Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
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 Advanced Rehabilitation & Healthcare Of Burleson during CMS and state inspections, most recent first.
A resident with COVID-19, heart failure, Barrett’s esophagus, dysphagia, and difficulty swallowing experienced unplanned weight loss while on a pureed diet with thin liquids and required assistance with eating and oral hygiene. Speech therapy documented oral and pharyngeal swallowing impairments and the resident’s refusal of solid trials, while nutrition notes indicated the resident disliked pureed foods, had ill-fitting dentures due to weight loss, and was receiving oral supplements. Weight records showed significant weight loss, but required weekly weights for a new admission with weight loss were not consistently obtained. A hospital RN later found impacted food and denture adhesive in the resident’s mouth and throat, and the family reported ongoing eating and mouth-care problems despite staff being expected to assist. Staff interviews revealed that oral and denture care needs and feeding assistance were communicated verbally rather than clearly documented, and that nursing staff were unsure why weekly weights were missed, despite facility policy requiring regular weight monitoring.
A resident with dysphagia, weight loss, and a mechanically altered diet required assistance with eating and oral hygiene, yet the comprehensive care plan did not address oral care or denture care despite documented issues with food loss from the mouth and food retention after meals. The resident was later found at the hospital with impacted food in the gums and denture adhesive lodged in the throat, and family and a speech therapist reported ongoing problems with dentures and eating. Staff interviews revealed there was no written documentation or care plan guidance on the resident’s denture status or oral care needs, with CNAs relying on verbal reports. Nursing leadership acknowledged that oral and denture care should have been included in the care plan per facility policy requiring comprehensive, measurable care plans to meet identified needs.
A resident's MDS assessment failed to accurately reflect her oral/dental status, as it did not indicate the absence of natural teeth or the use of dentures, despite evidence from dental records, staff interviews, and direct observation confirming the presence and use of dentures. Staff awareness and documentation of the resident's denture use were inconsistent, and the MDS Coordinator acknowledged the assessment should have been completed differently.
A resident's care plan did not accurately reflect her oral care needs related to denture use, despite dental records showing she had full dentures and a broken tooth. Staff were often unaware of her denture status, and documentation of her preferences and refusals was inconsistent. The care plan failed to address her need for assistance with denture care or her refusal to wear dentures, contrary to facility policy.
The facility failed to clean the griddle in the kitchen according to professional standards, leading to a significant build-up of grease and food crumbs. The griddle had not been cleaned since its last use, and staff cited a shortage of cleaning supplies as the reason. This oversight poses a risk of cross-contamination and foodborne illnesses, especially for residents with weakened immune systems.
The facility failed to maintain the dignity of two residents by not ensuring they were clean-shaven, despite their expressed embarrassment and the facility's policy requiring grooming during bathing. Both residents, with conditions requiring assistance in personal hygiene, were observed with significant facial hair growth, indicating a lapse in care.
A facility failed to update a resident's care plan to include catheter management, which was necessary for wound healing. The resident, with a history of heart failure, hypertension, diabetes, and a stage 3 pressure injury, had a Foley catheter inserted, but this was not reflected in her care plan. The MDS Nurse and DON acknowledged the oversight, which could risk inadequate care.
Two residents with dementia and other health issues were not kept clean-shaven, leading to embarrassment. Observations showed facial hair growth, and a CNA was unaware of when they were last shaved, despite the facility's policy requiring grooming during bathing.
A resident with multiple health conditions fell during a transfer when a nursing assistant attempted to use a Hoyer lift alone, against facility policy requiring two staff members. The assistant struggled to position the lift, causing it to tilt and the resident to fall. The incident was recorded on video, and the resident confirmed the fall, though no injuries occurred.
A facility failed to maintain an oxygen humidifier for a resident requiring respiratory care, as the humidifier bottle was found empty on multiple occasions. Despite the resident's denial of discomfort, staff interviews confirmed the oversight and the potential risk of nasal passages drying out. The facility's policy required pre-filled humidifier bottles to be changed when empty, which was not adhered to, indicating a lapse in following the care plan and physician orders.
A resident with moderate cognitive impairment had Dulcolax Docusate Sodium stored at their bedside, contrary to facility policy requiring medications to be locked away. Staff were unaware of the medication's presence, and interviews revealed a lack of familiarity with the policy and recent in-servicing on self-administered medications. This oversight posed a risk of unauthorized access to medications.
