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 Garland Nursing And Rehabilitation during CMS and state inspections, most recent first.
Two residents with dementia and severe cognitive impairment, sharing a room, became involved in an altercation over the room light, during which one resident struck and grabbed the other’s arm, causing bruising and a hematoma, with additional bruising documented on other body areas. Both residents had care plans addressing cognitive and behavioral issues, including monitoring for mood and behavior changes and documenting triggers and de-escalation techniques, yet they remained roommates until the incident occurred. The injured resident, who required a translator, consistently reported arm injury from being hit and grabbed, while the other resident denied recollection of the event. A CNA reported prior verbal exchanges and doorway-blocking behavior but no known prior physical aggression. The facility’s abuse policy states that residents must be protected from abuse by anyone, including other residents, and that all allegations must be identified, investigated, reported, and addressed with interventions to prevent recurrence, but this incident demonstrated a failure to ensure a resident’s right to be free from abuse.
The facility failed to ensure accurate medication administration and proper observation of medication ingestion for three cognitively intact residents. One resident with significant cardiac and bleeding risk factors was ordered a specific nightly dose of Warfarin but was given an additional dose on at least two evenings, after being approached by staff twice during the same medication pass. The resident reported hiding the extra tablets when staff walked away without observing ingestion and later returned them to another CMA, who passed them to an RN; the RN then handed them to an LVN without documenting or discarding them. Two other residents reported that staff did not consistently watch them take their bedtime Melatonin and Zolpidem, and they often held onto these medications until they chose to take them. Interviews with the DON and staff, along with policy review, showed that these practices did not align with facility expectations and written policies requiring administration as ordered, direct observation of ingestion, and documentation and reporting of medication errors.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy requiring gown and glove use during high-contact care for two residents with pressure ulcers. One resident with severe cognitive impairment and sacral and foot pressure ulcers had EBP signage and a care plan directing staff to wear gowns and gloves, yet an RN and a CNA provided incontinence care and the RN performed wound care wearing only gloves. Another resident with moderate cognitive impairment and sacral and ankle pressure ulcers also had an EBP care plan, but an LVN completed wound care using only gloves. In interviews, staff acknowledged they knew gowns and gloves were required under EBP, cited forgetting and the absence of PPE at the doorway, and recognized that failure to use EBP could lead to cross contamination, while training records showed these staff had not attended the facility’s EBP training.
A resident with a Foley catheter and neuromuscular bladder dysfunction was observed with her catheter bag uncovered and visible from the hallway, contrary to facility policy and staff expectations. Both an LVN and the DON acknowledged that a privacy bag should have been used to maintain the resident's dignity, but it was not in place at the time of observation.
Surveyors found that three residents with significant mobility or cognitive impairments did not have their call lights within reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed that call lights were often left out of reach after care was provided, and some residents were unaware of their location, potentially preventing them from obtaining assistance when needed.
Two residents requiring respiratory care were found with their nasal cannulas and CPAP mask left unbagged and improperly stored when not in use. Nursing staff and the DON confirmed that respiratory devices should be bagged to prevent infection, and facility policy requires safe handling of such equipment.
A resident with significant neurological and mobility impairments, requiring a two-person Hoyer lift transfer, was improperly transferred by a CNA using a sliding board without assistance or proper training. The resident fell during the transfer, resulting in a head injury and subarachnoid hemorrhage. Facility staff and policy reviews confirmed that only therapy staff were authorized to use sliding boards for this resident, and that the CNA did not follow established protocols.
The facility failed to maintain a clean and homelike environment for residents in 9 of 12 rooms reviewed. Observations showed dirty air vents, stained faucets, and unclean mini fridges. Interviews with housekeeping staff revealed confusion about cleaning responsibilities, and the administrator acknowledged inadequate cleaning and supervision. These deficiencies could impact infection control.
The facility failed to maintain a safe environment for three residents by not adhering to fall prevention measures. A resident with a history of falls had a scoop mattress without a physician order, while another resident had a scoop mattress despite not being identified as a fall risk. Additionally, a resident with bone density disorders was found without a fall mat alongside her bed, contrary to her care plan. These oversights were identified through observations and staff interviews.
The facility's kitchen failed to meet professional standards for food service safety, with issues including an uncovered ice scoop, a dirty ice machine, unclean kitchen surfaces, and improperly stored food items. The Dietary Manager cited staffing challenges as a barrier to thorough cleaning, while the Administrator acknowledged the need for improved practices to prevent contamination.
The facility failed to ensure call lights were within reach for several residents, risking their ability to obtain assistance. A resident with severe cognitive impairment had her call light clipped out of reach, while another with mobility issues did not know where his call light was. A third resident's call light was attached to a roommate's bedrail, and another's was on the floor under a wheelchair. Staff interviews highlighted the importance of accessible call lights, and the DON and ADON acknowledged the issue, emphasizing staff responsibility to ensure accessibility.
The facility failed to provide proper respiratory care for several residents, leading to potential risks of respiratory infections. A resident's nasal cannula was found unbagged, another's humidifier bottle was empty, and several residents had improperly stored breathing masks. These lapses in equipment storage and maintenance highlight systemic issues in the facility's handling of respiratory care.
Two residents were exposed to potential infection due to improper glove use and hand hygiene by CNAs during incontinence care. One CNA used gloves from her pocket, risking cross-contamination, while another failed to perform hand hygiene between glove changes. Both incidents violated the facility's infection control policies.
A resident's privacy was compromised when RN B assessed and flushed her midline catheter in the hallway instead of in her room, contrary to facility policy. The resident, who was receiving IV antibiotics for a UTI, was observed by the DON, who confirmed that such procedures should be conducted in private to maintain dignity. Interviews with staff reinforced the expectation of conducting treatments in residents' rooms.
