Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beacon Harbor Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Multiple residents with significant medical conditions, including stroke, COPD, heart failure, and muscle weakness, consistently received breakfast oatmeal that was cold, lumpy, thick, and sometimes removable from the bowl in a single solid mass. Several residents refused to eat the oatmeal due to its poor quality, while one cognitively impaired resident ate it despite acknowledging it was cold and lumpy. A CNA reported that the oatmeal was always served this way, that many residents complained, and that she had informed the kitchen without any change, sometimes mixing the cold oatmeal with warm eggs to encourage intake. Another resident reported routinely requesting extra toast instead of eating the oatmeal and stated she had told CNAs about the issue. The Dietary Manager stated the oatmeal left the kitchen warm and was unaware of grievances, and the Administrator and DON reported they were not aware of any oatmeal problems, despite the facility’s policy requiring food to be prepared according to applicable food service regulations.
A resident with severe cognitive impairment and multiple comorbidities experienced a significant change in condition when a midline IV was found removed, resulting in a skin tear and abnormal skin findings. Although the physician and a family member were informed, the resident's representative was not notified at the time, contrary to facility policy. Staff interviews confirmed that the RP should have been contacted directly regarding the change in condition.
A resident with dementia in an LTC facility experienced a failure in maintaining a clean and comfortable environment when her stained bed sheets were not changed for several days. Despite the facility's policy on resident rights, staff did not notice or address the need for changing the sheets until a new mattress was provided. Interviews revealed that sheets were typically changed on shower days or as needed, but this need was overlooked.
A facility failed to update a resident's care plan quarterly as required, with the last revision occurring several months prior. The oversight was attributed to the electronic system not prompting staff, and the social worker had not contacted the resident's family to schedule a meeting until much later. Despite this, the administrator believed that resident care was not impacted.
A facility failed to maintain accurate clinical records for a resident with dementia, stroke, and Parkinson's disease. Nursing notes incorrectly documented bruises as old following a fall, which were actually new. This discrepancy was confirmed by the DON, and the facility did not provide a documentation policy when requested.
A resident with multiple health conditions and cognitive impairment was injured during a Hoyer lift transfer when a PT failed to follow facility policy requiring two staff members for the transfer. The PT improperly attached the lift sling, causing the resident to fall and sustain serious injuries, including fractures and a brain hemorrhage.
The facility failed to ensure privacy during incontinence care for several residents, leading to potential exposure due to broken or missing window blinds. A resident with a history of stroke was observed receiving care with inadequate privacy, and other residents reported similar issues with broken blinds. Staff interviews confirmed the expectation to maintain privacy, but the facility's ongoing construction and delay in replacing blinds contributed to the deficiency.
The facility failed to comply with professional standards for food service safety, as observed in their kitchen, refrigerators, freezer, and dry storage areas. Food items were not properly labeled with necessary information, and some were outdated. Additionally, cleanliness and functionality issues were noted with the handwashing sink and eyewash station. These deficiencies could lead to contamination and food safety hazards.
The facility failed to maintain a safe and homelike environment, with issues such as dusty vents, missing blinds compromising privacy, detached baseboards, and broken handrails posing safety risks. Staff interviews revealed a lack of awareness and communication about these maintenance issues.
Three CNAs failed to perform hand hygiene after serving meals to residents, despite recent training and available hand sanitizer. This non-compliance with infection control protocols involved residents with conditions like dementia and hypertension, potentially risking cross-contamination.
A resident was mistakenly given another resident's medications due to a miscommunication and lack of verification by the staff. The error was discovered after the resident left the facility, and the family confirmed the medications were not taken. The incident involved a mix-up of names and a failure to follow the facility's medication administration policy.
The facility failed to notify a hospice agency of a resident's falls and changes in condition on two occasions. The resident, who had dementia and muscle wasting, experienced falls that were documented by nursing staff but not communicated to the hospice agency immediately. Interviews revealed that the facility staff were aware of the notification protocol but did not follow it, leading to a lapse in communication and documentation.
