Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 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.
Food Items Found Unlabeled and Past Use Dates: Surveyors observed multiple food items in dry storage, the refrigerator, and the freezer that were missing required labels such as descriptions, open dates, and use by dates. Items included opened chips, bread, cheeses, turkey, ground meat patties, cookie dough, burritos, ice cream, and pepperoni stored well past its shelf life. The DM stated she expected opened items to be labeled and monitored by dietary staff and the activities director.
A resident with COPD and intact cognition had DNR status documented in the chart, but the OOH-DNR form was incomplete because the physician did not sign Section D. SW notes showed the DNR code status was chosen during care plan meetings and the form was sent to the physician, while the ADMN acknowledged the missing signature had been missed during a recent audit.
The facility failed to develop accurate, person-centered care plans for two residents. One resident had a suprapubic catheter noted in records and physician orders, but the comprehensive care plan did not address the catheter. Another resident had weight loss identified on the MDS and a triggered nutritional care area, but the care plan used blank, non-measurable goals and an unrelated intervention about diverting attention from food. The DON, ADON, MDS Coordinator, and ADMN could not explain the omissions or inaccuracies.
Failure to Assess, Consent, and Maintain Bed Rails: Two residents had bed rails in use without documented entrapment risk assessments, informed consent, or review of risks and benefits. One resident had moderate cognitive impairment and was dependent for bed mobility, while the other had severe cognitive impairment and required supervision for bed mobility. In both cases, the EMR lacked evidence of consent, inspection, or an order for bed rails, and the residents stated they did not recall being told about the risks.
Survey Results Binder Not Kept Current: The facility failed to keep the survey results binder current and available for review. The binder outside the admin office contained only the last re-certification results and did not include the last 3 survey results or investigation reports with the POC. The ADM stated she believed only the last full book survey results needed to be kept in the binder, acknowledged the missing information, and stated the facility had no policy for posting survey results.
Daily nursing staffing information was not posted in a prominent, readily accessible location with the census, total number, and actual hours worked by RN, LPN/LVN, and CNA staff. During observation, the staffing form was found on only one unit, lacked required details, and was not posted on the other units. The DON and ADMN stated the information should have been available to residents and visitors, and the facility had no policy for posting daily nursing staff.
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.
Food Items Found Unlabeled and Past Use Dates
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during a kitchen observation. In dry storage, surveyors found an opened bag of potato chips in a see-through plastic bag that was closed to air but not labeled with an open date, and an opened bag of bread stored outside the original container without a description, open date, or use by date. In the refrigerator, surveyors observed opened sliced white cheese without a use by date, opened sliced yellow cheese without a description or use by date, and smoked sliced turkey breast in a sealed plastic bag with a freeze by/use by date of 11/25/2025 on the original package and a handwritten date of 12/13 with no year and no explanation of what the date represented. In the freezer, surveyors found an opened bag of ground meat patties without a description, opened date, or use by date; pepperoni dated 10/12/2025 with a shelf life of 3 days and stored 90 days after shelf life; chicken flour tortillas with an open date of 1/8/2026 and a use by date of 1/11/2026 stored 2 days past the use by date; cookie dough without a description, opened date, or use by date; beef burritos without a use by date; vanilla ice cream without an open date; and five logs of ground meat in the original package with no description. The DM stated she expected all opened items to be labeled with an open date, use by date, and description, and said staff responsible for labeling included the cook, dietary aides, and activities director.
Incomplete OOH-DNR Form
Penalty
Summary
The facility failed to ensure that one resident had a properly completed advance directive form. Resident #13, an [AGE]-year-old female admitted and readmitted with COPD, had a quarterly MDS showing a BIMS of 15, indicating intact cognition, and no life expectancy of less than 6 months. Her record also reflected a DNR status, and her care plan noted that her DNR decision would be honored and that social services would consult with her regarding continuing DNR status. Record review showed an electronic physician order for DNR and an Out of Hospital Do Not Resuscitate (OOH-DNR) form dated [DATE], but Section D of the form, the physician declaration section, did not contain a physician signature. Social services progress notes documented that care plan meetings were held and that the DNR code status was chosen, with the DNR form sent to the physician. During interviews, the SW stated she was responsible for ensuring OOH-DNR forms were completed and uploaded, and the ADMN stated the physician signature had been missed during a recent audit and that the form was not completed.
