Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Red Oak Health And Rehabilitation Center during CMS and state inspections, most recent first.
Improper Food Labeling and Dating in Kitchen Storage Areas: Multiple items in the pantry and walk-in refrigerator were found without required open dates and/or use-by dates, including dry goods, condiments, prepared foods, and refrigerated items. The PC and RPM stated that opened food should be dated and labeled, and the ADM acknowledged staff were not properly dating all food items despite prior in-service education.
Medication Left Unsecured During Administration: A resident with severe cognitive impairment and diagnoses including CVA, HTN, A-fib, and dementia had a pill found in her bed after med pass. The MA initially thought it was aspirin and believed the resident had swallowed her meds, but the pill was later identified as lisinopril, which was ordered for HTN. Staff stated they were expected to remain with residents until meds were swallowed, and the facility policy required drugs and biologicals to be stored securely.
The facility failed to properly store and label medications in Hall 400, with expired supplies not removed from a storage room and undated medications found on two medication carts. Staff interviews revealed non-compliance with policies requiring dating of opened medications and removal of expired items, potentially affecting resident care.
The facility failed to ensure dietary staff had valid Texas Food Handler Certificates, with five staff members working numerous shifts uncertified. The District Manager in training was unfamiliar with staff qualifications, leading to management lapses. Interviews with the DON, ADON, and ADM revealed expectations for proper training and certification were not met, potentially risking resident safety.
The facility failed to maintain food safety standards, with issues such as improperly labeled and expired food, mold in ice machines, and inadequate staff training. Observations showed unlabeled food items, a dented can, and moldy ice machines. Staff interviews revealed gaps in training and maintenance, with the DON and ADON expressing concerns about potential contamination risks.
A facility failed to revise a resident's care plan to include the use of a fall mat, despite the resident's impaired cognition and functional limitations. The resident, who had multiple diagnoses including dementia and Alzheimer's, was admitted after hip replacement surgery. Although a fall mat was placed at the family's request, it was not documented in the care plan, and the MDS coordinator acknowledged the oversight. The facility's policy requires care plans to be updated as conditions change, but this was not followed, potentially risking the resident's well-being.
A CNA failed to follow proper hand hygiene protocols during incontinent care for a resident, who was incontinent of bowel and bladder and had multiple health conditions. The CNA changed gloves without sanitizing hands, contrary to the facility's infection control policies. Interviews confirmed the expectation for staff to sanitize hands between tasks to prevent infection, and training records showed the CNA had been trained on these protocols.
A medication aide left a resident's medication on the bedside table for self-administration without ensuring it was taken, contrary to facility policy. The resident, who was cognitively intact, reported that staff often left medications unsupervised. The facility's administration confirmed that staff should ensure medications are taken, as per their policy.
The facility failed to ensure call lights were within reach for two residents with cognitive impairments, risking unmet needs. One resident had his call light on the floor, while another had it on the nightstand, both out of reach. Staff interviews confirmed the expectation for call lights to be accessible, aligning with facility policy.
A resident with dementia and other medical conditions was found lying in a soiled bed with saturated sheets and an empty milk carton at the foot of the bed. The resident's call light was out of reach, potentially delaying care. Despite regular staff training on maintaining clean linens and accessible call lights, these standards were not met, risking skin breakdown for the resident.
A resident with severe cognitive impairment and multiple medical conditions fell and sustained injuries after being left unattended at the nurse's station. Despite being a known fall risk, the resident was not under 1:1 monitoring, leading to a fall, a hematoma, and subsequent unresponsiveness. The facility's staff acknowledged the lapse in supervision, which directly contributed to the incident.
A resident with severe cognitive impairment and high fall risk experienced a fall resulting in a head injury. The facility failed to report the incident to state authorities within the required timeframe, citing incomplete information and a decision to wait for the hospital report. This delay violated state regulations and could place residents at risk for abuse, neglect, and decreased quality of life.
