Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Heritage At Turner Park Health & Rehab during CMS and state inspections, most recent first.
A resident with a BIMS of 14 and a history of NPO noncompliance entered an unsecured employee breakroom, used a microwave to heat water, and spilled the hot liquid on his hand, causing a second-degree burn. Staff did not learn of the injury until a hospice RN noticed a bandage and reported it. Records showed the resident believed he could do it on his own and did not report the injury because he was not in pain.
A registered nurse failed to sanitize a shared blood pressure device and wrist cuff before and after use with two residents, contrary to facility policy and infection control standards. Both residents had complex medical histories and required assistance with daily activities. Facility leadership confirmed that equipment should be sanitized between each use, but the nurse reported only cleaning it every two residents and lacked specific training on this protocol.
A resident with a history of Rhabdomyolysis and neuropathy experienced inadequate pain management due to the facility's failure to administer prescribed medications. Despite reporting moderate to severe pain, the resident did not receive timely pain relief, as LVN A did not administer PRN Tylenol, relying instead on routine Gabapentin. This oversight occurred despite the facility's policy requiring comprehensive pain assessment and management.
A resident with multiple health conditions and pressure ulcers on both heels did not receive the physician-ordered wound care from an LVN over several days. The LVN documented the care as completed but later admitted to not performing it. The ADON and DON were unaware of the lapse, and the facility's policy on following physician orders was not adhered to, placing the resident at risk for infection.
A resident with multiple health conditions did not receive physician-ordered wound care, as LVN A falsely documented the treatments were completed. The resident's heel wounds were left untreated, contrary to the facility's policies. The ADON and DON were unaware of the lapse, which could lead to infection.
A resident with severe cognitive impairment and a risk for falls did not have their call light within reach, contrary to their care plan. Staff interviews revealed a lack of awareness and consistency in ensuring the call light was accessible, with the resident's behavior of moving the call light not addressed in the care plan.
A facility failed to maintain proper infection control when an ADON did not wear a gown while assessing a resident's foot wounds, despite the resident being on enhanced barrier precautions. The resident had pressure ulcers on both heels, and the ADON's scrubs touched the bed during the procedure, increasing the risk of infection transmission. The facility's policy requires gowns to prevent contamination, but the ADON admitted to forgetting to wear one.
A resident with cognitive impairment and high elopement risk exited a dining room into a courtyard without supervision due to removed door alarms. The resident was found on the ground, complaining of knee pain, after being reported missing. The facility's failure to maintain door alarms and provide adequate supervision led to an Immediate Jeopardy situation.
A resident's room in an LTC facility was found to have a hole in the wall and a gap above the air conditioning unit, compromising the environment's safety and comfort. The resident, who was severely cognitively impaired, could not report these issues. Staff, including a CNA and the Maintenance Supervisor, were unaware of the deficiencies, despite regular rounds and a policy requiring repairs as needed.
A resident with cognitive impairments was verbally abused by an LVN during lunch service, involving derogatory remarks and a public altercation. The resident, who required assistance due to mobility issues, was upset by the LVN's comments, which were witnessed by others. Despite receiving training on abuse, the LVN did not recognize her actions as abusive.
The facility failed to transmit MDS assessments for three residents within the required timeframe, risking timely data submission. The assessments were due in early May but remained unencoded and untransmitted by June. The MDS coordinator, new to the role, acknowledged the delay, and the new DON had not yet received MDS training.
A facility failed to lock an emergency exit, allowing a resident with dementia to exit and fall, resulting in a forehead injury. Additionally, the dining room door to the courtyard was unlocked and unalarmed, posing a risk of residents being left outside unsupervised. Despite the facility's Secure Care Program policy, these oversights placed residents at risk of accidents and exposure to environmental hazards.
