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 The Carlyle At Stonebridge Park during CMS and state inspections, most recent first.
A resident admitted after knee revision surgery did not receive several physician-ordered medications, including an IV antibiotic, Adderall, and a therapeutic nutrition powder, due to delays in acquiring and administering the drugs. Record review and staff interviews confirmed that multiple doses were missed over several days, and staff were unclear about the reasons for the delay or the steps taken to resolve it.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
The facility did not ensure accurate and complete clinical documentation for two residents: one resident's G-tube feedings were not administered as documented by an LPN, and another resident's wound care treatments were not consistently recorded on the TAR. These lapses resulted in medical records that did not accurately reflect the care provided or the residents' medical needs, as confirmed by interviews, record reviews, and direct observation.
A resident with multiple medical conditions, including dysphagia and dementia, did not receive prescribed G-tube feedings for approximately 11 hours after a fall, when an LVN disconnected the feeding tube and failed to reconnect it. The lapse was discovered by the resident's family member via in-room camera footage, and the resident was without enteral nutrition until the issue was reported and addressed. No immediate adverse effects were documented.
A resident, who required a bedpan due to mobility issues, was instructed by a CNA to use her brief instead of receiving assistance with toileting. The resident was cognitively intact and her medical records indicated she was continent and used a bedpan. The CNA admitted to telling a resident to use their brief due to staffing constraints, although she could not recall if it was this specific resident. The facility's policy on resident rights mandates treating each resident with respect and dignity, which was not adhered to in this case.
A facility failed to develop a comprehensive care plan for a resident, omitting pain management and behavior issues. The resident, with moderate cognitive impairment, expressed concerns about not receiving pain medication and exhibited behaviors of picking at scabs, leading to reopened wounds. Despite receiving scheduled medications and wound care, these issues were not care planned, as confirmed by staff interviews.
The facility failed to store food in accordance with professional standards, as observed in the kitchen's dry pantry. Unsealed and unlabeled boxes of macaroni and linguine were found, contrary to the facility's policy requiring all opened items to be sealed, dated, and labeled. Staff interviews confirmed the policy and expressed concerns about potential resident illness due to non-compliance. The Dietary Manager was identified as responsible for ensuring food safety.
A resident with multiple health conditions was transferred to a hospital without the facility providing written notification to the resident, their representative, or the ombudsman. The facility staff were unaware of the requirement to send such notification, despite the facility's policy outlining the need to provide reasons for transfer, appeal rights, and ombudsman contact details.
A resident with moderate cognitive impairment experienced ant bites due to the facility's failure to maintain an effective pest control program. Ants were found in the resident's room, leading to medical treatment for itching. The maintenance director confirmed the presence of ants and contacted pest control for treatment. Staff interviews indicated a lack of prior reports of ants, despite a process for reporting pest sightings.
A resident with severe cognitive impairment and osteoporosis was improperly transferred by a CNA who failed to use a gait belt and did not seek assistance from another staff member, as required by the facility's policy. The CNA lifted the resident under her armpits, contrary to training and guidelines, which was captured in a video by the resident's family. Interviews with staff confirmed the resident's need for a two-person transfer with a gait belt.
A resident in an LTC facility was mistakenly given another resident's IV antibiotic due to a medication administration error by an LVN. The resident, who was supposed to receive Micafungin for candidiasis, was given Meropenem instead. The error was identified by the resident's family, who noticed the wrong IV bag. The facility's investigation confirmed the mistake, despite the LVN's denial, and highlighted a failure to follow medication administration protocols.
A resident with a history of infections and delusional disorders was mistakenly given another resident's IV antibiotic, Meropenem, instead of her prescribed Micafungin. The error was identified by the resident's family, who noticed the wrong name on the IV bag. Despite the LVN's denial, the facility confirmed the mistake and monitored the resident for adverse reactions.
A resident was admitted without physician orders for immediate wound care, despite having significant medical needs, including a wound vacuum. The orders were not entered until two days later, on the day of discharge. Interviews revealed that the admitting nurse is responsible for entering all hospital discharge orders, which was not done in this case.
A resident did not receive wound care for a left lower leg wound from admission until discharge, despite specific hospital discharge instructions. The admitting nurse failed to enter the wound care orders, and there was no documentation of wound care being provided. The resident's family was unhappy with the care, leading to a transfer to another facility.