A nurse failed to follow Enhanced Barrier Precautions (EBP) by not wearing a gown while providing care to a resident with a gastrostomy tube, despite facility policy requiring gown and gloves. The resident was on EBP due to the presence of a medical device, and the oversight was noted during a survey. Interviews with staff confirmed the expectation to use PPE, highlighting a lapse in infection control practices.
A facility failed to implement an antibiotic stewardship program, leading to a resident being prescribed Cefdinir for UTI prevention without sufficient justification. The resident, with severe cognitive impairment and a history of recurrent UTIs, was on a daily regimen of Cefdinir indefinitely. Interviews revealed confusion among staff and hospice providers about the prescription's origin, with the primary care physician denying long-term use. The facility's policy aimed to promote appropriate antibiotic use, but was not followed, risking unnecessary exposure and potential resistance.
A resident in an LTC facility did not receive prescribed anti-convulsant medications for eight days due to communication and procedural failures among staff. The resident experienced seizures and required emergency care. The facility did not notice the pharmacy's request for a triplicate prescription, and staff failed to notify the pharmacy, doctor, or DON about the medication unavailability.
A facility failed to ensure a resident's call light was within reach, as required by their care plan and facility policy. The resident, with limited mobility and cognitive impairments, was unable to access the call light, which was often found on the floor. Interviews with staff revealed a lack of adherence to the facility's policy that mandates ensuring call light accessibility during rounds.
A resident's room in a LTC facility was found with trash that had not been removed for two days, despite the resident's requests. Interviews with the ADM, DON, and HD revealed a lack of awareness and communication regarding trash removal responsibilities. The facility's policy emphasized maintaining a clean environment, but the failure to adhere to these standards resulted in the deficiency.
A resident with cognitive and physical impairments was found to have a non-functioning call light, which was often on the floor and not accessible. Despite the resident informing staff, the issue was not addressed, leaving the resident without a reliable means to call for assistance. Interviews revealed that the facility's administration and nursing staff were unaware of the problem, contrary to the facility's policy requiring immediate reporting and resolution of call light issues.
Failure to Maintain Nutritional Status and Monitor Weight for Resident With Dysphagia and Denture Issues
Penalty
Summary
The deficiency involves the facility’s failure to maintain acceptable nutritional status and accurately monitor weight for a cognitively intact male resident with multiple diagnoses, including COVID-19, acute kidney failure, heart failure, Barrett’s esophagus with dysphagia, and difficulty swallowing. On admission, he was placed on a mechanically altered/pureed diet with thin liquids and required set-up assistance for eating and partial to moderate assistance with oral hygiene. The admission MDS documented loss of liquids/solids from the mouth and food holding in the cheeks, but oral/dental status was marked as having no denture issues. The care plan identified unplanned weight loss related to poor PO intake and included interventions such as supplements, an appetite stimulant (mirtazapine), monitoring and evaluating weight loss, and providing the ordered diet. Speech therapy’s bedside swallowing evaluation documented oral and pharyngeal phase impairments, including anterior spillage, oral residue, and reflexive throat clearing, and noted that the resident declined solid trials and remained on a pureed diet. Subsequent speech therapy notes described ongoing concerns about food feeling stuck with mechanical soft trials and the need for further instrumental assessment. A nutritional assessment recorded that the resident did not like pureed foods, reported drinking 1–2 Ensure drinks daily, and that his dentures were too big due to weight loss. The dietitian recommended continuing the current diet, adding Ensure twice daily, and Med Plus twice daily. A weight change communication form showed a significant weight loss of 16 pounds (9%), with a recent weight of 162 pounds, and noted his pertinent history and current use of diuretics. The facility’s weight records showed an admission weight of 170 pounds, followed by 162 pounds and then 155 pounds at discharge, but weekly weights for the first four weeks after admission were not consistently obtained as required for residents with weight loss, new admissions, and readmissions. Staff interviews revealed gaps in communication and documentation regarding the resident’s oral and denture care needs and assistance with eating. A hospital RN reported that the resident was admitted to the hospital without dentures, with impacted food in his gum line and a large glob of pink denture adhesive lodged in the back of his throat that required suctioning, raising concerns about oral care at the facility. A family member stated the resident had difficulty with dentures due to weight loss, was having problems eating, and that staff were supposed to assist with feeding and mouth cleaning. A CNA stated there was no written place to see that a resident required oral or denture care and that such information was passed only verbally, while an LVN acknowledged the resident’s weight loss, swallowing difficulty, food pocketing, and occasional need for feeding assistance, and was unsure why weekly weights were not obtained. The DON stated that the restorative aide was responsible for weekly weights on triggered residents and that the ADON was responsible for monitoring completion, and that not weighing residents weekly could delay interventions.