A resident with neuromuscular dysfunction of the bladder was using a Purewick system for urinary incontinence, but the Quarterly MDS assessment failed to reflect this. The MDS Nurse admitted the oversight, and the facility's policy requires accurate MDS assessments to reflect the resident's status.
The facility failed to implement comprehensive care plans for two residents, one requiring smoking management and the other needing breathing treatments. A resident with COPD and a history of smoking was not care planned for smoking, while another with acute respiratory failure did not have breathing treatments included in their care plan. Staff acknowledged these oversights, which could impact the residents' care.
A probiotic medication requiring refrigeration was improperly stored on a nurse's cart, contrary to its instructions. LVN A was unaware of the need for refrigeration, which was confirmed during an inspection. Interviews with the facility's administration highlighted a lack of adherence to the medication storage policy, potentially affecting the effectiveness of the probiotics.
A resident with muscle wasting and atrophy was transferred in the hallway instead of her room, breaching privacy. Two CNAs used a Hoyer lift to move her, initially closing the door but then transferring her in the hallway where her wheelchair was located. Interviews with staff highlighted that such transfers should occur in the resident's room to ensure privacy and dignity, as per facility policy.
A resident with severe cognitive impairment and a history of wandering eloped from a secured unit in an LTC facility. The resident was able to exit the facility with the assistance of another resident who knew the door code. The facility's policies for supervision and care planning were not effectively implemented, leading to the incident.
The facility failed to manage beverage containers according to professional standards, as observed during a lunch service. Two beverage containers were not changed out in a timely manner, with labels indicating they were filled the previous day. Staff interviews revealed inconsistencies in practice and a lack of specific policy for managing beverage containers, contributing to the oversight.
An LTC facility failed to report an altercation between two residents to HHSC within the required timeframe. A resident reported being hit by another resident's motorized wheelchair, but the Administrator did not report the incident, considering it an accident. Despite the altercation, both residents felt safe and did not wish to change rooms. The facility's policy mandates immediate reporting of such incidents, which was not followed.
A facility failed to investigate and report an altercation between two residents, where one resident allegedly hit another with a motorized wheelchair. Despite being notified, the Administrator did not report the incident to HHSC or conduct an investigation, as it was initially seen as an accident. The facility's policy requires immediate investigation and reporting of abuse allegations, which was not followed, potentially risking residents' safety.
A resident with Multiple Sclerosis fell from bed and sustained leg fractures, but the incident was not documented or reported to the physician by the attending LVN. The resident was later hospitalized, and the facility's failure to follow protocol delayed medical intervention.
A resident with multiple medical conditions fell from her bed while receiving care, but the incident was not documented or reported by the CNA or LVN involved. The resident was later diagnosed with fractures in her left leg, highlighting a failure in communication and documentation within the facility.
A resident with multiple medical conditions fell from her bed, and the incident was not reported or documented by the staff. The resident's condition worsened, leading to the discovery of fractures days later. The facility's failure to follow protocols for reporting falls and changes in condition resulted in a deficiency, identified as Immediate Jeopardy, due to the risk posed to all residents.
A resident with multiple medical conditions fell out of bed due to inadequate assistance during care. The LVN failed to notify the doctor or document the incident, leading to a delay in medical evaluation. The resident was later diagnosed with fractures in the tibia and fibula.
A resident with Multiple Sclerosis and severe physical impairments was not provided with an updated care plan reflecting her need for a two-person assist, as indicated by her MDS Assessment. Interviews revealed discrepancies between the care plan and assessment, with staff unaware of the inaccuracies. The facility's policy requiring regular review and revision of care plans was not followed.
A facility failed to reposition a resident with a pressure ulcer every two hours as required, leading to the risk of worsening the ulcer. Staff interviews confirmed the resident needed repositioning due to his condition, but this was not done because the staff were busy and the responsibility was not clearly assigned.
Resident-to-resident altercation resulting in bruising and failure to ensure freedom from abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident, resulting in physical injury. One resident with dementia, psychotic disturbance, anxiety disorder, and major depressive disorder had a care plan that included monitoring for changes in behavior, mood, cognition, and fall risk, reflecting significant cognitive and physical vulnerability. Her MDS showed a BIMS score of 03, indicating severe cognitive impairment. On the date of the incident, progress notes documented that this resident reported being clawed and scratched by her roommate, another cognitively impaired resident, and assessment identified bruising and a hematoma to the right wrist, hand, and arm, as well as bruising to the left eye. A same-day skin assessment documented multiple new in-house–acquired injuries, including bruising to the right outer forearm, left side of the face, and right medial shin, along with edema to the right foot and discoloration to the right leg. The other resident involved had dementia, moderate intellectual disabilities, Parkinsonism, generalized anxiety disorder, and major depressive disorder, with an MDS BIMS score of 05, also indicating severe cognitive impairment. Her care plan included monitoring for adverse reactions to antidepressant therapy and for gait instability and fall risk, and a later care plan entry directed staff to analyze and document triggers, behaviors, and effective de-escalation techniques, indicating a recognized need for behavioral monitoring. Progress notes for the date of the incident documented an allegation that this resident scratched her roommate, and that a urinalysis and culture and sensitivity were ordered to evaluate for a possible UTI as a contributing factor. Despite these known cognitive and behavioral risks, the two residents continued to share a room until the altercation in which one resident physically injured the other. During interviews, the injured resident, who spoke limited English and required a translator, reported that the altercation arose from a disagreement about the room light; she wanted the light on while her roommate wanted it off. She stated that the roommate became upset and hit her on the right arm, grabbing the arm and causing the bruising observed, and she denied being hit or scratched on her face, legs, or other body parts. The translator confirmed that this account was consistent with the resident’s initial report at the time of the incident and that she was unable to recall additional details. The alleged aggressor denied recollection of any altercation and did not acknowledge having hurt anyone. A CNA who had worked with both residents reported prior verbal exchanges between them, noted that the injured resident sometimes stood in the doorway limiting the roommate’s ability to exit or access the bathroom, and stated that the roommate had previously shown verbal agitation but no known physical aggression. The facility’s abuse policy states that residents have the right to be free from abuse and that the facility is responsible for protecting residents from abuse by anyone, including other residents, and for identifying, investigating, and reporting all allegations of abuse and implementing interventions to prevent recurrence, underscoring that the physical altercation and resulting injuries constituted a failure to ensure freedom from abuse. The DON reported that the injured resident had visible bruises and a hematoma on the arm and a small red mark near the eye, which led to documentation of multiple injury sites, and that staff documented all observed marks regardless of severity. Follow-up with the resident showed she consistently reported injury only to the arm and denied other areas of harm, but the initial documentation still reflected multiple areas of bruising and injury acquired in-house. The Psychiatric NP who evaluated the alleged aggressor stated that the resident did not recall the altercation and only mentioned that her roommate would not allow her to leave the room, and that it was unclear whether this perception was accurate due to cognitive status. The NP described the incident as isolated and noted that the resident was typically cooperative and mild-mannered, with no prior similar incidents reported. Despite these characterizations, the documented event shows that one resident physically struck and injured another resident in the shared room, demonstrating that the facility did not effectively prevent resident-to-resident abuse as required by its abuse prevention policy.