Incomplete Care Plans for Catheter Care and Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for 2 residents reviewed. For Resident #55, the comprehensive care plan did not address the resident’s suprapubic urinary catheter, even though the resident had diagnoses including chronic kidney disease and a history of urinary tract infections, had a BIMS score of 10 indicating moderately impaired cognition, and had physician orders for suprapubic catheter changes every 28 days, PRN complication checks every 24 hours, and suprapubic catheter care every shift. The baseline care plan and care conference documentation noted the suprapubic catheter, but the comprehensive care plan last reviewed on 10/21/2025 contained no evidence of the catheter. For Resident #72, the comprehensive care plan did not include measurable goals or appropriate interventions related to weight loss. The resident had diagnoses including osteomyelitis of the vertebra, anxiety, dysphagia, Alzheimer’s disease, spinal stenosis, weakness, high cholesterol, glaucoma, high blood pressure, atrial fibrillation, and cerebral infarction, and had a BIMS score of 4 indicating severe cognitive impairment. The Significant Change MDS identified weight loss and triggered nutritional status care planning, but the comprehensive care plan listed a goal with blanks for baseline weight, percentage, and meal intake targets, and included an intervention to offer activities of choice to help divert attention from food. During interviews, the DON, ADON, MDS Coordinator, and ADMN stated care plans were a multidisciplinary responsibility and that accuracy was expected, but they could not explain why the catheter was omitted from Resident #55’s care plan or why Resident #72’s goals were not measurable and an inappropriate intervention was documented. The facility policy stated that comprehensive person-centered care plans must include measurable objectives and timeframes and describe services to meet the resident’s needs. The DON and MDS Coordinator stated that inaccurate or incomplete care plans could result in staff not being aware of needed interventions or information.
Failure to Assess, Consent, and Maintain Bed Rails
Penalty
Summary
The facility failed to assess two residents for risk of entrapment from bed rails before the rails were used, failed to review the risks and benefits of bed rails with the resident or resident representative, failed to obtain informed consent, and failed to follow the manufacturer’s recommendations for maintaining the bed rails. The report states these failures involved Resident #3 and Resident #19, both of whom had bed rails in use without documentation of the required assessment, consent, or maintenance review. Resident #3 was a male resident admitted and readmitted with diagnoses including muscle wasting and atrophy. His quarterly MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and he was dependent on staff for rolling and for moving between sitting and lying positions. His care plan and physician orders reviewed by the surveyor did not show evidence of bed rail use or an order for bed rails, and the EMR did not show consent, inspection of the rails, or an entrapment risk assessment. During observation, both sides of his bed had bed rails in the up position, and he stated the rails were to keep him in bed and that he did not remember anyone telling him about the risks. Resident #19 was a male resident admitted with diagnoses including muscle wasting and atrophy and was his own responsible party. His quarterly MDS reflected a BIMS score of 6, indicating severe cognitive impairment, and he required supervision to roll and to move between sitting and lying positions. His care plan did not include bed rails until after the review date, and the physician orders did not show an order for bed rails. The EMR did not show consent, inspection of the rails, or an entrapment risk assessment. During observation, a bed rail was raised on the left side of his bed, and he stated he did not mind the rails but did not remember anyone ever telling him about the risks.
Survey Results Binder Not Kept Current
Penalty
Summary
The facility failed to make reports with respect to the last 3 surveys, certifications, investigations, and any plan of correction in effect available for review upon request for 3 of 3 days. The survey results binder, observed outside the administrative offices on 01.15.2026 at 10:55 a.m., contained only the last re-certification results dated 10.10.2024 and did not include the results for the last 3 surveys or the investigation surveys dated 11.16.2025, 12.22.2025, and 12.26.2025. The report states that family members and residents were unable to review the survey and investigation reports with the plan of corrections. During interview, the ADM stated she believed only the last full book survey results needed to be kept in the survey results book, acknowledged that the missing investigation results meant anyone reviewing the binder would not have all the information, and stated she was responsible for keeping the survey results book up to date. The ADM also stated the facility did not have a policy regarding posting survey results.
Daily Nursing Staffing Information Not Properly Posted
Penalty
Summary
The facility failed to ensure nursing staffing information was posted in a prominent place readily accessible to residents and visitors and included the census, the total number, and the actual hours worked by the RN, LPN/LVN, and CNA staff directly responsible for resident care per shift. On one day reviewed, the daily staffing information was not posted as required, and the report states the facility failed to ensure the daily staffing information for licensed and unlicensed nursing staff was posted with the census and staffing details. During an observation, the daily nursing staffing form was found on only 1 of 4 units in the nurse's station. The form did not include the daily census, the total number, or the actual hours worked for the RN, LVNs, or CNAs, and it was not posted on any of the other 3 units in the facility. The DON stated the staffing information should have shown the total hours and number of each discipline working that day and should have been available to anyone who wanted to see it. The DON identified the staffing coordinator as responsible for posting the information and stated she was responsible for monitoring the task. The ADMN stated her expectation was that the staffing be posted each day in the front lobby and on each unit, and the facility did not have a policy regarding posting the daily nursing staff.
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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Illustrative
What surveyors actually found near you
We read the 58 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 14 | 0 |
| Harbor Lakes Nursing And Rehabilitation Center | 13.4 mi | ★★★★★ | 0 | 0 |
| Granbury Care Center | 14.2 mi | ★★★★★ | 12 | 0 |
| Avir At Granbury | 14.7 mi | ★★★★★ | 3 | 0 |
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