Failure to Care Plan and Implement Oral and Denture Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and update a comprehensive, person-centered care plan addressing a resident’s oral care and denture needs. The resident, an adult male admitted with COVID-19, acute kidney failure, low back pain, hypertension, Barrett’s esophagus, and dysphagia, had a BIMS score of 14 indicating intact cognition and required setup assistance with eating and partial to moderate assistance with oral hygiene. The admission MDS documented that the resident had loss of liquids/solids from the mouth while eating or drinking and retained food in the mouth after meals, and he was on a mechanically altered diet. Despite these identified needs, the care plan dated 12/20/2025 only addressed an ADL self-care performance deficit and risk of unmet needs in general, with interventions such as therapy to screen, evaluate, and treat as needed, but did not include specific interventions for oral care or denture care. Interviews and observations further demonstrated that the resident’s oral and denture needs were not incorporated into the care planning process or communicated in a consistent, written manner. A hospital RN reported that the resident was admitted to the hospital without dentures in place, with impacted food in the gum line and a large glob of pink denture adhesive lodged in the back of his throat that required suctioning, and expressed concern about lack of oral care at the facility. The resident’s family member stated the resident previously wore dentures all the time but had difficulty with them after weight loss, was having problems eating, and that staff were supposed to assist with feeding and mouth cleaning. The speech therapist confirmed the resident had dentures that were poorly fitting and that he was on a puree diet, keeping food at the front of his mouth due to decreased tongue strength. A CNA stated he did not recall whether the resident had dentures or teeth and that there was no written place to see if a resident required oral or denture care, relying instead on verbal report. An LVN and the DON both acknowledged that oral and denture care should have been included in the care plan and that nurse managers were responsible for ensuring the care plan accurately reflected such needs, which would then be assigned to CNAs via the task system. The facility’s written policy required comprehensive care plans with measurable objectives and timeframes to meet identified needs, including services to attain or maintain the resident’s highest practicable well-being, but this was not implemented for the resident’s oral and denture care needs.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that a resident's comprehensive Minimum Data Set (MDS) assessment accurately reflected her oral and dental status. Specifically, the MDS indicated that the resident had no natural teeth, dentures, oral abnormalities, pain, or inability to examine the oral cavity, when in fact, the resident had no natural teeth and used full top and bottom dentures. This discrepancy was identified through record review, interviews, and direct observation, which revealed the presence of denture care items in the resident's bathroom and the resident's own statements about her dentures. Further investigation showed that the resident had a history of living without natural teeth for years and was admitted to the facility with dentures. Dental records confirmed ongoing denture care, including inspection and cleaning, and noted a broken tooth on the top denture. Interviews with staff indicated that while some were aware of the resident's use of dentures, others were unsure, and documentation practices varied. The resident herself reported not wearing her dentures due to the broken tooth and awaiting dental repair, but she continued to take pride in her appearance and managed the storage of her dentures independently. The MDS Coordinator acknowledged that the assessment should have indicated the absence of natural teeth and the presence of dentures. Facility policy required that MDS assessments be completed accurately by qualified staff familiar with the resident's status, using direct observation and communication with both the resident and care staff. The failure to accurately document the resident's dental status on the MDS was contrary to both facility policy and federal regulatory requirements.
Failure to Accurately Care Plan for Denture Use and Oral Care Needs
Penalty
Summary
The facility failed to ensure that the care plan for a resident accurately reflected her oral care needs, specifically regarding her use of dentures. Despite documentation in the dental record that the resident had full top and bottom dentures, including a broken tooth on the upper denture and a recent dental cleaning, the comprehensive care plan and MDS assessment did not indicate that the resident had dentures or required related care. The care plan also did not address the resident's refusal to wear her dentures or her preferences regarding their use. Observations and interviews revealed that the resident kept her dentures in her backpack and was often seen without them, including during meals. The resident expressed concern about her appearance without dentures and stated she was advised not to use them until the broken tooth was repaired. Staff interviews indicated a lack of awareness about the resident's denture status, with some staff unsure if she wore dentures and others unaware of the broken denture. Documentation of denture care and refusals was inconsistent, and staff did not consistently communicate or document the resident's preferences or refusals regarding denture use. The facility's policy required that care plans describe all services provided to maintain the resident's well-being, including documenting refusals and informing the resident of risks and alternatives. However, the care plan did not reflect the resident's denture use, her refusal to wear them, or the need for assistance with denture care, despite clear evidence from dental records, staff, and family interviews that these needs existed.