Failure to Ensure Accurate Medication Administration and Observation of Ingestion
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate dispensing and administration of medications, including failure to follow prescriber orders and to observe residents ingest their medications. One cognitively intact female resident with extensive cardiac, hepatic, hematologic, and psychiatric diagnoses, including a prosthetic heart valve and a care plan identifying risk for bleeding, was ordered Warfarin Sodium 4 mg, two tablets by mouth at bedtime for clotting related to heart failure. Interview and record review showed that on two evenings she was provided a total of four Warfarin tablets instead of the ordered two, after being approached by staff on two separate occasions during the same evening medication pass. The resident reported receiving two Warfarin pills from a certified medication aide (CMA) around one hour after already receiving two Warfarin pills earlier that evening, and on the second night she again received an additional two Warfarin pills after having already taken her ordered dose. The resident stated that on the second night she informed the staff member that she had already received her medications and was not supposed to receive another dose, but the staff member told her they knew what she was supposed to receive and proceeded to give the medication, then walked away without observing ingestion. The resident hid the additional Warfarin tablets under her blanket instead of taking them and later showed them to her roommate, who confirmed that the CMA did not observe either resident swallow their medications. The next morning, the resident gave the two Warfarin tablets to a different CMA, explaining they were extra pills she had not taken. That CMA reported receiving the pills and the explanation from the resident, then passed the pills to the floor RN. The RN acknowledged receiving the returned Warfarin tablets, being informed they were not taken the previous night, and then handing them off to an LVN at shift change without documenting the event, discarding the medication, or following up. Additional interviews revealed a pattern of staff not consistently observing residents take their medications, particularly bedtime medications for sleep. The roommate of the first resident, who was cognitively intact and required staff assistance with several ADLs, reported that she was given Melatonin 3 mg at bedtime but that the CMA did not watch her take it; she held onto the pill until she was ready to sleep and stated that staff did not always observe her or her roommate taking medications. A cognitively intact male resident with insomnia and multiple comorbidities, including COPD and CNS disorder, reported that staff did not always observe him take his Zolpidem Tartrate 5 mg; he stated that staff often gave his sleep medication early in the evening and he would hold onto it until he was ready for sleep, sometimes calling staff over later to show he had taken it. The DON and Administrator stated they were not aware of the Warfarin medication errors and confirmed that the expectation and facility policy were that nurses and CMAs must monitor residents while taking medications, never walk away without observing ingestion, and that any medication returned by a resident should be discarded, documented, and reported. Facility policies on administering medications and on adverse consequences and medication errors required medications to be administered as prescribed, inappropriate or excessive doses to be addressed with the prescriber, and medication errors to be documented and monitored, which did not occur in these instances. Further interviews with staff involved in the Warfarin administration showed additional failures in medication control and documentation. The CMA who worked weekend double shifts acknowledged administering Warfarin to the resident twice in the evening on at least one day, totaling four pills, stating she gave what appeared in the electronic system and that both med aides and nurses were responsible for administering blood thinners. She stated she believed she observed the resident take the medications and was unaware the resident had not taken the extra pills. The LVN who received the returned Warfarin from the RN identified the pills as Warfarin, determined they could only belong to the resident on Warfarin, and learned from the resident that she had received an additional dose after already taking two pills. The LVN reported finding two packs of Warfarin on the med aide cart in addition to packs on the nurse’s cart, removed the extra packs from the med aide cart, and discarded the returned pills without documenting the incident or reporting it to the DON. These actions and inactions, including duplicate Warfarin availability on multiple carts, failure to follow physician orders, failure to observe medication ingestion, and failure to document and report medication errors, led to the cited deficiency in pharmaceutical services.