Resident Burned Hand After Using Unsecured Employee Microwave
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment when a cognitively intact resident with a history of noncompliance with NPO status entered the employee breakroom, used a microwave to heat water, and spilled the hot liquid on his right hand. The resident’s diagnoses included throat cancer, anemia, thyroid disorder, aphasia, malnutrition, depression, dysphagia, and adult failure to thrive. His MDS reflected a BIMS score of 14 and indicated he was set up assistance with transfers, toileting hygiene, and eating, with a feeding tube as his nutritional approach. The resident’s care plan identified that he was NPO with PEG tube feedings and was noncompliant with tube feeding and NPO. It also documented impaired safety awareness and the need for staff to reinforce safety awareness and to educate him to call staff when handling hot liquids and other environmental hazards. The facility’s investigation report stated the resident entered the breakroom and microwaved hot water without asking for assistance, and that he had a history of noncompliance and often attempted tasks independently without requesting help. The resident reported that he believed he could do it on his own and did not notify staff because he was not in pain. The injury was first identified when a hospice nurse noticed a homemade-style bandage on the resident’s right hand and notified facility leadership. Nursing documentation described a burn to the right hand measuring approximately 5.5 cm by 4.5 cm by 0.1 cm, with redness and no bleeding. The resident later stated he had gone to the employee breakroom, used his personal cup, heated water in the microwave, and spilled it on his hand. Staff interviews reflected that the facility did not know exactly when the incident occurred, that the resident had not reported it immediately, and that the microwave had been located in the employee breakroom, which was not secured at the time of the incident.
Failure to Sanitize Shared Equipment Between Resident Uses
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices when a registered nurse did not sanitize shared use equipment, specifically a blood pressure device and wrist cuff, before and after use with two residents. During observation, the nurse used the same blood pressure device and wrist cuff on two different residents without cleaning the equipment between uses. The nurse later stated that she only sanitized the equipment every two people and had not been specifically trained by the facility to clean it between each resident. Interviews with the Assistant Director of Nursing, Director of Nursing, and Administrator confirmed that their expectation was for all shared use equipment to be sanitized before and after each resident use. The two residents involved had significant medical histories, including dementia, cerebrovascular insufficiency, depression, and other neurological and psychiatric conditions. Both residents required assistance with activities of daily living and used mobility aids such as wheelchairs and walkers. Review of facility policies indicated that standard precautions and infection control measures required cleaning non-invasive resident care equipment between uses, but these procedures were not followed during the observed incident.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident #1, who required such services. The resident, a female with a history of Rhabdomyolysis, Hereditary and idiopathic neuropathy, and Spondylolysis in the cervical region, was admitted without a completed Admission MDS assessment. This assessment did not reflect a BIMS summary score, a staff assessment for mental status, or any indication of pain or its effects on the resident's daily life. Despite having orders for pain management medications such as Tylenol and Gabapentin, the resident's pain was not adequately addressed. LVN A, who was responsible for Resident #1 during several shifts, failed to administer pain medication despite the resident reporting moderate to severe pain levels ranging from 4 to 7 out of 10 on multiple occasions. LVN A noted the resident's pain in nursing notes but did not administer the prescribed PRN Tylenol, believing that the routine Gabapentin was sufficient for pain relief. This oversight occurred even though the resident was capable of expressing her needs and had reported pain consistently. The facility's policy on pain management, which includes assessing physical symptoms, performing comfort measures, and monitoring the effectiveness of interventions, was not followed. Interviews with LVN A and RN E revealed a lack of consistent pain assessment and management, with RN E administering Tylenol only after the resident's pain was reported as severe. The failure to adhere to the facility's pain management policy placed the resident at risk of prolonged pain and diminished quality of life.
Failure to Administer Ordered Wound Care for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as per professional standards of practice. The resident, an elderly male with multiple health conditions including heart failure, peripheral vascular disease, and end-stage renal disease, had pressure ulcers on both heels. The care plan documented a pressure ulcer on the left heel but failed to include the right heel. Physician orders required specific wound care for both heels, which was not administered by LVN A from January 4 to January 7, 2025. During this period, LVN A documented that the ordered wound care was completed, but later admitted to not performing the care as prescribed. Instead, she applied skin prep/betadine and left the wounds uncovered, contrary to the physician's orders. The resident's feet were observed without dressings, and the necrotic areas on the heels were not off-loaded as required. The ADON, who also served as the wound care nurse, was unaware of the lapse in care and did not realize the wounds were not treated as ordered. The DON confirmed that the resident was supposed to receive an air mattress and acknowledged that the staff nurses were responsible for wound care. The DON was informed that LVN A did not administer the ordered treatment and was unaware of any other residents missing their treatments. The facility's policy emphasized the importance of following physician orders and documenting completed treatments, which was not adhered to in this case, placing the resident at risk for infection and other complications.