Failure to Maintain Griddle Cleanliness
Penalty
Summary
The facility failed to maintain food safety standards in its kitchen, specifically regarding the cleanliness of the griddle. During an observation, it was noted that the griddle had a significant build-up of grease and food crumbs, approximately 0.25 inches thick towards the back half. This observation was made on 08/20/24, and it was confirmed through interviews that the griddle had not been cleaned since it was last used on 08/19/24 during the breakfast shift. The facility's policy requires the griddle to be cleaned and scrubbed with degreaser after each use, but this was not adhered to. Interviews with the staff, including the cook and the Dietary Manager, revealed that the griddle was not cleaned due to a shortage of degreaser packets, with only one packet available when ideally two were needed. The Dietary Manager acknowledged that other cleaning products could have been used but were not. The failure to clean the griddle as per the facility's policy poses a risk of cross-contamination and potential foodborne illnesses, especially given the residents' weakened immune systems. The facility's Dietary Policy and Procedure Manual, as well as the FDA Food Code, emphasize the importance of keeping food-contact surfaces clean to prevent such risks.
Failure to Maintain Resident Grooming and Dignity
Penalty
Summary
The facility failed to treat two residents with respect and dignity by not maintaining their personal grooming, specifically keeping them clean-shaven. Resident #42, a female with intact cognition and a history of dementia, diabetes, and communication deficit, expressed embarrassment due to facial hair growth on her upper lip and chin, which was approximately an inch long. Despite being bathed twice a week, she reported not being shaved for about two weeks, and observations confirmed she remained unshaven even after a recent bath. Similarly, Resident #32, who also required assistance with personal hygiene due to conditions including heart failure and dementia, was observed with facial hair on her upper lip and chin, approximately half an inch long. She expressed embarrassment about her facial hair and believed she was shaved the previous week. A CNA interviewed stated that residents were typically shaved during their shower or bath process but was unaware of the specific grooming status of Residents #32 and #42. The facility's ADL Care policy mandates grooming activities such as shaving during bathing, which was not adhered to in these cases.
Failure to Update Resident Care Plan for Catheter Management
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical needs. Specifically, the care plan did not include the management of the resident's catheter, which was necessary for wound healing. The resident, a female with a history of heart failure, hypertension, diabetes, and a stage 3 pressure injury, had a Foley catheter inserted for wound healing, but this was not reflected in her care plan. Interviews with facility staff revealed that the MDS Nurse was responsible for updating care plans and acknowledged that the catheter care plan was missed. The Director of Nursing (DON) also confirmed that nursing staff should have ensured the care plans were updated. The facility's policy mandates the development of comprehensive care plans that include measurable objectives and timeframes, but this was not adhered to in this case, potentially placing residents at risk of inadequate care.
Failure to Maintain Resident Grooming
Penalty
Summary
The facility failed to ensure that residents who are unable to carry out activities of daily living received the necessary services to maintain good grooming. Specifically, two residents, a [AGE] year-old female with dementia, diabetes, communication deficit, and a history of falling, and another [AGE] year-old female with heart failure, dementia, sleep apnea, and diabetes, were not kept clean-shaven. Both residents expressed embarrassment due to facial hair, with one resident noting that the last time she was shaved was about two weeks prior, and the other resident believing she was shaved the previous week. Observations revealed that both residents had noticeable facial hair growth, which was not addressed during their regular bathing routines. Interviews with a CNA indicated that shaving was part of the shower or bath process, but the CNA was unaware of when the two residents were last shaved due to working throughout the facility. The facility's ADL Care policy stated that residents would receive essential services for activities of daily living, including grooming activities such as shaving, but this was not consistently implemented for the residents in question.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who required maximum assistance with transfers. The resident, who had diagnoses including emphysema, diabetes, morbid obesity, and heart failure, was being transferred by a nursing assistant (NA) using a Hoyer lift device. The NA attempted to perform the transfer alone, contrary to the facility's policy requiring two staff members for mechanical lift transfers. During the transfer, the NA encountered difficulties positioning the lift's support legs under the bed, causing the lift to tilt sideways and the resident to fall onto the bed and then roll off onto the floor. The incident was captured on video by the resident's camera, and the resident confirmed the fall during an interview, stating that the NA attempted the transfer without assistance. The NA admitted to starting the transfer alone after being unable to find the nurse who was supposed to assist. The facility's policy for using the Hoyer lift was not followed, as it was intended to enable one individual to lift and move a resident safely with minimal effort, but required two staff members for safety. The failure to adhere to this policy resulted in the resident's fall, although no injuries were reported.