Failure to Implement Enhanced Barrier Precautions During Wound and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) infection control program for residents with pressure ulcers. Resident #1, an older female with severe cognitive impairment (BIMS score of 0) and pressure ulcers on the sacral region and medial lateral foot, had a care plan requiring staff to wear gowns and gloves during high-contact care activities under EBP. A sign was posted on her door indicating EBP and the requirement for gown and gloves with all direct care. However, there was no PPE available outside her room at the time of observation. On the observed date and time, RN A and CNA B provided incontinence care to Resident #1 while only wearing gloves and not donning gowns, despite the EBP signage and care plan requirements. Later, RN A performed wound care on Resident #1’s sacral and foot pressure ulcers, again wearing only gloves and not a gown. RN A followed hand hygiene and glove changes between steps but did not use a gown at any point during the wound care. In interviews, CNA B stated she knew she was supposed to wear PPE when an EBP sign was present and that staff should wear gowns and gloves when caring for residents with wounds, but she reported she did not recall seeing the sign and that there was no PPE cart at the door. RN A acknowledged she was aware of the requirement to wear a gown and gloves for Resident #1 under EBP, stated she forgot because she was anxious and there was no PPE bin by the door, and confirmed that failure to use EBP could lead to cross contamination. Resident #2, an older female with moderate cognitive impairment (BIMS score of 10) and pressure ulcers on the sacral region and left ankle, also had a care plan requiring EBP with staff wearing gowns and gloves during high-contact care activities. During observation, LVN C performed wound care on Resident #2’s sacral and ankle pressure ulcers, including removal of old dressings with drainage, cleansing of the wounds, and application of collagen powder, calcium alginate, and dry dressings, while only wearing gloves and not a gown. In an interview, LVN C stated she forgot to wear PPE because she was nervous, noted that PPE had previously been placed in bins by residents’ doors but was not present that day, and acknowledged awareness of the requirement to wear a gown and gloves for Resident #2 under EBP and that failure to use EBP could result in cross contamination. The DON stated staff were required to wear gowns and gloves for direct contact with residents on EBP, such as turning, incontinence care, and wound care, and that EBP were in place to protect residents from exposure to infectious agents on providers’ clothing. Training records showed that RN A, CNA B, and LVN C had not attended the facility’s EBP training.
Failure to Conceal Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not concealing her catheter bag from public view. During observations, the resident's catheter bag was seen hanging from her bed without a privacy bag, making it visible from the hallway. Interviews with an LVN and the DON confirmed that the resident should have had a privacy bag to maintain her dignity, and that it was standard practice for nursing staff to ensure all residents with catheter bags had privacy bags in place. The resident involved was a female with neuromuscular dysfunction of the bladder, an active urinary tract infection, and a physician's order for a Foley catheter. The facility's own policy on dignity emphasized care that promotes residents' well-being and self-worth. Despite this, the catheter bag was left uncovered and visible, contrary to both facility policy and staff expectations, resulting in a failure to maintain the resident's right to a dignified existence.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents who required assistance, as observed during a survey. For one resident with a history of stroke, muscle weakness, and total dependence on staff for activities of daily living, the call light was found on the floor near the nightstand, out of reach while the resident was lying in bed. A registered nurse confirmed uncertainty about the resident's ability to use the call light and acknowledged that staff should ensure call lights are within reach during rounds. Another resident with severe cognitive impairment and reduced mobility was observed with the call light under the bed and out of reach, despite care plan interventions specifying the need for the call light to be accessible and for staff to encourage its use. A third resident, who had a displaced fracture, reduced mobility, and was a fall risk, was found with the call light hanging off a side rail and nearly touching the floor, also out of reach. The resident was unaware of the call light's location. Interviews with nursing staff, including an LVN and the DON, revealed that staff often forgot to return the call light to an accessible position after providing care, and that this oversight could prevent residents from calling for help. The facility's policy requires that each resident be provided with a means to call staff for assistance from their bed and other locations, but this was not consistently followed for the residents observed.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents requiring such care, as evidenced by improper storage of respiratory equipment for two residents. For one resident with COPD and respiratory failure, observations revealed that her nasal cannula was left hanging unbagged from her wheelchair and her CPAP mask was placed unbagged on her nightstand, despite not being in use. The resident confirmed she had not used the oxygen or CPAP since the previous night or earlier that morning. A registered nurse acknowledged that respiratory devices should be bagged when not in use to prevent infection and stated it was the nurses' responsibility to ensure this was done. Another resident with chronic respiratory failure was observed with her nasal cannula on the floor, hanging from her wheelchair and unbagged when not in use. A licensed vocational nurse confirmed that the devices needed to be bagged to avoid infection and that it was the nurses' responsibility to check for this. The Director of Nursing also stated that respiratory devices should be bagged when not in use and that she and the nurses check for this throughout the day. Review of the facility's policy on oxygen administration indicated the need to follow physician's orders and ensure safe handling of respiratory equipment.