A resident with multiple medical conditions was readmitted to a facility and was not allowed to choose her attending physician, despite having a primary care physician and specialists listed in her hospital discharge summary. The facility assigned a physician without consulting the resident or her representative, leading to concerns about continuity of care and lack of scheduled follow-up appointments. Interviews with staff revealed a lack of clarity regarding the resident's rights and procedures for coordinating care.
Cold, Unpalatable Oatmeal Served Repeatedly at Breakfast
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met residents’ daily nutritional and special dietary needs and preferences, specifically related to the breakfast oatmeal served to multiple residents. Surveyors reviewed records for four residents and observed breakfast service on Hall 200. Resident #1, an elderly female with severe cognitive impairment and diagnoses including cerebral infarction, chronic respiratory failure, and atrial fibrillation, was observed eating oatmeal in bed; she stated she knew the oatmeal was cold and lumpy but was eating it because she was hungry. The oatmeal appeared sticky, and when the bowl was touched it was cold. Resident #1 later stated she did not mind cold food and would try to eat anything, but acknowledged the oatmeal would taste better if it were warm. Resident #2, an elderly male with cerebral infarction, hypertension, and edema who was alert, oriented, and able to make decisions, was observed in the same room as Resident #1. He had eaten the rest of his breakfast but refused to eat the oatmeal, stating it was sticky, cold, lumpy, and looked disgusting, and that it was always served that way. He demonstrated that the oatmeal could be lifted from the bowl in one whole piece. Resident #3, an elderly male with COPD, heart failure, and congestive heart failure who was also alert and oriented, had finished his eggs and toast but had not touched his oatmeal. He stated he could not eat the oatmeal because it was terrible, always thick and cold, and showed that the entire bowl of oatmeal came out in one piece when he tried to stir it. He reported that he had told staff about the problem but nothing had changed. Resident #4, an elderly female with cerebral infarction, hypertension, and muscle weakness who was alert and oriented, stated during breakfast that she would like her oatmeal to be warm and edible. She reported that the oatmeal was always served cold, sticky, and in one big lump, so she asked for extra toast instead, and said she had told CNAs but did not like to make a fuss. CNA A confirmed during interview that the oatmeal was always served lumpy and cold, that many residents complained, and that although she had informed the kitchen, nothing had changed. CNA A stated she tried to mix the cold oatmeal with warm eggs for Resident #1 and that residents declined offers of fresh oatmeal because they believed it would be the same. The Dietary Manager stated the oatmeal left the kitchen warm and she did not know what happened afterward, and reported no recollection of grievances about cold, inedible oatmeal. The Administrator and DON stated they were unaware of any problems with the oatmeal. The facility’s Dietary Services Meal and Food policy stated that food prepared for residents is to be prepared according to all applicable food service regulations.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's representative (RP) of a significant change in the resident's condition when the resident was found with a removed midline IV from his left arm, resulting in the need for his arm to be elevated and wrapped to manage swelling and bleeding. The resident, an elderly male with severe cognitive impairment and multiple serious diagnoses including atherosclerotic cardiovascular disease, chronic kidney failure, dementia, and malignant brain neoplasm, was noted to have a new skin tear and abnormal skin findings following the incident. Documentation showed that while the physician and a family member (FM) were informed, the RP was not notified at the time of the incident. Interviews with facility staff, including nurses and administrative personnel, confirmed that the standard protocol was to notify the RP of any change in condition. However, in this case, the nurse involved informed the FM who was visiting, but did not contact the RP directly. The nurse acknowledged that this was not in line with facility policy, which requires direct notification of the RP regardless of whether a family member is present or informed. The RP only learned of the incident later, when contacted about the possibility of inserting a new midline IV. Further interviews with clinical and administrative staff reiterated the expectation that the RP should be notified as soon as possible in the event of a change in condition. The facility's policy, revised in April 2025, also specifies that the resident or their representative must be informed of any change in condition and related changes in care. The failure to notify the RP promptly was confirmed by both staff statements and documentation review.