Failure to Maintain Oxygen Humidifier for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as evidenced by the failure to replace the resident's oxygen humidifier bottle when it was empty. The resident, a female with a history of dementia, hypertension, colon cancer, and diabetes, was observed on multiple occasions with an empty humidifier bottle while receiving oxygen via nasal cannula. Despite the resident's denial of discomfort, the empty humidifier bottle was noted during observations on consecutive days, indicating a lapse in the facility's adherence to the care plan and physician orders. Interviews with facility staff, including an LVN, ADON, and DON, revealed that the humidifier bottle should have been filled with water to prevent the resident's nasal passages from drying out. The staff acknowledged the oversight and the potential risk associated with the empty humidifier bottle. The facility's policy on oxygen administration required the use of pre-filled humidifier bottles, which should be changed when empty and labeled with the date and initials. The deficiency highlights a failure in the facility's processes to ensure compliance with professional standards of practice and the resident's care plan.
Medication Storage Deficiency
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. This deficiency was identified during an observation, interview, and record review, which revealed that a resident had Dulcolax Docusate Sodium 100 mg/Stool Softener Laxative stored at their bedside table. The resident, who had moderate cognitive impairment, had received the medication from a family member and had been using it without informing the staff. The medication was observed at the bedside over several days, and staff were unaware of its presence until notified by a surveyor. Interviews with facility staff, including CNAs, LVNs, the ADON, and the DON, revealed a lack of awareness and adherence to the facility's policy regarding medication storage. Staff members admitted they had not observed the medication at the bedside and were not familiar with the policy that prohibited medications from being accessible to residents without an order. The staff also acknowledged that they had not been recently in-serviced on the topic of self-administered medications, which contributed to the oversight. The facility's Medication Storage Policy, dated January 2021, clearly stated that all drugs and biologicals should be stored in locked compartments. However, the policy was not followed, as evidenced by the medication being left at the resident's bedside. The failure to adhere to this policy posed a risk to residents, as it allowed for the possibility of unauthorized access to medications, which could lead to overdosing or other adverse effects.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN H, who did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident. The resident, a female with a history of Parkinsonism, aphasia, and feeding difficulties, was on EBP due to having a gastrostomy tube. Despite the presence of a sign indicating EBP and a bin of personal protective equipment (PPE) at the resident's door, RN H only donned gloves and neglected to wear a gown while preparing to administer a bolus feeding. This oversight occurred even though the facility's policy required the use of both gown and gloves during high-contact care activities for residents on EBP. Interviews with RN H, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) revealed a lack of compliance with the facility's infection control policy. RN H, despite acknowledging the requirement for PPE, believed her extensive experience negated the need for a gown during bolus feedings. The ADON and DON both confirmed that residents with medical devices such as feeding tubes should be on EBP, and staff are expected to follow the policy by donning appropriate PPE. The failure to adhere to these precautions posed a risk of infection transmission, as highlighted by the facility's infection prevention and control program policy.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. This deficiency was highlighted by the case of a resident who was prescribed the antibiotic Cefdinir for UTI prevention without sufficient justification. The resident, a female with severe cognitive impairment and a history of recurrent UTIs, was placed on a daily regimen of Cefdinir starting on 11/11/23, based on family concerns about increased confusion and strong urine odor. However, the order for the antibiotic was indefinite, and there was no clear documentation or communication regarding the prescribing physician, leading to confusion among the staff and hospice care providers. Interviews with facility staff, including the Hospice Nurse, ADON, and DON, revealed a lack of communication and understanding about the origin and necessity of the antibiotic order. The Hospice Nurse indicated that the hospice company did not prescribe antibiotics for daily use as a preventative measure, and the resident's primary care physician denied prescribing the medication for long-term use. The facility's Antibiotic Stewardship Program policy, revised in June 2020, aimed to promote appropriate antibiotic use and limit resistance, but the lack of adherence to this policy in the resident's case placed her at risk for unnecessary antibiotic exposure and potential development of multi-drug resistant organism infections.