Inadequate Supervision and Improper Transfer Technique Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) attempted to transfer a resident who required a two-person assist with a Hoyer lift, using a sliding board and without assistance from another staff member. The resident, who had a history of Parkinson's disease, prior stroke with left-sided deficits, non-Alzheimer's dementia, hemiplegia, and was on blood thinners for atrial fibrillation, was care planned for two-person Hoyer lift transfers due to her high risk for injury and fear of falling. Despite these documented needs, the CNA proceeded with a one-person sliding board transfer, for which she was not trained or delegated, and did not request help from another staff member. During the transfer, the CNA left the resident unattended while preparing the bed, at which point the resident attempted to scoot forward onto the sliding board from her wheelchair. The resident lost balance, fell to the floor, and struck her head. The incident was witnessed by another CNA who heard the fall and immediately notified the charge nurse. Upon assessment, the resident was found to have a hematoma on the left side of her head, bruising to both hands, and was subsequently sent to the hospital where a CT scan revealed a subarachnoid hemorrhage in the left temporal lobe. Interviews with staff and review of facility policies confirmed that nursing staff were not permitted to use sliding boards for this resident, and that at least two staff were required for mechanical lift transfers. The CNA involved admitted to not being trained for sliding board transfers for this resident and acknowledged that the resident was normally a two-person assist. The therapy department had been working with the resident on sliding board transfers, but only therapy staff were authorized and trained to perform them. The facility did not provide a specific transfer policy when requested.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in 9 of 12 rooms reviewed. Observations revealed that air vents in these rooms were covered with thick black and brown dirt, and bathroom sink faucets had thick white stains. Additionally, soap dispensers had reddish stains, and some rooms had large holes in the walls or debris behind beds. Mini fridges in certain rooms contained brown and red stains, indicating a lack of thorough cleaning and sanitation. Interviews with housekeeping staff and the supervisor highlighted a lack of clarity and responsibility regarding cleaning duties. Housekeepers acknowledged their responsibility for cleaning various areas, including vents, windows, and bathrooms, but there was confusion about who was responsible for cleaning mini fridges. The housekeeping supervisor admitted to not knowing who should clean the mini fridges and stated that leadership was supposed to check for cleanliness issues during morning rounds. The facility's administrator recognized that housekeeping was not performing thorough cleaning, and the housekeeping supervisor was not adequately checking their work. Leadership was also not ensuring room cleanliness during daily rounds. The administrator noted that these deficiencies could impact infection control, as the facility's policy emphasized providing a clean, sanitary, and homelike environment for residents.
Failure to Ensure Environment Free from Accident Hazards
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents. Resident #17, a female with a history of falls and moderate cognitive impairment, was observed with a scoop mattress on her bed without a corresponding physician order, despite her care plan indicating the need for such a mattress. Similarly, Resident #26, a male with a history of stroke and an amputation, was also found with a scoop mattress on his bed without a physician order, although his care plan did not identify him as a fall risk. Resident #34, a female with a history of falls and bone density disorders, was observed without a fall mat alongside her bed, contrary to her care plan's intervention for fall prevention. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed that the absence of the fall mat was due to oversight after the resident's return from the hospital. The facility's policy on fall prevention requires that each resident be assessed for fall risk and receive care according to their individualized risk level, which was not adhered to in these cases.
Deficiencies in Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. The ice scoop for the ice machine was not properly covered, exposing it to air-borne contaminants, and the ice machine itself had a dirty filter and stained interior walls. The kitchen floor and walls were not adequately cleaned, with dirt and dried stains present. Additionally, kitchen equipment, including a microwave and a table with drink dispensers, had visible stains, and containers of flour and sugar were not clean. Food storage practices were also deficient, with items in the refrigerator and freezer not being properly labeled, dated, or sealed, increasing the risk of contamination. Interviews with the Dietary Manager and Administrator revealed that the facility had a cleaning schedule, but staffing challenges hindered thorough cleaning efforts. The Dietary Manager acknowledged the issues, noting that the kitchen and equipment were cleaned monthly, but staff often hurried and neglected to seal food items properly. The Administrator recognized the need for improved cleaning and food storage practices to prevent potential infections. The facility's policy on kitchen sanitation emphasized the importance of routine cleaning and proper food storage, aligning with FDA guidelines to protect food from contamination.
Failure to Ensure Call Lights Are Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach and accessible for five residents, which could place them at risk of being unable to obtain assistance when needed. Resident #58, a female with severe cognitive impairment and a history of falls, was observed with her call light clipped to the light over her bed, out of reach. Similarly, Resident #56, a male with moderate cognitive impairment and mobility issues, did not know where his call light was, as it was attached to the bedrail of an unoccupied bed. Resident #54, a female with severe cognitive impairment and muscle wasting, had her call light attached to her roommate's bedrail, making it inaccessible. Resident #61, a female with severe cognitive impairment and a history of falls, had her call light on the floor under her wheelchair, which was not easily reachable. Resident #120, a male with moderate cognitive impairment and extensive assistance needs, had his call light on the floor, out of reach, until a CNA picked it up and clipped it to his bed. Interviews with staff, including CNAs and LVNs, highlighted the importance of having call lights within reach to alert staff for assistance, especially in emergencies. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the issue, noting that residents might not know how to use the call light or might disconnect it. They emphasized the responsibility of all staff to ensure call lights are within reach, as residents might not receive help when needed if they cannot access their call lights. The facility's policy on answering call lights, revised in March 2021, stated that call lights should be within easy reach when residents are in bed or confined to a chair.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide proper respiratory care for several residents, leading to potential risks of respiratory infections and unmet respiratory needs. Resident #120's nasal cannula was observed hanging unbagged on the oxygen concentrator, which could lead to contamination and infection. The resident, a male with heart failure and respiratory failure, had a care plan that included oxygen therapy, but the lack of proper storage for the nasal cannula was a significant oversight. Resident #10, a female diagnosed with respiratory failure, was found using an oxygen concentrator with an empty humidifier bottle. Despite having a care plan that required monitoring and refilling the humidifier bottle every shift, the resident reported dryness in her nose, indicating the humidifier had not been maintained as required. This neglect in maintaining the humidifier bottle could lead to nasal irritation and discomfort for the resident. Other residents, including Resident #11, #49, and #32, also experienced similar issues with their respiratory equipment. Resident #11's breathing mask was not stored properly, and Resident #49's nasal cannula and breathing mask were found unbagged, with the nasal cannula even on the floor. Resident #32's breathing mask was left unbagged on her side table. These lapses in proper storage and maintenance of respiratory equipment highlight a systemic issue in the facility's handling of respiratory care, potentially exposing residents to cross-contamination and infection.