Failure to Document and Administer Ordered Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of physician-ordered wound care. The resident, an elderly male with multiple health conditions including heart failure, peripheral vascular disease, and end-stage renal disease, was supposed to receive specific wound care treatments for his heel wounds. However, LVN A falsely documented that the wound care was completed over several days, despite not performing the ordered treatments. This discrepancy was discovered during an observation and interview, where it was noted that the resident's heels were not dressed as required, and LVN A admitted to not completing the wound care as ordered. Further interviews revealed that the Assistant Director of Nursing (ADON), who also served as the wound care nurse, was unaware that the treatments were not administered as ordered. The ADON confirmed that the heel wounds were still active and required treatment. The Director of Nursing (DON) was informed of the situation and acknowledged that the failure to administer the ordered wound care could lead to infection and other complications. The facility's policies emphasized the importance of accurate documentation and adherence to treatment protocols, which were not followed in this instance.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the facility did not ensure that the call light was within reach for a resident who was severely cognitively impaired and required substantial assistance with transfers and toileting. The resident's care plan indicated a risk for falls and included an intervention to ensure the call light was within reach. However, during an observation, the call light was found behind a dresser, out of the resident's reach, and the resident confirmed they could not access it. Interviews with staff revealed a lack of awareness and consistency in ensuring the call light was accessible. A CNA found the call light behind the dresser and placed it within reach, acknowledging its importance for the resident's ability to call for assistance. The RN and DON were unaware of the issue, and the Administrator noted that the resident had a behavior of moving the call light, which was not addressed in the care plan. The facility's policy on resident rights emphasizes the importance of communication and access to services, which was not upheld in this instance.
Inadequate PPE Use During Wound Assessment
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the inappropriate use of personal protective equipment (PPE) by the Assistant Director of Nursing (ADON) while assessing a resident's foot wounds. The resident, a male with multiple health conditions including heart failure, peripheral vascular disease, and end-stage renal disease, was on enhanced barrier precautions due to the presence of pressure ulcers on both heels. During an observation, the ADON entered the resident's room, donned gloves but failed to wear a gown, which is required for residents on enhanced barrier precautions. This oversight occurred while the ADON was measuring and assessing the resident's wounds, and her scrubs came into contact with the bed, increasing the risk of infection transmission. The resident's medical records indicated that he had a stage 4 pressure wound on the right heel and an unstageable wound on the left heel, both with black necrotic tissue. The facility's policy on infection control mandates the use of gowns to prevent contamination and transmission of microorganisms. Despite this, the ADON admitted to forgetting to wear a gown during the procedure. The Director of Nursing (DON) confirmed that the resident was on enhanced barrier precautions and acknowledged that the failure to wear appropriate PPE could lead to the spread of infection. The facility's policy clearly outlines the necessity of gowns to protect against blood and body fluid exposures and to prevent the transmission of pathogens within the facility.
Failure to Supervise and Maintain Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to an incident where the resident was able to exit the dining room and enter a courtyard without supervision. The courtyard was not visible from inside the facility due to closed blinds, and there were no cameras monitoring the area. The alarms on the doors leading to the courtyard had been removed by the Maintenance Supervisor prior to the incident, which contributed to the resident being trapped outside. The resident, who was moderately cognitively impaired and at high risk for elopement, was found on the ground by her wheelchair in the courtyard after being reported missing by her roommate. The resident complained of knee pain, and although no injuries were noted during the initial assessment, she was later sent to the hospital at the request of her family. The facility's failure to maintain door alarms and provide adequate supervision placed the resident at risk for harm. Interviews with facility staff revealed that the alarms on the doors had been removed due to incorrect installation as informed by HHSC Life Safety. The lack of alarms and supervision allowed the resident to exit the facility unnoticed, resulting in her being trapped in the courtyard. The facility's policies on elopement prevention were not effectively implemented, leading to the identification of an Immediate Jeopardy situation.