Improper Food Labeling and Dating in Kitchen Storage Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in its only kitchen reviewed for dietary services. During observation of the kitchen pantry on 03/11/2026, multiple food items were found without required open dates and/or use-by dates, including quick creamy wheat, BBQ sauce, apple cider vinegar, soy sauce, peanut butter, liquid smoke, molasses, chips, wafer cookies, graham crackers, saltine crackers, elbow macaroni, spaghetti noodles, dill weed, brown gravy mix, yellow cake mix, and chocolate cake mix. Several of these items were opened, and some had dates that were incomplete or inconsistent, while others had no date documentation at all. Observation of the walk-in refrigerator on 03/11/2026 also revealed multiple improperly dated items. These included garlic bread, apples, thickened lemon-flavored water, peaches, ham, lettuce and tomatoes, potato wedges, hash browns, and strawberries. Several items had an open date documented, but no use-by date was listed, and one container of strawberries had no open date or use-by date at all. A sign posted in the refrigerator stated that everything must be labeled and dated before it enters the cooler/freezer and that all cooked items must be discharged within 48 hours. During interviews, the PC stated that once food was opened, it should have an open date and a use-by date, and that not properly dating and labeling food could put residents at risk of food-borne illnesses. The RPM stated that pantry items should be dated when received and that opened containers should have an open date and use-by date, with refrigerated items dated when opened and used within 48 hours. The ADM stated he did not know staff were not properly dating all food items and acknowledged that an in-service had been completed in February 2026 regarding dating and labeling food in the kitchen.
Medication Left Unsecured During Administration
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments for one resident reviewed for medication storage. During observation, a round light orange pill was found beside the resident’s arm in her bed. The resident, who had diagnoses including cerebral infarction, hypertension, atrial fibrillation, and dementia, was pleasantly confused and stated she did not know what the pill was or who gave it to her. She moved the pill from her bed to her bedside table and said she did not know whose pill it was or whether someone had brought it to her. Record review showed the resident had a Quarterly MDS with a BIM’s score of 05, indicating severe cognitive impairment, and required supervision or assistance with eating, toileting, showers, and personal hygiene. Her physician’s orders included Lisinopril 20 mg daily for hypertension, and the MAR reflected the medication was administered on 03/11/26 with a blood pressure of 126/63. The resident did not have an order for aspirin. The medication found in the bed was later identified by staff as Lisinopril 20 mg. In interview, the medication aide stated she had given the resident her medication that morning and believed the resident had swallowed it, but later found the pill on the resident’s bed and initially thought it was aspirin. She later checked the MAR, identified the pill as Lisinopril, and reported it to the nurse. The ADON and DON stated staff were expected to stay with residents until medications were swallowed, and that medications left out in the open could be taken by another resident. The facility policy stated drugs and biologicals were to be stored in a safe, secure, and orderly manner, and that compartments containing drugs and biologicals were to be locked when not in use.
Improper Storage and Labeling of Medications in Hall 400
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals in one of its medication storage rooms and on two medication carts located in Hall 400. Specifically, expired medication administration supplies and COVID-19 tests were not removed from the medication storage room. Additionally, medications on the Hall 400 Medication Aide's Cart and the Hall 400 Nurse's Cart were opened without being dated, contrary to the facility's policy. This oversight was observed during a survey, where several bottles of vitamins and medications were found undated, and expired COVID-19 tests and medical supplies were still present in the storage room. Interviews with staff, including a Medication Aide, an LVN, the DON, and the ADM, revealed a lack of adherence to the facility's policies regarding the dating of opened medications and the removal of expired supplies. The staff acknowledged the importance of these policies, noting that undated medications could become ineffective or harmful, and expired supplies could lose potency, potentially affecting resident care. The facility's policies, as reviewed, clearly stated the need for dating opened medications and discarding expired items, yet these procedures were not followed, leading to the identified deficiencies.
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. This was determined through observation, interview, and record review, revealing that five dietary staff members did not obtain or maintain their Texas Food Handler Certificates. The dietary staff, identified as DS B, DS D, DS E, DS G, and DS H, worked numerous shifts without verified valid food handler certificates, which could place residents at risk of foodborne illness. The District Manager in training (DDM) was responsible for overseeing the dietary services but was unfamiliar with the staff and their qualifications, leading to a lapse in management and record-keeping. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator (ADM) revealed that it was their expectation that the contracted company for dietary services would ensure staff were properly trained and certified. The DDM admitted to not having all the past and current food handler certificates and relied on staff confirmation of their certification status. The report highlights the facility's failure to ensure dietary staff were properly certified, as required by job descriptions and the 2022 United States Food and Drug Administration Food Code, potentially compromising resident safety.