Failure to Timely Acquire and Administer Physician-Ordered Medications Upon Admission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident who was admitted following knee revision surgery with a polymicrobial infection and a chronic open wound. Upon admission, the resident had physician orders for an intravenous antibiotic (Daptomycin-Sodium Chloride), a central nervous system stimulant (Adderall), and a therapeutic nutrition powder (Juven) for wound healing. However, the facility did not acquire and administer these medications in a timely manner, resulting in the resident missing one dose of the antibiotic, six doses of Adderall, and seven doses of Juven over several days after admission. Record reviews showed that the first dose of the antibiotic was not given until the day after admission, Adderall was not administered until several days later, and multiple doses of Juven were missed. Interviews with the resident and staff revealed confusion and lack of clarity regarding the delay in medication delivery. The resident reported not receiving some medications for a few days and was told the facility was trying to obtain them from the pharmacy. Staff interviews indicated that the pharmacy did not deliver all medications as expected, and there was uncertainty about the steps taken to resolve the issue. The facility's policy required that upon admission, the charge nurse and DON or designee review and reconcile physician orders for accuracy in the electronic medical record. However, interviews with staff, including the ADON and RDCS, indicated that the process for ensuring timely medication acquisition and administration was not effectively followed, and there was no clear documentation or explanation for the missed doses. The failure to provide the ordered medications as prescribed was confirmed through both record review and staff interviews.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the resident’s medical history or condition at the time, are not provided in the report.
Failure to Maintain Accurate and Complete Clinical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, resulting in documentation that did not reflect the actual care provided. For one resident with a history of dementia, gastro-esophageal reflux, hypertension, Parkinson's disease, and seizure disorder, the care plan required tube feeding via a G-tube. The Medication Administration Record (MAR) indicated that the resident received tube feedings as ordered on a specific date, but video evidence and family observation revealed that the resident was disconnected from the feeding pump for approximately 11 hours. The nurse responsible documented that the feedings were given, despite the resident not receiving them during that period. In another case, a resident with heart failure, hypertension, hypothyroidism, and a colostomy had physician orders for wound care to be performed three times a week. The Treatment Administration Record (TAR) for this resident showed multiple blank entries on days when wound care was ordered, and there was no alternative documentation in the progress notes to indicate that the treatments were provided. The wound care nurse acknowledged that she was supposed to document each treatment but was unaware that her documentation was not appearing on the TAR. The DON confirmed that documentation was missing and that she had not recently provided staff training on documentation practices. These failures resulted in clinical records that did not accurately represent the care provided or the residents' medical conditions and needs. The lack of accurate documentation was confirmed through interviews, record reviews, and direct observation, including review of video footage and resident interviews. The facility's own policy required proper documentation of medication administration and treatments, which was not followed in these instances.
Failure to Provide Continuous Enteral Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident who was dependent on enteral nutrition via a G-tube did not receive prescribed feedings for approximately 11 hours. The resident, who had diagnoses including dementia, dysphagia, Parkinson's disease, and seizure disorder, was ordered to receive Isosource 1.5 at 70cc/hr for 22 hours daily. On the day of the incident, the resident's feeding tube was disconnected by an LVN around 11:30 AM after the resident experienced a fall. The feeding tube was not reconnected until approximately 10:54 PM that night. During this period, the resident was observed to be without his feeding pump, and the pump itself was left in the room turned off. The lapse in care was discovered when the resident's family member, who had a camera in the room, noticed the disconnection and notified facility staff. Documentation and interviews confirmed that the nurse responsible forgot to reconnect the feeding tube after assisting the resident post-fall. The physician and DON were notified after the incident was brought to their attention. The resident did not experience any immediate adverse effects, as confirmed by assessments, lab results, and weight checks. However, the failure to follow physician orders and provide continuous enteral feeding as prescribed constituted a deficiency in care for residents receiving nutrition by enteral means.
Failure to Assist Resident with Toileting Needs
Penalty
Summary
The facility failed to provide care and services in accordance with the comprehensive assessment of a resident, specifically in assisting with activities of daily living (ADLs) such as toileting. A certified nursing assistant (CNA) instructed a resident, who was cognitively intact and required a bedpan due to mobility issues, to use her brief instead of providing the necessary assistance with a bedpan. This incident was reported by the resident, who stated that the CNA did not have time to assist her. The resident's medical records indicated she was continent and used a bedpan, requiring extensive assistance from one person for ADLs. Interviews with staff revealed that the CNA admitted to telling a resident to use their brief due to staffing constraints, although she could not recall if it was the specific resident in question. The Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) were unaware of such incidents, and the Director of Nursing (DON) emphasized that residents should not be told to use their briefs as it could lead to dignity issues and skin breakdown. The facility's policy on resident rights mandates treating each resident with respect and dignity, which was not adhered to in this case.