Failure to Administer Anti-Seizure Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in the resident not receiving prescribed anti-convulsant medications for eight days. This lapse occurred from the time the resident was admitted to the facility, during which the medications Lacosamide and Phenobarbital were not administered due to them being unavailable. The resident experienced seizures on two separate occasions, leading to emergency department visits. The deficiency was primarily due to a breakdown in communication and procedure adherence among the facility's staff. The Director of Nursing (DON) was unaware of the missing medications until after the resident's second hospital visit. The Assistant Director of Nursing (ADON), who was working as a medication aide at the time, did not follow up on the missing medications despite being authorized to do so. Additionally, the charge nurse and other nursing staff failed to notify the pharmacy, doctor, or DON about the unavailability of the medications, and did not document the issue properly. The facility's failure to ensure the resident received his medications was compounded by the lack of awareness and action from multiple staff members. The pharmacy had sent an electronic message indicating the need for a triplicate prescription, which went unnoticed by the facility. This oversight, along with the staff's failure to follow established procedures for handling unavailable medications, directly contributed to the resident's adverse health events.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was placed within reach, which is a necessary accommodation for residents with limited mobility and cognitive impairments. The resident in question, a male with a history of edema, lack of coordination, muscle weakness, muscle wasting, and cognitive communication deficit, was observed to have his call light on the floor, out of reach. This resident required substantial assistance for daily activities such as toileting and dressing, as indicated by his care plan and MDS assessment. During an interview, the resident expressed difficulty in picking up the call light when it was on the floor and mentioned that it often did not work. Interviews with facility staff, including a CNA, HA, ADM, and DON, revealed that it was the responsibility of all staff members to ensure that call lights were within reach of residents during their rounds. The CNA admitted to not noticing the call light on the floor during her rounds. The facility's Call Light Response policy mandates that staff ensure call lights are accessible to residents and report any issues immediately. However, this policy was not adhered to, resulting in the resident's inability to call for assistance, potentially leading to unmet needs and increased risk of injury.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, as observed during a survey. The resident's room was found to have two clear trash bags containing food and other items, one tied to a bedside table and the other in a trash can, which had not been removed for two days. Despite the resident's requests for the trash to be taken out, the staff did not address the issue, leading to potential risks of infection, odors, and unsanitary conditions. Interviews with the facility's administration, including the Administrator (ADM), Director of Nursing (DON), and Housekeeping Director (HD), revealed a lack of awareness and communication regarding the trash removal responsibilities. The ADM and DON stated that the trash should be taken out once per shift or as needed, while the HD expected housekeepers to remove trash twice daily. The facility's policy on housekeeping standards emphasized maintaining a clean and sanitary environment, but the failure to adhere to these standards resulted in the deficiency observed during the survey.
Non-Functioning Call Light Puts Resident at Risk
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident, which could place residents at risk of not being able to get assistance when needed. The deficiency was identified for a male resident who was admitted with diagnoses including edema, lack of coordination, muscle weakness, muscle wasting, and cognitive communication deficit. The resident's Quarterly MDS Assessment indicated a BIMS score of 12, reflecting moderately impaired cognition, and he required substantial assistance for various activities of daily living. During an observation, the resident's call light was found on the floor and not functioning, and the resident reported that the call light had not been working for some time, requiring him to seek assistance by other means. Interviews with the facility's administration and nursing staff revealed that they were unaware of the non-functioning call light, although the resident had informed the nurses. The facility's policy mandates that call lights should be functioning and accessible to residents, and any issues should be reported immediately to maintenance for resolution. However, in this case, the call light issue was not addressed promptly, leaving the resident without a reliable means to call for assistance.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burleson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Burleson | 1.4 mi | — | 3 | 0 |
| Crowley Nursing And Rehabilitation | 3.6 mi | — | 0 | 0 |
| Allegiant Wellness And Rehab | 4.2 mi | — | 0 | 0 |
| Park Bend Rehabilitation And Healthcare Center | 4.8 mi | — | 7 | 2 |
| Estates Healthcare And Rehabilitation Center | 8.2 mi | — | 29 | 3 |
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