Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 Glen Rose Nursing And Rehab Center during CMS and state inspections, most recent first.
Care plans for several residents with complex medical and cognitive needs did not include documentation of discharge preferences or assessment of their desire to return to the community, and one resident's care plan was not updated to reflect a current DNR order. Staff interviews revealed confusion about responsibility for updating care plans, resulting in omissions and conflicting documentation.
Two residents were not protected from abuse: one was verbally abused by a hospitality aide who used profane and derogatory language and refused care, while another was physically abused by her spouse, who slapped her during a visit, resulting in redness to her cheek. Both incidents were witnessed by staff and confirmed through interviews and record review.
A resident with dementia and other mental health diagnoses was found agitated and missing from her room, later located in the secure unit courtyard without injury. The Administrator did not submit the required 5-day investigatory findings to the State Survey Agency, as she believed the incident did not constitute an elopement and reporting was unnecessary, resulting in a failure to comply with reporting requirements.
A resident with multiple chronic conditions and on hospice care had their Tramadol discontinued prior to passing away. Following the resident's death, a discrepancy in the Tramadol count was discovered, with one tablet missing. An LVN failed to conduct the required medication count at shift change, did not report the discrepancy promptly, and did not participate in a drug screening as requested. The facility's policy requiring joint shift counts and immediate reporting of discrepancies was not followed.
The facility failed to secure medication and treatment carts, leaving SS Cart 1, SS Cart 2, SS Cart 3, and GV Cart unlocked and unattended. These carts contained various medications and wound care items, posing a risk to residents. Staff interviews revealed distractions and oversight as reasons for the failure, despite facility policy requiring carts to be locked when not in use.
The facility failed to document weekly skin assessments for two residents, leading to incomplete medical records. One resident with Alzheimer's and other conditions had a rash that was not documented, while another resident with dementia had a scabbed wound and abrasion from a fall, also undocumented. The absence of the treatment nurse contributed to this lapse, as acknowledged by the DON and RN A.
The facility failed to properly label and date food items in storage, risking the use of expired food. Additionally, the ice machine was not cleaned as required, with a dirty panel observed. Staff interviews confirmed non-compliance with facility policies and FDA guidelines.
A dietary staff member in an LTC facility was found working without a Food Handlers Certificate, despite being employed for two months. The facility's DM and ADMN acknowledged the oversight, citing language barriers and lack of monitoring as contributing factors. The dietician stressed the importance of certification within 30 days to ensure proper food handling and prevent cross-contamination.
Failure to Update Care Plans with Discharge Preferences and Advanced Directives
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all resident needs, specifically omitting documentation of services provided due to residents' exercise of rights, residents' preferences, and potential for future discharge. For five out of seven residents reviewed, care plans did not include information regarding the residents' preferences for discharge or whether their desire to return to the community had been assessed. Additionally, the care plan for one resident was not updated to reflect an advanced medical directive, despite a current and verified Do-Not-Resuscitate (DNR) order being present in the medical record. Record reviews revealed that residents with significant cognitive impairments and complex medical histories, including severe anxiety, dementia, depression, heart failure, and respiratory failure, did not have discharge planning documented in their care plans. In one case, a resident with a DNR order had conflicting documentation in the care plan, which still listed a Full Code CPR order. Interviews with facility staff, including the RN, DON, MDS Coordinator, and Administrator, indicated a lack of clarity regarding responsibility for updating care plans, particularly for DNR status and discharge planning. Staff interviews further revealed that the social worker (SW) was generally expected to update care plans with DNR status and discharge planning, but there was confusion and lack of awareness among the interdisciplinary team about these responsibilities. The absence of discharge planning and updated advanced directives in the care plans was not recognized by the staff until brought to their attention during the survey, and the SW responsible for these updates was unavailable for interview at the time.