Failure to Address Pain Management and Behaviors in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which did not address pain management and behaviors. The resident, a male with moderate cognitive impairment, had concerns about not receiving his pain medication as scheduled and exhibited behaviors of picking at scabs on his toes, leading to reopened wounds. Despite receiving scheduled pain medications and wound care, these issues were not included in the resident's care plan. Interviews with facility staff, including an LVN, MDS Coordinator, Wound Care Nurse, and ADON, revealed that the care plan was not updated to address the resident's pain management and behaviors. The staff acknowledged that these aspects should have been care planned, and the lack of a comprehensive care plan could result in the resident receiving improper care. The facility's policy requires individualized comprehensive care plans with measurable objectives and timetables, which were not met in this case.
Improper Food Storage in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, specifically in the storage of food items. During an observation and interview with the Dietary Manager, it was discovered that the dry pantry contained an unsealed and unlabeled 10-pound box of enriched macaroni and a similar box of linguine. The Dietary Manager admitted to being unaware of these improperly stored items and acknowledged that it was the Cook's responsibility to ensure food was stored in sealed, dated, and labeled containers. The facility's policy mandates that all opened items should be sealed, dated, and labeled, which was not followed in this instance. Interviews with staff members, including [NAME] A and [NAME] B, confirmed that the facility's policy required all items in the dry pantry to be in sealed containers, labeled, and dated. Both staff members expressed concern that failure to follow this policy could lead to residents becoming sick. The Administrator also confirmed that opened packages should be sealed, labeled, and dated, and that the Dietary Manager was responsible for ensuring food safety. However, the Administrator did not comment on the potential risk to residents if these procedures were not followed. The facility's Food Storage policy, dated March 2009, specifies the use of plastic containers with tight-fitting covers for storing various food items, which was not adhered to in this case.
Failure to Notify Resident and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident, their representative, and the Office of the State Long-Term Care Ombudsman regarding the resident's transfer to a hospital. The resident, a male with multiple health conditions including COVID-19, heart failure, and asthma, was experiencing shortness of breath and chest pain. Despite receiving some treatment, the resident refused further medication and was subsequently transferred to a hospital. The facility did not provide the required written notice detailing the reasons for the transfer, the resident's right to appeal, or contact information for the ombudsman. Interviews with facility staff revealed a lack of awareness regarding the requirement to send written notification. The Social Worker was unsure if any discharge paperwork had been sent with the resident, and the Administrator admitted to not knowing that written notification was necessary, as they anticipated the resident's return. The facility's policy, revised in November 2016, clearly outlines the need to provide such information, including the reason for transfer, appeal rights, and ombudsman contact details, but these procedures were not followed in this instance.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a resident experiencing ant bites. The resident, who had a moderate cognitive impairment and multiple health conditions, reported ant bites on his arms, legs, and stomach. Upon assessment, ants were found in the resident's room, including on the carpet, walls, and bed. The nursing notes indicated that the resident complained of itching due to the ant bites, and medical treatment was provided. The facility's maintenance director was notified and confirmed the presence of ants in the resident's room and another room. The pest control company was contacted to address the issue. Interviews with staff revealed that the facility had a process for reporting pest sightings, but no ants had been reported prior to this incident. The maintenance director and staff conducted inspections and found no further ant infestations in other rooms. The facility had a pest control program in place, with monthly treatments and additional treatments as needed.