Failure to Maintain Clean and Comfortable Environment for Resident
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the presence of stained bed sheets that were not changed in a timely manner. The resident, who has dementia and moderate cognitive impairment, reported that the sheets had been stained for a few days after spilling something on them, and expressed a desire for them to be changed. Despite the resident's condition, the staff did not notice or address the need for changing the sheets until after a new mattress was provided. Interviews with the CNA and the Director of Nursing revealed that the sheets were typically changed on shower days or as needed, but in this instance, the need was overlooked. The Director of Nursing acknowledged that any staff member could change bed linens if they noticed they needed changing, but there had been no prior issues reported with bed linen changes in the facility. The facility's policy on resident rights emphasizes the right to a safe, clean, and comfortable environment, which was not upheld in this case.
Failure to Update Resident Care Plan Quarterly
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive assessment and quarterly review assessments. This deficiency was identified for a resident who had been admitted to the facility with diagnoses including dementia, high blood pressure, and heart failure. The resident's care plan, which was last revised in June 2024, was not updated quarterly as required, with the last care plan conference held in May 2024. Interviews with facility staff revealed that the care plan conferences were supposed to be held quarterly, but the social worker had not contacted the resident's family to schedule the meeting until December 2024. The social worker attributed the oversight to the electronic system not prompting her that the care plan was due. The administrator acknowledged the lapse, noting that the system had failed to notify staff, and stated that the social worker was auditing resident files to ensure care plans were current. Despite the deficiency, the administrator believed that resident care did not suffer due to the lack of a formal care plan conference.
Inaccurate Documentation of Resident's Condition
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in the documentation of a resident's condition. The nursing notes for a resident indicated that bruises on the bilateral upper arms, chest area, and knees were old, following a fall on the same day. However, these bruises were new and should have been documented as such. This discrepancy in documentation was identified during a review of the resident's incident report and nursing notes. The resident involved was an elderly female with a history of dementia, stroke, and Parkinson's disease, who had experienced multiple falls in the past. The incident report authored by an LVN on the day of the fall inaccurately described the bruises as old, which was later confirmed to be incorrect by the Director of Nursing. The facility's failure to accurately document the resident's condition could place residents at risk for medication and/or treatment errors and omissions in care. Despite a request, the facility did not provide a policy regarding documentation prior to the exit of the surveyors.
Improper Hoyer Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and provided adequate supervision to prevent accidents. This deficiency was identified when a physical therapist (PT) improperly used a Hoyer lift to transfer a resident, resulting in the resident falling and sustaining multiple serious injuries. The PT conducted the transfer alone, without the assistance of a second staff member, as required by the facility's policy. Additionally, the PT incorrectly attached the Hoyer lift sling pad, which led to the resident slipping from the sling during the transfer. The resident involved was a male with a history of diabetes, dialysis, osteoporosis, and a left above-knee amputation. He was assessed as having moderate cognitive impairment and was dependent on two or more staff members for transfers. Despite these needs, the PT attempted the transfer alone, contrary to the care plan that specified the use of mechanical assistance and two staff members for transfers. The improper transfer resulted in the resident suffering a fractured right clavicle, right femoral neck, right proximal tibia, and an intraventricular hemorrhage. The incident was confirmed through a provider investigation report, which revealed that the PT knowingly did not follow the facility's policy for mechanical transfers. The PT admitted to not securing the Hoyer lift sling pad correctly and failing to request assistance from other staff members, despite their availability. This negligence directly led to the resident's fall and subsequent injuries, highlighting a significant lapse in adherence to established safety protocols.