Failure to Maintain Safe and Homelike Environment for Resident
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, as observed during a survey. The resident's room had a hole in the wall above the baseboard and a gap above the air conditioning unit, which allowed visibility to the outside. These issues were not recorded in the maintenance log, indicating a lack of attention to necessary repairs. The resident, who was severely cognitively impaired with a BIMS score of 0 out of 15, was unable to respond to the surveyor's questions, highlighting the importance of staff vigilance in maintaining the environment. Interviews with facility staff, including a CNA and the Maintenance Supervisor, revealed a lack of awareness regarding the room's condition. The CNA was unaware of the issues and stated that he would inform the nurse and Maintenance Supervisor if repairs were needed. The Maintenance Supervisor, responsible for facility repairs, admitted to not knowing about the gap and hole in the resident's room, despite making rounds four times a day. The facility's policy on preventative maintenance indicated that repairs should be made as needed, yet these deficiencies were overlooked, compromising the resident's environment.
Verbal Abuse Incident During Lunch Service
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically an LVN, during a lunch service. The incident involved a verbal altercation between the LVN and the resident, which was witnessed by other residents. The LVN made derogatory remarks towards the resident, calling him a liar and suggesting he was lazy, which the resident found upsetting. This exchange occurred in the dining room, where the resident had requested assistance with refilling his coffee, a task he found difficult due to the height of the coffee container. The resident involved was an elderly male with moderately impaired cognition, using a wheelchair for mobility, and requiring assistance with daily activities. His medical history included hypertension and non-Alzheimer's dementia, which contributed to his cognitive and behavioral challenges. Despite these challenges, the resident was generally described as polite and able to make his needs known, although he occasionally exhibited abrupt behavior depending on his mood. The LVN involved in the incident had received training on abuse and neglect but did not consider her actions to be abusive. She justified her behavior by claiming the resident often acted differently when management was present. The facility's policy clearly defines verbal abuse as the use of disparaging language, which the LVN's comments fell under. The incident was reported to the facility's administration, and the LVN was suspended pending further investigation.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit resident assessments within the required time frame for three discharged residents, placing them at risk for not having their MDS Assessments transmitted in a timely manner. Specifically, the assessments for Resident #1, Resident #3, and Resident #59 were not encoded and transmitted by the required dates. Resident #1's assessment was due on May 3, 2024, Resident #3's on May 3, 2024, and Resident #59's on May 2, 2024. As of June 10, 2024, these assessments had not been encoded and transmitted, which is a violation of the timeliness criteria set by CMS. The MDS coordinator, who had taken over the position about a month prior, acknowledged that some MDS assessments had been completed but not sent to CMS. The coordinator follows the facility's MDS Policy for scheduling assessments and mentioned that the corporate office assists with signing the MDS for transmittal. The new Director of Nursing had not yet been trained in MDS, which may have contributed to the delay. The facility's policy requires that the OBRA schedule and, if applicable, the Medicare PPS assessment schedule be followed for setting the Assessment Reference Date and completing the MDS assessment, as outlined in CMS's RAI 3.0 Version Manual.
Failure to Secure Emergency Exits and Monitor Residents
Penalty
Summary
The facility failed to ensure the emergency exit door was locked, which allowed a resident with severe cognitive impairment to exit the secure unit. This resident, who had a history of dementia, agitation, and anxiety disorder, managed to leave through the back door and subsequently fell outside, resulting in a serious forehead injury that required three stitches. Despite the alarm sounding when the door was opened, the staff was unable to prevent the resident from exiting and falling. Additionally, the facility did not have a monitoring system in place for residents who wished to go outside from the dining room exit door to the courtyard in the secure unit. Observations revealed that the dining room door was unlocked and unalarmed, allowing residents to go outside unsupervised. Interviews with staff indicated that residents could be left outside exposed to the elements, and there was a potential security risk as the courtyard was only fenced in. The facility's Secure Care Program policy aimed to provide a safe environment for residents with dementia, but the lack of proper door security and supervision contradicted this goal. Interviews with the Director of Nursing and the Administrator confirmed that the dining room door had always been unlocked and unalarmed, and corporate had been contacted about the issue, but no changes had been made. This oversight placed residents at risk of accidents and exposure to environmental hazards.
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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 Grand Prairie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arlington Residence And Rehabilitation Center | 2.7 mi | ★★★★★ | 1 | 0 |
| Avante Rehabilitation Center | 5.2 mi | ★★★★★ | 1 | 0 |
| The Villa At Mountain View | 5.5 mi | ★★★★★ | 6 | 0 |
| Avir At Irving | 5.7 mi | ★★★★★ | 10 | 0 |
| Ashford Hall | 6.5 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.