Infection Control Deficiencies in Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by two separate incidents involving improper glove use and hand hygiene during incontinence care. In the first incident, a CNA was observed using gloves taken from the pocket of her scrub top while providing care to a resident. This resident, who had severely impaired cognition and required extensive assistance with toileting, was at risk for cross-contamination due to the CNA's actions. The CNA admitted to storing gloves in her pocket because the facility did not provide gloves in the resident's room, acknowledging the risk of cross-contamination. In the second incident, another CNA failed to perform hand hygiene between glove changes while providing incontinence care to a different resident. This resident, diagnosed with Alzheimer's disease and requiring extensive assistance with toileting, was exposed to potential infection due to the CNA's failure to use hand sanitizer or wash her hands after removing soiled gloves. The CNA acknowledged the importance of hand hygiene and admitted to not following the facility's training on proper handwashing procedures. Both incidents highlight a lapse in adherence to the facility's hand hygiene policy, which mandates handwashing or the use of hand sanitizer before donning and after doffing gloves. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that the actions of the CNAs constituted cross-contamination and increased the risk of infection for the residents involved.
Failure to Maintain Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident during a medical procedure. On the specified date, RN B assessed and flushed a midline catheter for a resident in the hallway instead of inside the resident's room. This action was observed by the Director of Nursing (DON), who noted that the procedure should have been conducted in private to ensure the resident's dignity and privacy were maintained. The resident, who had a urinary tract infection and was receiving intravenous antibiotics, was in the hallway with RN B when the procedure was performed. Interviews with the DON, RN B, the Administrator, and the Assistant Director of Nursing (ADON) confirmed that the expectation was for all medical treatments to be conducted in the privacy of the resident's room. The facility's policy on dignity and privacy was not adhered to, as the procedure was performed in a public area, potentially exposing the resident's medical condition to others. The resident expressed that while she did not mind the procedure being done in the hallway, she acknowledged that it should have been done in her room if that was the requirement.
Inaccurate MDS Assessment for External Catheter Use
Penalty
Summary
The facility failed to ensure that a resident's Quarterly MDS assessment accurately reflected the use of an external catheter, specifically a Purewick system, which is a non-invasive urinary drainage device. The resident, a cognitively intact female with a diagnosis of neuromuscular dysfunction of the bladder, was frequently incontinent and used the Purewick system while in bed. Despite this, the MDS assessment did not indicate the use of an external catheter, which was an oversight by the MDS Nurse. The resident's care plan and physician orders did reflect the use of the Purewick system, and staff interviews confirmed its use and monitoring. The Director of Nursing (DON) was not familiar with the MDS process, and the MDS Nurse acknowledged the oversight, stating that the MDS should have included the use of the Purewick system. The MDS Nurse admitted that the omission was an error and planned to audit the MDS assessments to ensure accuracy. The facility's policy requires that the MDS assessment accurately reflects the resident's status during the observation period, and the Resident Assessment Coordinator is responsible for ensuring the completion of the MDS for each resident.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which could potentially impact the care they receive. Resident #50, a female with a history of heart failure, absence of both legs below the knees, and chronic obstructive pulmonary disease, was identified as a smoker. However, her care plan did not include any provisions for her smoking habits, despite being listed as a smoker in the facility's records. The Social Worker, responsible for completing smoking assessments, acknowledged the oversight and the potential impact on the resident's care. Resident #11, a male with acute respiratory failure and severe cognitive impairment, required breathing treatments as per his physician's orders. However, his care plan did not reflect this need, which was confirmed during an observation of a Licensed Vocational Nurse administering the treatment. The Assistant Director of Nursing and the Director of Nursing both recognized the importance of having a comprehensive care plan to ensure all staff are aware of the necessary interventions for each resident. Interviews with facility staff, including the MDS Nurse and the Administrator, highlighted the expectation that all residents should have detailed and individualized care plans. The absence of such plans for these residents was acknowledged as an oversight, with staff admitting the potential for confusion and inadequate care provision without proper documentation in the care plans.
Improper Storage of Probiotic Medication
Penalty
Summary
The facility failed to ensure proper storage of a probiotic medication, which was observed on a nurse's cart with instructions to refrigerate after opening. LVN A, who was responsible for the cart, was unaware that some probiotics required refrigeration to maintain their effectiveness. During an inspection, LVN A acknowledged the oversight and indicated she would inform the Director of Nursing (DON) about the issue. Interviews with the facility's administration, including the Administrator, Assistant Director of Nursing (ADON), and DON, revealed a lack of awareness and adherence to the facility's medication storage policy. The Administrator and ADON both recognized the importance of refrigerating certain probiotics to ensure their effectiveness. The DON confirmed that the expectation was for staff to be vigilant about storing medications and supplements that required refrigeration, and acknowledged that the failure to refrigerate the probiotics could render them ineffective.
Privacy Breach During Resident Transfer
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during a transfer procedure. The resident, a cognitively intact female with muscle wasting and atrophy, required extensive assistance from two staff members for transfers using a mechanical lift. On the day of the incident, two CNAs were observed transferring the resident from her bed to a wheelchair. Although the CNAs initially closed the door while raising the resident with the Hoyer lift, they proceeded to transfer her in the hallway, where her wheelchair was located, rather than inside her room. Interviews with the CNAs, ADON, DON, and the Administrator revealed that the transfer should have been conducted inside the resident's room to ensure privacy and dignity. The CNAs acknowledged the potential dignity issue, and the ADON and DON emphasized that all care should be provided in the privacy of the resident's room, regardless of the resident's expressed indifference. The facility's policy on dignity and privacy was not adhered to during this incident, as the transfer in the hallway exposed the resident to potential embarrassment.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in the elopement of a resident from the secured care unit. The resident, who had a history of severe cognitive impairment and wandering behavior, was able to exit the facility and was found sitting outside on a bench. The resident's comprehensive care plan identified her as at risk for wandering and elopement, necessitating her residence in the secured unit. On the day of the incident, a staff member observed the resident outside and redirected her back inside. It was determined that another resident, who was cognitively intact and had access to the facility's front door code, facilitated the elopement by opening the door for the resident. The facility's doors were alarmed with codes that only staff were supposed to have access to, but the resident who assisted in the elopement was aware of the code. Interviews with staff and the facility's administration revealed that the resident was able to exit the secured unit, although the exact method was unclear. The facility's administrator and DON confirmed that the doors were functioning properly and that the codes had been changed following the incident. The facility's policy required adequate supervision and a person-centered care plan to prevent such incidents, but these measures were not effectively implemented, leading to the resident's elopement.