Privacy Breach During Incontinence Care
Penalty
Summary
The facility failed to ensure personal privacy during incontinence care for four residents, leading to potential exposure to view from outside the facility and other windows. Resident #78, a female with a history of stroke and muscle weakness, was observed receiving incontinence care with inadequate privacy due to missing slats in the window blinds, which left her exposed to the outside. The privacy curtain was only partially effective, as it did not cover the window. Interviews with staff and the resident confirmed concerns about privacy and the discomfort it caused. Resident #3 reported that her blinds had been broken since her admission two years ago, and despite requests for repairs, the issue remained unresolved. Her window faced the dining room, and she expressed discomfort with the lack of privacy. Similarly, Resident #38, who is legally blind, was unaware of the privacy issue due to broken blinds in his room, which faced the parking lot. He expressed a lighthearted concern about the potential exposure. Staff interviews revealed that the expectation was to close blinds and use privacy curtains, but broken blinds were a known issue throughout the facility. Resident #71 also experienced privacy issues due to the absence of functional blinds, as her window faced the gazebo and courtyard. She had been requesting blinds since her admission, but the facility had not yet addressed the issue. Interviews with various staff members, including CNAs and LVNs, highlighted the importance of closing blinds and using privacy curtains to maintain residents' dignity during personal care. The facility's policy on incontinence care emphasized the need for privacy, but the ongoing construction and delay in replacing blinds contributed to the deficiency.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen, refrigerators, freezer, and dry storage areas. Food items were not properly labeled with necessary information such as item description, received by date, opened date, discard by date, or expiration dates. This lack of labeling was noted on various food items, including containers of coffee and tea, leftover breakfast items, oatmeal, bread slices, and cereals. Additionally, large bins containing cornmeal, sugar, and thickener were not labeled with discard by dates, and some items were found to be outdated. The facility also failed to maintain cleanliness and functionality in certain areas, such as the handwashing sink and eyewash station. The handwashing sink's garbage receptacle contained trash other than paper towels, and the eyewash station bowl was found to be dusty, with a substantial crack that could potentially compromise its functionality. These issues could contribute to cross-contamination and pose a risk of food-borne illness to residents. Observations in the walk-in refrigerator and freezer revealed further deficiencies, including improperly labeled and stored food items such as shredded cheese, mixed vegetables, garden salads, deli meats, and chicken with ice crystals. The dry storage room also contained improperly stored and labeled items, such as flour left open to air and cereal bags not securely wrapped. These findings indicate a systemic failure in the facility's food storage and safety practices, which could lead to contamination and food safety hazards.
Deficiencies in Facility's Physical Environment and Maintenance
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in three of the six resident halls reviewed. Specifically, the intake vent at the beginning of the 100 hall was observed to be covered in dust, indicating a lack of cleanliness. Additionally, resident rooms 102, 106, and 133 were found to have missing vertical blinds, compromising the privacy of the residents. Interviews with a resident and an LVN confirmed concerns about privacy due to the gaps in the blinds. Further deficiencies were noted in the physical environment, including a detached baseboard in one resident room, which exposed the wall and created an unsightly and potentially unsafe condition. Additionally, broken plastic handrails with sharp edges were observed in the 300 hall, posing a risk of injury to residents. Interviews with staff, including a CNA, LVN, and the Maintenance Director, revealed a lack of awareness and communication regarding these maintenance issues, despite the facility undergoing renovations and having a system in place for reporting maintenance requests.
Inadequate Hand Hygiene Practices by CNAs
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of three CNAs who did not perform hand hygiene after direct contact with residents during meal service. Specifically, CNA M, CNA P, and CNA Q were observed serving meals to residents without washing their hands or using hand sanitizer between serving trays. This lapse in protocol occurred despite the availability of hand sanitizer in the hallway and recent in-service training on hand hygiene. The residents involved included individuals with various medical conditions such as dementia, Parkinson's disease, hypertension, and atrial fibrillation, who required assistance with activities of daily living. The CNAs' failure to adhere to hand hygiene protocols after interacting with these residents could potentially lead to cross-contamination and the spread of infections. Interviews with the CNAs and the DON confirmed awareness of the hand hygiene requirements and the potential consequences of non-compliance.