Failure to Prevent Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from abuse and neglect. In one incident, a male resident with multiple cognitive and behavioral diagnoses, including delusional disorder, dementia, and impulse disorder, was subjected to verbal abuse by a hospitality aide (HA). The aide yelled at the resident, used profane and derogatory language, and refused to provide care after the resident expressed discomfort due to being wet. The incident was witnessed by other staff, and the aide admitted to using inappropriate language, citing personal stress as a trigger. The resident did not recall the event and showed no signs of distress or injury upon assessment. In a separate incident, a female resident with severe cognitive impairment, dementia, and major depressive disorder was physically abused by her spouse during a visit. The spouse slapped the resident on the cheek after she spit water on him, resulting in visible redness. The event was witnessed by staff, who immediately intervened and separated the resident from her spouse. The resident did not display emotional distress or behavioral changes following the incident, and her family and staff reported no prior history of aggression from the spouse. Both incidents were confirmed through interviews with staff, the residents' family members, and review of medical records and facility policies. The facility's failure to prevent these instances of verbal and physical abuse constituted noncompliance with regulations designed to protect residents from abuse, neglect, and exploitation.
Failure to Timely Report Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of an investigation to the State Survey Agency within 5 working days of an incident involving a resident. The incident involved a female resident with diagnoses including unspecified dementia, senile degeneration of the brain, anxiety disorder, major depressive disorder, and muscle weakness. On the day of the incident, the resident was found agitated and pounding on the secure unit door. Staff later discovered the air conditioning unit on the floor and the window open in her room. After a search, the resident was located in the secure unit courtyard within 30 minutes, with no injuries noted but continued agitation. She was subsequently discharged to a behavioral health hospital. The Administrator did not submit the required 5-day investigatory findings to the State Survey Agency, as she determined the event was not an elopement and believed reporting was unnecessary. The facility's policy requires comprehensive investigations and written reports to be sent to the appropriate authorities within five working days. Interviews with staff confirmed that the Administrator was responsible for the report and that the 5-day report was not submitted until after the surveyor's inquiry.
Failure to Reconcile and Report Discrepancy in Controlled Substance Count
Penalty
Summary
The facility failed to ensure that a resident was protected from misappropriation of controlled drugs, specifically Tramadol, by not maintaining and periodically reconciling the medication count as required. The deficiency involved a resident with multiple diagnoses, including congestive heart failure, type 2 diabetes, cardiac pacemaker, senile degeneration of the brain, and muscle wasting. The resident was admitted on 07/03/24 and was placed on hospice care, with Tramadol discontinued on 3/23/25. The resident passed away on 3/24/25. On the morning following the resident's death, a nurse discovered that the count for the resident's Tramadol was off by one tablet. The nurse who had worked the previous night shift admitted to noticing the discrepancy during her shift but did not report it immediately, nor did she conduct the required count with the outgoing nurse at shift change. The nurse stated she did not want to disturb the previous nurse and failed to follow protocol for reporting and reconciling the count. Statements from other staff confirmed that the nurse in question was frequently late and often refused to participate in the required medication counts at shift change, despite being counseled and trained on this responsibility. The facility's policy required that both the oncoming and outgoing nurses count controlled substances together at each shift change and report any discrepancies to the DON. In this case, the count was not performed as required, the discrepancy was not reported in a timely manner, and the nurse involved did not comply with requests for drug screening following the incident. The failure to follow established procedures resulted in the unaccounted loss of a controlled medication after it had been discontinued and the resident had passed away.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments, as observed with four medication/treatment carts (SS Cart 1, SS Cart 2, SS Cart 3, and GV Cart) being left unlocked, unsecured, and unattended. During observations, SS Cart 1 and SS Cart 2 were found parked against the hallway wall with drawers facing outward and not in the line of sight of any staff. A resident was seen moving in a wheelchair within arm's length of these carts. SS Cart 3 was similarly left unlocked and unattended. These carts contained various medications, including Lasik, Levetiracetam, and others, as well as wound care creams and inhalers. Interviews with staff revealed that RN A was not responsible for SS Cart 1 and SS Cart 2 and was unsure why they were left unsecured. RN A admitted to being distracted and forgetting to lock SS Cart 3. MA B, responsible for SS Cart 1 and SS Cart 2, acknowledged leaving the carts open due to being in a hurry. GV Cart was also found unlocked near the nurse's station, with RN C admitting it should have been locked. The DON and ADMN both stated that medication carts should be locked when unattended, attributing the failure to staff oversight. The facility's policy requires medication carts to be secured during medication passes and locked when not in use.