Failure to Properly Manage Beverage Containers
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an observation of the lunch dining service, two beverage containers were found in the dining area with labels indicating they were filled the previous day. The staff member responsible for these containers admitted to not changing out the beverages in a timely manner due to a busy morning, which is against the facility's expectations for daily cleaning and changing of beverage containers. Interviews with various staff members, including the Dietary Manager (DM), Assistant Director of Nursing/Infection Control Preventionist (ADON/ICP), Director of Nursing (DON), and the facility's Administrator, revealed a lack of consistent practice and policy regarding the cleaning, labeling, and changing of beverage containers. The facility did not have a specific policy for beverage container management, which contributed to the oversight. The U.S. Food Code requires that ready-to-eat, time/temperature control for safety (TCS) food be marked with a date or day for consumption or disposal, which was not adhered to in this instance.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report an alleged altercation between two residents to the Health and Human Services Commission (HHSC) within the required timeframe. The incident involved a resident who reported being hit on the leg by another resident's motorized wheelchair. The altercation was reported to the facility's Assistant Director of Nursing (ADON) and subsequently to the Director of Nursing (DON) and the Administrator. However, the Administrator did not report the incident to HHSC, as it was perceived as an accident rather than an intentional act of abuse. Resident #2, who was cognitively intact, reported that Resident #3 deliberately hit him with a motorized wheelchair. Resident #3, who had moderate cognitive impairment, admitted to bumping into Resident #2 but denied any intentional harm. The ADON intervened promptly during the incident and separated the residents. Despite the altercation, both residents expressed feeling safe at the facility and did not wish to change rooms or facilities. The facility's policy requires immediate reporting of any alleged abuse, neglect, or mistreatment to the Administrator and state agency. The Administrator acknowledged the responsibility to report such incidents but failed to do so, as the event was not initially considered abuse. This oversight could potentially place residents at risk of continued abuse and injuries of unknown origins, affecting their emotional and physical well-being.
Failure to Investigate and Report Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate and report an alleged altercation between two residents, as required by state law. The incident occurred when one resident, who uses a motorized wheelchair, allegedly hit another resident's leg while trying to pass in a common area. The resident who was hit reported feeling safe overall but described the other resident as a bully. The facility's Assistant Director of Nursing (ADON) intervened during the incident and reported it to the facility's Abuse Coordinator and Administrator. Despite being notified of the incident, the Administrator did not report it to the Health and Human Services Commission (HHSC) or conduct an investigation, as it was initially presented as an accident. The Director of Nursing (DON) stated that it was the Administrator's responsibility to report and investigate any allegations of abuse or neglect. The facility's policy requires immediate investigation and reporting of any suspected abuse, but this protocol was not followed in this case. The failure to investigate and report the incident within the required timeline could place residents at risk of continued abuse and injuries of unknown origins. The facility's policy emphasizes the importance of protecting residents' health, welfare, and rights by promptly addressing any allegations of abuse. The Administrator acknowledged the importance of reporting and investigating such incidents to prevent ongoing abuse.
Failure to Notify Physician and Document Resident Fall
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify relevant parties following an accident involving the resident, which resulted in injury and had the potential for requiring physician intervention. The incident involved a resident with multiple medical conditions, including Multiple Sclerosis, who was nonverbal and dependent on staff for all activities of daily living. On the evening of the incident, a CNA was providing incontinent care when the resident rolled off the bed onto a floor mat. The CNA then sought assistance from an LVN, who helped return the resident to bed without documenting the incident or notifying the physician or family. The resident was later diagnosed with fractures in the tibia and fibula of the left leg after being sent to the hospital several days following the fall. The LVN did not report the fall or complete an incident report, and the resident's physician was not informed until several days later. The lack of immediate notification and documentation of the fall delayed the resident's assessment and treatment, potentially exacerbating the injury. Interviews with facility staff revealed that the LVN and CNA did not follow the facility's protocol for reporting falls and changes in condition. The LVN admitted to forgetting to document the incident due to being busy with other residents. The facility's Director of Nursing and Administrator were unaware of the fall until several days later, prompting an investigation and subsequent staff training on proper notification procedures.
Neglect and Documentation Failure Leads to Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a fall that was not properly documented or reported. The incident involved a resident with multiple medical conditions, including multiple sclerosis, who was dependent on staff for all activities of daily living. On the day of the incident, a CNA was providing incontinent care when the resident fell from the bed onto a floor mat. The CNA did not report the fall to the Director of Nursing (DON) or the Administrator, and the Licensed Vocational Nurse (LVN) who assessed the resident also failed to document the incident or notify the resident's doctor. The resident was later sent to the hospital, where she was diagnosed with fractures in her left tibia and fibula. The facility's records did not initially reflect any fall or incident, and the resident's care plan did not indicate any changes in her condition. Interviews with staff revealed that the CNA and LVN did not follow proper procedures for reporting and documenting the fall, and the resident's condition was not adequately monitored following the incident. The lack of documentation and communication led to a delay in identifying the resident's injuries, which were only discovered after the resident was transferred to the hospital. The facility's failure to report and document the fall, as well as the lack of immediate medical assessment, constituted neglect and placed the resident at risk of further harm.