Food Safety and Maintenance Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen and nourishment rooms, leading to multiple deficiencies. Observations revealed that food items in the kitchen refrigerator were not properly dated and labeled, with several containers of ricotta cheese and stacks of sliced American cheese lacking necessary labeling. Additionally, a dented can of pears was found in the dry goods storage area, and expired food items were not discarded in a timely manner. The facility also failed to maintain accurate freezer temperature logs and did not provide a thermometer for one of the freezers in the nourishment rooms. The ice machines in both the kitchen and one nourishment room were found to have mold, mildew, and slime build-up, indicating a lack of proper cleaning and maintenance. Interviews with staff revealed that the Maintenance Technician (MNT) was responsible for cleaning the ice machines but did not maintain a cleaning log, and the last cleaning was conducted by a former Dietary Manager. Furthermore, the Dietary Services Director (DDM) was responsible for auditing food items and ensuring policy compliance but failed to provide explanations for the deficiencies observed. Staff training and familiarity with kitchen equipment were also inadequate, as evidenced by a dietary staff member's lack of knowledge about operating the dishwasher and checking chemical concentrations. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) expressed concerns about the potential for food contamination and illness due to improper staff certification and training. The facility's policies and procedures outlined requirements for food storage, equipment maintenance, and ice machine cleaning, but these were not consistently followed, contributing to the observed deficiencies.
Failure to Revise Care Plan for Fall Mat Use
Penalty
Summary
The facility failed to ensure that a comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team, specifically regarding the use of a fall mat. The resident, an 82-year-old female with diagnoses including hypertension, type 2 diabetes, hyperlipidemia, dementia, Alzheimer's Disease, and muscle weakness, was admitted to the facility following hip replacement surgery. The resident's comprehensive care plan did not include a fall-injury prevention program or the use of a fall mat, despite the resident's impaired cognition and functional limitations. The resident's admission MDS Comprehensive Assessment did not address the risk for falls, and there were no physician's orders for assistive devices to prevent falls. The facility's MDS Resident Matrix also did not mark any specific care areas related to falls for the resident. Observations revealed that a fall mat was placed next to the resident's bed as a safety measure, but this was not reflected in the care plan. Interviews with the resident's responsible representative and facility staff confirmed the use of the fall mat, which was initially placed at the family's request. The Director of Nursing (DON) and the MDS coordinator acknowledged the oversight in care planning. The DON was unaware of the fall mat's presence, while the MDS coordinator admitted to not care planning the fall mat despite being aware of its use. The facility's policy requires that care plans be revised as residents' conditions change, but this was not adhered to in this case, potentially placing the resident at risk of not receiving appropriate care and services.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not follow proper hand hygiene protocols during incontinent care for a resident. The resident, who was incontinent of bowel and bladder, required substantial assistance with personal hygiene. During the care, the CNA changed gloves without washing or sanitizing her hands, which is a critical step in preventing cross-contamination and infection. The resident involved was a cognitively intact female with multiple diagnoses, including hemiplegia, diabetes, anxiety, and respiratory failure. Her care plan emphasized the importance of maintaining cleanliness to prevent infections such as urinary tract infections (UTIs). Despite this, the CNA failed to adhere to the facility's infection control policies, which require hand hygiene between glove changes when moving from dirty to clean surfaces. Interviews with the infection preventionist (IP), the CNA, the Director of Nursing (DON), and the Administrator (ADM) confirmed the expectation that staff should change gloves and sanitize hands between tasks to prevent infection. The CNA admitted to being nervous during the procedure, which may have contributed to the oversight. The facility's training records indicated that the staff, including the CNA, had been trained on proper hand hygiene and glove use, yet the deficiency occurred, posing a risk of infection to the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional standards, specifically for one resident reviewed for pharmacy services. The deficiency occurred when a medication aide (MA A) left a resident's medication on her bedside table for self-administration without ensuring the resident took the medication. This action was contrary to the facility's policy, which required staff to stay with the resident and ensure medications were swallowed. The resident, who was cognitively intact with a BIMS score of 15, had a history of being resistive to care and refusing medication, as noted in her care plan. During an interview, the resident stated that staff often left her medication on the bedside table without supervision. MA A admitted to administering the medication and then leaving to document it, assuming the resident had taken it. The facility's administration, including the ADM and DON, confirmed that staff were not supposed to leave medications in the room and were responsible for ensuring residents took their medications. The facility's in-service training and policy also reflected that medications should not be left for residents to take later, and MA A had signed this in-service training.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a violation of resident rights. Resident #1, a male with dementia, anxiety, seizures, and cerebral infarction, was observed with his call light on the floor, out of reach, while he lay in bed with spilled milk on his sheets. His care plan indicated he required substantial assistance with daily activities, yet the call light was not accessible, potentially compromising his ability to request help. Resident #2, also a male with dementia and other health issues, was found with his call light on the nightstand, out of reach. Despite his severe cognitive impairment and need for assistance with personal care, he stated he would yell for help if needed. This situation highlights the facility's failure to accommodate the residents' needs by ensuring their call lights were accessible, as required by their care plans. Interviews with various staff members, including the ADON, LVNs, CNAs, and the DON, confirmed that call lights should always be within residents' reach. The staff acknowledged the potential risks of falls or delayed care if call lights are not accessible. The facility's policy on call light placement, revised in 2012, mandates that call lights be within easy reach of residents, yet this was not adhered to in these instances.