Failure to Document Weekly Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, specifically regarding the documentation of weekly skin assessments. Resident #3, a male with Alzheimer's disease, heart disease, high blood pressure, and repeated falls, was admitted on 10/24/2024. His care plan required weekly skin inspections, but there was no evidence of these assessments being documented from his admission until 11/18/2024. During an observation on 11/21/2024, it was noted that Resident #3 had a rash on his back, arms, and legs. RN A acknowledged that she had assessed the resident's skin but failed to document it due to the treatment nurse's absence. Similarly, Resident #7, a female with senile degeneration of the brain, dementia, repeated falls, and Type 2 diabetes mellitus, also required weekly skin inspections as per her care plan. However, her medical records showed no documentation of these assessments between 10/03/2024 and 11/06/2024. An observation on 11/21/2024 revealed a scabbed wound on her right elbow and an abrasion on her left shoulder blade, resulting from a fall. The DON and RN A both stated that skin assessments were supposed to be documented weekly, but the absence of the treatment nurse led to a lapse in documentation. The ADMN expressed that the lack of documentation could potentially result in missing a skin condition that might worsen or become infected.
Deficiencies in Food Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was found that numerous food items in the refrigerators, freezer, and dry storage were not properly labeled or dated. This included containers of pickles, ranch, gravy, soup, greens, chicken, pineapple, chili, jello, milk, peanut butter, baking powder, soy sauce, bread, and various frozen items like chicken strips, meatballs, briskets, pizzas, tator tots, bacon, and ham. The absence of labeling and dating could lead to the use of expired or spoiled food, posing a risk to residents' health. Interviews with staff, including dietary aides, the dietary manager, and the administrator, confirmed that the facility's policies required all food items to be labeled and dated, but these procedures were not followed. Additionally, the facility's ice machine was found to be improperly maintained, with a dirty black substance observed on the inside panel. The dietary manager stated that the maintenance man was responsible for cleaning the ice machine, but he did not have a logbook for cleaning and had never cleaned the inside of the machine. The administrator clarified that it was the kitchen staff's responsibility to clean the ice machine, and there was a schedule for cleaning equipment, which was not adhered to. This oversight could result in residents receiving contaminated ice. The facility's policies from 2012 regarding storage refrigerators and dry storage were reviewed, which emphasized the importance of maintaining cleanliness and proper labeling of food items. The FDA Food Code 2022 was also referenced, highlighting the necessity of date marking and proper labeling of food products. However, the facility did not provide a policy concerning the cleaning of equipment prior to the exit of the surveyors.
Deficiency in Dietary Staff Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service department. Specifically, one dietary staff member, DA A, was found to be working in the kitchen without a current Food Handlers Certificate. This deficiency was identified during an observation of the kitchen where DA A was preparing a meal. The Dietary Manager (DM) acknowledged that DA A's certification was in progress, despite DA A having been employed for two months. Interviews with facility staff revealed a lack of oversight and follow-up regarding the certification process. The Administrator (ADMN) admitted that the dietary staff should have their Food Handlers Certification as soon as possible and that the DM should have ensured its completion. The ADMN noted that DA A primarily spoke Spanish, which may have contributed to the delay, although translation services were available. The dietician emphasized that certification should be obtained within 30 days of hire to prevent issues such as improper food preparation and cross-contamination. The DM admitted to not being aware of the certification timeline and acknowledged her responsibility in monitoring staff certifications. She expressed concern about the potential negative impact on residents, such as improper food portioning and nutritional deficiencies. A review of DA A's personnel file confirmed the absence of a Food Handlers Certificate, despite the job description requiring compliance with company policies and procedures, including proper food handling practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Glen Rose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherokee Rose Nursing And Rehabilitation | 0.5 mi | — | 11 | 0 |
| Granbury Rehab & Nursing | 13.1 mi | — | 20 | 0 |
| Harbor Lakes Nursing And Rehabilitation Center | 13.4 mi | — | 8 | 0 |
| Granbury Care Center | 14.2 mi | — | 13 | 1 |
| Trinity Nursing & Rehab Of Granbury | 14.7 mi | — | 3 | 0 |
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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.