Failure to Report and Document Resident Fall
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent neglect, resulting in a deficiency related to the care of a resident. The resident, who had multiple medical conditions including Multiple Sclerosis and was nonverbal, experienced a fall on August 2, 2024, which was not properly reported or documented by the staff involved. CNA A was providing incontinent care when the resident rolled off the bed onto a floor mat. Despite the fall, no immediate injuries were noted, and the resident was assisted back into bed by CNA A and LVN B. However, the incident was not reported to the Director of Nursing (DON) or the Administrator, and no x-rays were conducted at that time. The resident's condition worsened over the following days, with swelling and discoloration observed in her left leg. It was not until August 8, 2024, that an x-ray revealed fractures in the resident's tibia and fibula, leading to her transfer to the hospital. The lack of documentation and notification of the fall delayed appropriate medical intervention and assessment, which could have mitigated the resident's injuries. Interviews with staff revealed a lack of understanding and adherence to the facility's protocols for reporting falls and changes in resident conditions. The deficiency was identified as Immediate Jeopardy on August 11, 2024, due to the potential risk to all residents from the failure to assess and treat incidents in a timely manner. The facility's neglect in following its own policies and procedures for reporting and responding to falls and injuries placed residents at risk of harm, highlighting significant gaps in communication and training among the staff.
Failure to Provide Appropriate Care and Incident Reporting
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one resident. A Certified Nursing Assistant (CNA) did not provide incontinent care with a second staff member assisting, which resulted in the resident falling out of bed. The Licensed Vocational Nurse (LVN) failed to notify the resident's doctor after the incident, did not complete and document a head-to-toe assessment, and did not monitor the resident or perform neuro checks. Consequently, the resident was sent to the hospital several days later and was diagnosed with fractures in the tibia and fibula of the left lower leg. The resident involved was a female with multiple medical conditions, including Multiple Sclerosis, hypertension, and cardiac arrhythmia, among others. She was nonverbal, bed-bound, and required total assistance for activities of daily living (ADLs). The resident's care plan indicated that she was at risk for falls and required a fall prevention program. Despite these needs, the incident was not documented in the resident's progress notes, and no immediate medical evaluation was conducted following the fall. Interviews with staff revealed that the CNA and LVN did not follow proper procedures for reporting and documenting the fall. The CNA stated that the resident rolled off the bed during care, and the LVN admitted to not notifying the doctor or completing an incident report. The Director of Nursing (DON) and other staff were unaware of the fall until several days later, leading to a delay in the resident receiving appropriate medical attention. The facility's failure to adhere to established protocols for incident reporting and resident care resulted in a deficiency being identified by surveyors.
Failure to Update Care Plan for Resident with Multiple Sclerosis
Penalty
Summary
The facility failed to review and revise the care plan for a resident after her Minimum Data Set (MDS) Assessment indicated she required a two-person assist for bed mobility and incontinent care. The resident, who was admitted with multiple health issues including Multiple Sclerosis, was assessed as having moderate impaired cognition, severe memory problems, and significant physical impairments. Despite these findings, the care plan was not updated to reflect the resident's current needs, which could lead to unmet needs and potential health risks. Interviews with facility staff revealed discrepancies between the MDS Assessment and the care plan. The Director of Nursing (DON) and the MDS Coordinator acknowledged that the care plan should match the MDS Assessment, but the resident's care plan inaccurately indicated a one-person assist for bed mobility and hygiene. The MDS Coordinator admitted that the resident's status varied due to muscle spasms, and the care plan should have been updated to reflect a two-person assist requirement. Further interviews highlighted a lack of awareness among staff regarding the inaccuracies in the care plan. The Medical Director confirmed the resident's need for total assistance due to her condition. The DON and the facility Administrator were unaware of the care plan discrepancies, indicating a breakdown in communication and oversight. The facility's policy mandates that care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, which was not adhered to in this case.
Failure to Reposition Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless unavoidable. Specifically, the facility did not reposition a resident with a pressure ulcer on his sacrum every two hours as required. Observations on the day of the survey showed the resident lying on his back for extended periods without being repositioned. Interviews with staff, including a CNA, an LVN, and the DON, confirmed that the resident needed to be repositioned every two hours due to his condition, but this was not done because the staff were busy and the responsibility was not clearly assigned. The resident in question was a [AGE] year-old male with a diagnosis that included a pressure ulcer on the sacrum, hemiplegia, and tracheostomy status. His care plan specifically required repositioning every two hours to prevent further skin breakdown. Despite this, the resident was observed lying on his back for over four hours without being repositioned. Staff interviews revealed a lack of clarity and execution in the responsibility for repositioning the resident, leading to a failure in providing the necessary care to prevent the worsening of the pressure ulcer. The facility did not provide a policy on repositioning at the time of the survey exit.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 772 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Nursing homes near Garland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legend Oaks Healthcare And Rehabilitation Garland | 2.1 mi | — | 4 | 0 |
| Beltline Healthcare Center | 2.4 mi | — | 9 | 4 |
| The Parks At Garland Healthcare And Rehab | 2.6 mi | — | 3 | 0 |
| Pleasant Valley Healthcare And Rehabilitation Cent | 3.6 mi | — | 1 | 0 |
| Advanced Health & Rehab Center Of Garland | 4 mi | — | 16 | 3 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.