Cedar Creek Nursing: Discharge Safety Failures - TX
During a standard health inspection on May 8, 2026, inspectors cited Cedar Creek for failing to ensure that transfers and discharges met residents' needs and preferences, and that residents were adequately prepared before leaving the facility. The citation fell under the category of Resident Rights deficiencies, a classification that reflects not just a lapse in medical procedure but a failure to honor what residents are entitled to by law: a say in what happens to them, and a safe path forward when they leave.
The violation was rated at Scope and Severity Level D, meaning inspectors identified an isolated incident with no documented actual harm. But the rating also carries a specific warning embedded in its definition. There was potential for more than minimal harm. That language matters. It means inspectors looked at what happened and concluded that a resident, or residents, could have been hurt.
The discharge and transfer process is not a formality. For an elderly or medically fragile person leaving a nursing facility, the gap between one care setting and the next is one of the most dangerous stretches in their medical trajectory. Medications can be misaligned. Follow-up appointments can go unscheduled. Family members can be left without instructions they need. Residents who are confused, frail, or without strong outside support can arrive somewhere, whether home, a hospital, or another facility, without the information or resources to stay safe.
Cedar Creek was not cited for one of these specific outcomes. The inspection report does not describe a resident who fell through the cracks after discharge, or a family member who was never called. What it documents is a system that was not working the way it should, in a way that created real risk.
The discharge citation was one of five deficiencies cited during the inspection. The others were not detailed in the inspection summary, but five citations in a single standard inspection points to a facility where multiple areas of resident care and rights warranted federal attention on the same day.
What stands out most in the record is not the citation itself. It is what came after. As of the inspection record, Cedar Creek has filed no plan of correction for the discharge deficiency. That means the facility has not submitted, at minimum on paper, any description of what went wrong, who is responsible for fixing it, or when the problem will be addressed.
A plan of correction is not proof that a problem has been solved. Nursing homes file them routinely, and the gap between a written plan and actual change on the floor of a facility can be wide. But the absence of one is its own signal. It means there is no documented acknowledgment of the problem, no stated timeline, and no named accountability. Inspectors cited a risk to residents, and the facility's formal response, so far, is silence.
Cedar Creek Nursing and Rehabilitation Center sits in Bandera, a small Hill Country city of roughly 900 people in Bandera County. For many residents of the surrounding area, it is likely one of very few nearby options for skilled nursing and rehabilitation care. That geography matters. Residents and families in rural communities have less ability to choose among facilities, and less leverage when something goes wrong.
The inspection was a standard health survey, the kind conducted periodically at every Medicare and Medicaid certified nursing home in the country. It was not triggered by a complaint or a reported incident. Inspectors came in as a matter of routine, and they found, among other things, that the facility was not consistently preparing its residents for one of the most consequential transitions in their care.
Whether that has changed since May 8 is not reflected in the public record. What the record shows is a citation, a risk, and no written plan to address either.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Creek Nursing and Rehabilitation Center from 2026-05-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 15, 2026 · Our methodology
CEDAR CREEK NURSING AND REHABILITATION CENTER in BANDERA, TX was cited for violations during a health inspection on May 8, 2026.
The violation was rated at Scope and Severity Level D, meaning inspectors identified an isolated incident with no documented actual harm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.