Resident Found in Soiled Bed with Call Light Out of Reach
Penalty
Summary
The facility failed to provide a clean and comfortable environment for a resident, who was observed lying in a soiled bed with saturated sheets and an empty milk carton at the foot of the bed. The resident, who had a history of dementia, anxiety, seizures, and cerebral infarction, was unable to complete a mental status interview and required substantial assistance with daily living activities. The resident's care plan indicated a need for extensive assistance with personal hygiene and toileting, as well as supervision during meals. Additionally, the resident had open wounds on the right buttocks, posterior scrotum, and lower sacrum, requiring daily wound care. During the observation, the resident's call light was found on the floor, out of reach, which could delay care or lead to falls. Interviews with facility staff, including the ADON, LVN, CNA, ADM, and DON, revealed that staff were regularly trained on maintaining clean and dry linens and ensuring call lights were within reach. However, the failure to adhere to these standards resulted in the resident lying in soiled sheets, which could contribute to skin breakdown. The facility's policies on dignity and routine resident checks emphasized the importance of maintaining a safe and clean environment, but these were not effectively implemented in this instance.
Failure to Supervise High-Risk Resident Leads to Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and prevent accidents for a resident who was at high risk for falls. The resident, a female with severe cognitive impairment and multiple medical conditions including dementia and muscle weakness, was left unattended at the nurse's station. Despite being known for her high fall risk and having a history of falls, the resident was not under 1:1 monitoring at the time of the incident. The resident fell from her wheelchair, resulting in a hematoma and subsequent unresponsiveness, leading to CPR administration and hospitalization. Interviews with staff revealed that the nurse on duty had left the resident unattended to pass medications, assuming other staff would keep an eye on her. However, no specific instructions were given to other staff members to monitor the resident. The incident was discovered by a dietary aide who found the resident on the floor and called for help. The nurse and other staff assessed the resident and moved her to her room, where she became unresponsive, necessitating emergency medical intervention. The facility's Director of Nursing and other staff acknowledged that the resident was a known fall risk and should have been supervised more closely. The facility's policy on safety and supervision emphasized the importance of individualized, resident-centered approaches to prevent accidents, but these measures were not adequately implemented in this case. The failure to maintain proper supervision directly contributed to the resident's fall and subsequent injuries.
Failure to Report Resident Fall and Injury in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or neglect, including injuries of unknown source, were reported immediately or not later than 24 hours to the State Survey Agency. This deficiency was identified in the case of a resident who experienced a fall resulting in a head injury. The resident, who had severe cognitive impairment and was at high risk for falls, was found on the floor near her wheelchair with a hematoma on her forehead. Despite the severity of the incident, the facility did not report it in a timely manner to the state authorities as required by state law and facility procedures. The resident involved was an elderly female with multiple diagnoses, including chronic kidney disease, dementia, anemia, hyperlipidemia, glaucoma, and muscle weakness. Her care plan indicated she was at high risk for falls and required substantial assistance for mobility. On the day of the incident, the resident was found unresponsive after the fall, and CPR was administered by the staff until paramedics arrived. The Director of Nursing (DON) and the Assistant Director (AD) were aware of the incident but failed to report it promptly, citing a lack of complete information and a decision to wait for the hospital report. Interviews with the DON and AD revealed that the facility did not have a documented policy on abuse, neglect, and exploitation but followed state provider letters. The AD admitted that the incident was not reported immediately because they were waiting for further information from the hospital. This delay in reporting violated state regulations, which require incidents involving serious bodily injury or unusual circumstances to be reported within specific timeframes. The facility's failure to report the incident promptly could place residents at risk for abuse, neglect, and a decreased quality of life.
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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 Red Oak
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Village Healthcare And Rehabilitation | 3.4 mi | — | 8 | 2 |
| Windsor Gardens | 4.9 mi | — | 1 | 0 |
| Millbrook Healthcare And Rehabilitation Center | 5 mi | — | 5 | 0 |
| Methodist Transitional Care Center-desoto Llc | 5.1 mi | — | 5 | 0 |
| Desoto Nursing & Rehabilitation Center | 5.5 mi | — | 12 | 1 |
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