Medication Error Due to Miscommunication and Lack of Verification
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services to meet the needs of a resident, resulting in a medication error. A resident was given the medications intended for another resident when he went on therapeutic leave. This error occurred because the medications were not double-checked before being provided to the resident, and there was a miscommunication between the staff members responsible for preparing and administering the medications. The resident involved in the incident had a history of atherosclerosis, muscle weakness, diabetes, hypertension, anxiety, depression, and pain, requiring a complex medication regimen. The error was discovered when the family member of the resident was contacted by the nurse, who realized the mistake after the resident had already left the facility. The family member confirmed that the resident did not take the incorrect medications, which included drugs for conditions the resident did not have, such as Alzheimer's disease and end-stage renal disease. The incident was reported to the Director of Nursing (DON) and the facility administrator, who acknowledged the miscommunication between the staff members. The error was attributed to a mix-up in the names of the residents, which were similar, and the medications were prepared in a rush without proper verification. The facility's policy on medication administration requires that medications be administered as prescribed by the attending physician, which was not followed in this case.
Failure to Notify Hospice of Resident's Condition Changes
Penalty
Summary
The facility failed to ensure that hospice care was properly coordinated for a resident receiving hospice services. Specifically, the facility did not immediately notify the hospice agency of significant changes in the resident's condition, including falls that occurred on two separate occasions. The resident, an elderly male with dementia and muscle wasting, experienced falls on 02/22/24 and 02/25/24, which were documented by the nursing staff but not communicated to the hospice agency in a timely manner. The nursing notes indicated that the resident was found on the floor on both occasions, with injuries such as a bruise under the right eye and a skin tear on the right forearm. The nursing staff notified the primary care clinician, the family, and the Director of Nursing (DON) but failed to notify the hospice agency immediately. The hospice agency was only informed of the incidents by the hospice aide and not by the facility staff, which was confirmed through interviews with the hospice supervising nurse and the DON. Interviews with the facility's nursing staff revealed that they were aware of the protocol to notify hospice, the family, the doctor, and the DON in case of any falls or changes in condition. However, this protocol was not followed, and the notifications to hospice were not documented in the nursing notes. The DON admitted that the hospice nurse was verbally informed of the falls two days later, but this was not documented, highlighting a lapse in communication and documentation procedures within the facility.
Failure to Honor Resident's Right to Choose Physician
Penalty
Summary
The facility failed to honor a resident's right to choose her attending physician upon readmission. The resident, an elderly female with multiple medical conditions including anemia, dementia, congestive heart failure, chronic kidney disease, and type 2 diabetes, was readmitted to the facility from a hospital. Despite having a primary care physician (PCP) and other specialists listed in her hospital discharge summary, the facility assigned her a physician provided by the facility without consulting her or her representative. The resident expressed concern about not being able to follow up with her PCP and cardiologist, especially after a recent heart attack. Her representative also voiced concerns about the lack of scheduled appointments and the facility's failure to ensure continuity of care. The representative was informed that a release of information form needed to be completed for each provider before appointments could be scheduled, and transportation arrangements were not adequately addressed by the facility. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's right to choose her physician. The social services worker and marketing specialist admitted to not being fully aware of the procedures for informing residents of their rights or coordinating follow-up care. The facility's policy on resident rights was not effectively communicated, leading to the oversight in honoring the resident's choice of physician.
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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 Rockwall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rowlett Health And Rehabilitation Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Rockwall Nursing Care Center | 2.8 mi | ★★★★★ | 10 | 1 |
| Broadmoor Medical Lodge | 3.9 mi | ★★★★★ | 5 | 0 |
| Highland Meadows | 4.5 mi | ★★★★★ | 10 | 0 |
| Pleasant Valley Healthcare And Rehabilitation Cent | 6 mi | ★★★★★ | 1 | 0 |
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