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Inspection visit

Inspection

PFLUGERVILLE NURSING AND REHABILITATION CENTERCMS #6762451 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, 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 very 3 months (08/01/2025 through 12/012025).This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information.Findings include:Record review of 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, 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 MDS dated [DATE] revealed that 67 residents have not had an updated quarterly care plan for longer than 3 months.During an interview with the DON on 02/06/2026 at 12:15 p.m., the DON stated that she expected the IDT to complete a new care plan for every newly admitted resident within 14 days of admission to the facility. The DON stated she expects staff to reassess each resident on a quarterly basis. The DON stated the Social Worker was responsible for coordinating the quarterly care plan meetings. She stated that the facility does not have a Social Worker at this time and Residents #'s 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 quarterly care plans have not been updated Since 8/2025.During an interview with the MDS Case Manager on 02/06/2026 at 12:47 p.m., the Case Manager confirmed the IDT Team was expected to meet on a quarterly basis to initiate and complete quarterly Care Plans assessments for each resident. The MDS Case Manager stated it was the responsibility of the facility's Social Worker to coordinate the quarterly care plan meetings. She revealed the facility has not had a social worker for most of 2025 and that the facility has hired a new Social Worker and that position will be filled soon.During an interview with the ADM on 02/06/2026 at 3:25 p.m., the ADM stated he expects the IDT to follow the RAI manual regarding the frequency of the Care Plan meetings. He stated the care plan meetings should be held on a quarterly basis.Record review of the CMS RAI Version 3.0 Manual, 4.7 The RAI and Care Planning As required at 42CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the residents' (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676245 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pflugerville Nursing and Rehabilitation Center 104 Rex Kerwin Court Pflugerville, TX 78660 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care.Record review of CMS Appendix PP Issued: 11-22-17, Implementation: 11-28-17 Reveals: Note: The quarterly MDS does not require the completion of Care Area Assessments. However, the resident's care plan must be reviewed and revised by the interdisciplinary team after each assessment as required at 483.21(b)(2)(iii). Event ID: Facility ID: 676245 If continuation sheet Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0657GeneralS&S Fpotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

FAQ · About this visit

Common questions about this visit

What happened during the February 6, 2026 survey of PFLUGERVILLE NURSING AND REHABILITATION CENTER?

This was a inspection survey of PFLUGERVILLE NURSING AND REHABILITATION CENTER on February 6, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at PFLUGERVILLE NURSING AND REHABILITATION CENTER on February 6, 2026?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.