorder, did not have a care plan in place for her use of antipsychotic and antianxiety medications. Despite her moderate cognitive impairment and the use of these medications being noted in her records, the care plan was not updated to reflect these critical aspects of her treatment, which was an oversight acknowledged by the MDS nurse. Resident #56, an elderly male with severe cognitive impairment and multiple diagnoses including a spinal cord injury and dysphagia, did not have a care plan for his PEG tube or orthotic flexion gloves. His records indicated detailed orders for the management of his PEG tube and the use of therapy gloves, but these were not included in his care plan. The Director of Rehab admitted to not documenting these needs in the care plan, and the MDS nurse mistakenly believed that existing care plans for NPO status were sufficient to cover the PEG tube requirements. Interviews with the Director of Rehab, MDS nurse, and DON revealed a lack of clarity and consistency in the care planning process. The staff acknowledged that care plans should be comprehensive and person-centered, covering all aspects of a resident's care, including medications and special treatments. However, the facility's current practices led to significant gaps in the care plans for these residents, potentially impacting their individualized care and services.
Failure to Document Monitoring of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident had the right to be free from physical restraints unless required for medical treatment. Specifically, the facility did not document ongoing monitoring of a lap belt used by a resident with severe cognitive impairment, cerebral palsy, and other medical conditions. The resident's care plan required the lap belt to be released and the resident to be repositioned every two hours, but this was not consistently documented by the staff. The resident was observed using the lap belt while in a wheelchair, and interviews with the Director of Nursing (DON) and the Administrator confirmed that the resident spent several hours a day in the wheelchair with the lap belt on. Although the staff frequently repositioned the resident and checked for incontinent episodes, these actions were not documented as required. The facility had a letter of medical necessity for the lap belt, but this did not exempt them from the need for proper documentation and monitoring. The facility's policy on restraints required that restrained residents be repositioned at least every two hours and each shift, but it did not address the need for documentation of restraint release or repositioning. The lack of documentation could place the resident at risk of complications such as skin breakdown and unnecessarily inhibiting the resident's freedom of movement. The Administrator acknowledged the absence of documentation and stated that the issue would be fixed immediately.
Failure to Ensure Accurate Administering of Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate administering of all drugs to meet the needs of the residents. During an inspection of the medication cart in the secure unit, an insulin pen was found that had expired according to the manufacturer's recommendations. The insulin pen was dated 03/06/24, and it was noted that insulin pens are good for 28 days once opened. LVN A, who was present during the inspection, acknowledged that the night shift staff were responsible for monitoring the medication cart for expired or undated medications. LVN A admitted that she had not noticed the expired insulin pen and disposed of it upon discovery. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) both confirmed that it was their expectation for staff to label and date insulin pens with expiration dates when first opened and to dispose of expired medications. The ADON stated that he checked the medication carts every two weeks but had missed the expired insulin pen. The facility's policy required that all medications, including insulin, be dated when opened and stored according to the manufacturer's recommendations. The failure to adhere to these procedures could result in residents receiving expired medications that may not be effective.
Failure to Securely Store Controlled Drugs
Penalty
Summary
The facility failed to ensure all controlled drugs and biologicals were stored in separately locked and permanently affixed compartments. During an observation of the medication room, a narcotic lock box containing lorazepam was found in the locked medication refrigerator, but the lock box was not secured to the fridge. LVN B stated that the lock box was normally glued to the bottom of the fridge but had become dislodged at some point. LVN B was unsure how long the box had been loose in the fridge, noting that it was affixed when she last worked a week prior. The Director of Nursing (DON) and the Administrator were unaware that the lock box was not affixed and had no explanation for why it was not properly secured. The Administrator mentioned that maintenance was trying to obtain a chain for the lock box but needed approval from the pharmacy company to alter it, though no documentation of this conversation was provided. The facility's policy titled 'Storage and Documentation of Schedule II Controlled Medications' states that all Schedule II controlled medications should be stored under double lock and checked for accountability at each change of shift. The policy, dated 2003, was not adhered to in this instance, as the narcotic lock box was not permanently affixed, potentially compromising the security of controlled drugs. This failure could place the facility at risk of drug diversion and unauthorized access to medications.
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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) |
|---|---|---|---|---|
| Ballinger Healthcare And Rehabilitation Center | 0.2 mi | — | 7 | 0 |
| Winters Healthcare Residence | 14.5 mi | — | 0 | 0 |
| Bronte Health And Rehab Center | 21.1 mi | — | 11 | 0 |
| Holiday Hill Inc | 31.1 mi | — | 0 | 0 |
| Coleman Healthcare Center | 32 mi | — | 11 | 0 |
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