Inadequate Supervision and Improper Transfer Technique
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices during a transfer for a resident, leading to a deficiency. The incident involved a CNA who transferred a resident from her bed to a shower chair without using a gait belt and without the assistance of another staff member, as required. The CNA lifted the resident under her armpits, which is against the facility's policy and training guidelines. The resident involved was an elderly female with osteoporosis and severe cognitive impairment, requiring substantial assistance for transfers. Her care plan specified that transfers should be conducted with two staff members and a gait belt. Despite this, the CNA proceeded with the transfer alone and without the proper equipment, as captured in a video provided by the resident's family member. Interviews with various staff members, including the Administrator, LVN, PT, ADON, and DON, confirmed that the resident was a two-person transfer with a gait belt. The CNA admitted to not following the proper procedure, citing a lack of readily available help. The facility's policy and training materials clearly state that gait belts must be used for all transfers, and lifting by the armpits is prohibited.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services by administering the incorrect IV antibiotic to a resident. The incident involved a resident who was supposed to receive Micafungin for candidiasis but was instead given Meropenem, which was intended for another resident. This error was discovered when the resident's family noticed the wrong IV bag hanging in the resident's room and reported it to the facility staff. The resident in question was a female with a history of malnutrition, bloodstream infection, recurrent enterocolitis due to Clostridium difficile, and delusional disorders. She had been receiving parenteral/IV therapy and was on Micafungin until a specified date. The error occurred when LVN A administered the wrong medication, despite the resident's care plan and medication sheet clearly indicating the correct medication and dosage. The facility's investigation revealed that the LVN responsible for the error denied administering the wrong medication, even though her initials were on the IV bag. The Director of Nursing and Assistant Director of Nursing were involved in addressing the situation, verifying the error, and ensuring the resident was monitored for adverse reactions. The incident highlighted a failure to adhere to the facility's medication administration protocol, which includes verifying the right person, medication, dose, time, route, reason, and documentation before administering any medication.
Medication Error: Wrong IV Antibiotic Administered
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was administered the incorrect intravenous (IV) antibiotic. The resident, a female with a history of malnutrition, bloodstream infection, recurrent enterocolitis due to Clostridium difficile, and delusional disorders, was supposed to receive Micafungin for candidiasis. However, she was mistakenly given Meropenem, which was intended for another resident. The error was discovered when the resident's family noticed that the IV bag hanging in the resident's room had another resident's name on it. This prompted them to report the issue to the facility's staff, who confirmed that the wrong medication had been administered. The Licensed Vocational Nurse (LVN) responsible for the administration denied giving the wrong medication, despite evidence to the contrary, including her initials on the medication bag. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were involved in addressing the situation, verifying the error, and ensuring the resident was monitored for adverse reactions. The incident highlighted a failure in following the facility's medication administration protocol, which includes verifying the right person, medication, dose, time, route, reason, and documentation before administering any medication.
Failure to Enter Physician Orders for Immediate Wound Care
Penalty
Summary
The facility failed to ensure that a resident had physician orders for immediate care upon admission. Specifically, RN A did not enter physician orders for the resident's wound vacuum and wound care, despite the resident having a significant medical history that included a bone infection of the sacrum and an open wound requiring a skin graft and wound vacuum. The resident was admitted with hospital discharge instructions that specified the need for immediate wound care, including the application of a hospital-grade wound vacuum. However, these orders were not entered until two days later, on the day the resident was discharged from the facility. Interviews with RN A and the Director of Nursing (DON) revealed that the admitting nurse is responsible for entering all hospital discharge orders, including wound care orders. RN A could not recall the specific resident but stated she always inputs all hospital discharge orders. The DON confirmed that there was no reason for the admitting nurse not to put in wound care orders and acknowledged that the admission note did not indicate that wound care had been done. The facility's policy on physician orders requires detailed treatment orders, which were not followed in this case.
Failure to Provide Wound Care
Penalty
Summary
The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, RN-A did not provide wound care for a resident's left lower leg wound from 1/10/24 to 1/12/24. The resident, a [AGE] year-old female, was admitted with diagnoses including a bone infection of the sacrum, an open wound to the left lower leg requiring a skin graft and wound vacuum, and emphysema. The hospital discharge paperwork included specific instructions for wound care, but these orders were not entered into the resident's physician orders until the day she was discharged from the facility. There was no documentation of any wound care being provided during the two days the resident was at the facility. Interviews with RN-A and the DON revealed that the admitting nurse was responsible for entering all admission orders from the hospital, but RN-A could not recall why the wound care orders were not entered until two days later. The DON confirmed that RN-A's note did not indicate that wound care was done upon the resident's arrival. Additionally, the Social Worker reported that the resident's family was unhappy with the treatment and lack of care, leading to the resident's transfer to another facility. The facility's policy on wound care was requested but not provided prior to the exit.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 853 citations issued within 25 miles in the last 12 months — including the 31 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Southlake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Discovery Village At Southlake | 0.5 mi | — | 2 | 0 |
| Keller Oaks Healthcare Center | 1.7 mi | — | 1 | 0 |
| Bear Creek Nursing And Rehabilitation | 3.9 mi | — | 4 | 2 |
| Heritage House At Keller Rehab & Nursing | 4.2 mi | — | 7 | 1 |
| Oakmont Guest Care Center | 4.9 mi | — | 2 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Carlyle At Stonebridge Park.
100% money-back within 48 hours.
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.