Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Legend Oaks Healthcare And Rehabilitation Garland during CMS and state inspections, most recent first.
Medications Left Accessible in Resident Rooms: An open tube of barrier ointment was observed on one resident’s bedside table and an unopened packet of ointment was observed on another resident’s bedside table. The residents had multiple medical conditions, including skin integrity concerns and cognitive impairment diagnoses, and staff stated creams and topical treatments should not remain in resident rooms or be kept at bedside without authorization.
Call lights were left on the floor and out of reach for two residents, including one with dementia and one who was cognitively intact and needed assistance with transfers and ADLs. Both residents were observed in bed with no accessible way to call staff, and one resident reported having no way to summon help after spilling coffee and wetting the bed. Staff and leadership stated call lights should be kept within reach at all times.
Open Buttock Wounds Left Uncovered During Incontinent Care: A resident with MASD and physician-ordered wound care for both buttocks was observed during incontinent care with loose stool on the wounds and no foam dressings in place. CNAs cleaned the resident and called the nurse, but staff stated they were unsure why the wounds were uncovered and the LPN had not been notified that the dressings were soiled or dislodged. The ADON/Treatment Nurse later cleaned the wounds and applied dressings.
A resident with reduced mobility and severe cognitive impairment was observed in bed on a scoop mattress, but the care plan did not include the mattress and there was no physician order for its use. The ADON said she did not know whether the resident had an order, and the DON stated she assumed an order for a wedge covered the scoop mattress; staff acknowledged the resident needed a physician order because it was part of her care.
G-tube Not Flushed as Ordered Before Medication Administration: A resident with dysphagia, gastrostomy status, and a memory problem had an order to flush the g-tube with 30 to 50 mL of water before and after medication administration. During observation, an LVN prepared crushed meds for g-tube delivery, checked placement and residuals, but did not flush before giving the meds and flushed with only 15 mL after administration. The LVN, ADON, and DON all acknowledged the ordered flushing procedure was not followed.
Infection control failures occurred when a resident receiving IV antibiotics had an uncovered midline port after the LPN disconnected the infusion, and another resident on EBP for a permacath and dialysis received incontinent care from a CNA who wore gloves but no gown. The DON and ADON stated gowns were required for EBP care and that IV ports should be capped after use, while the facility policy addressed gown and glove use for high-contact care and central vascular line care.
Two residents with cognitive impairment and complex medical/psychiatric histories were seated near each other in the dining area when one resident, upset that the other was coughing over and reaching for food on her tray, threw an empty plastic bowl that struck the other resident’s upper body. The injured resident, who had dementia and required extensive assistance with ADLs and mobility, was assessed with no injuries or pain reported. The resident who threw the bowl, who had a history of CVA, schizoaffective disorder, and bipolar disorder, acknowledged the behavior and stated she acted because the other resident would not stop reaching for her food. This incident occurred despite a facility policy stating residents must be free from abuse, neglect, exploitation, and mistreatment by anyone, including other residents.
A resident with dementia, morbid obesity, CKD, overactive bladder, and bowel/bladder incontinence, who required substantial assistance with ADLs and was dependent for mobility, was left in a urine-soiled brief for several hours after requesting help via the call light. A CNA responded, found that the preferred brief size was not in the room, went to another hall to obtain the correct size, and then chose not to wake the resident upon return when the resident was asleep, leaving the brief unchanged despite the resident’s expressed desire to be awakened for changing. The resident’s responsible party reported multiple unsuccessful attempts to reach staff by phone while the resident remained soiled and crying. This conduct was inconsistent with the resident’s care plan and facility policies requiring provision of toileting and hygiene services and maintenance of resident dignity and cleanliness.
Surveyors found that a crash cart containing emergency supplies and medications was left unlocked and unattended in a hallway, making its contents accessible to residents. Additionally, a resident with severe cognitive impairment was found with a tube of topical analgesic cream in her room, despite having no physician order or assessment for self-administration. Staff were unaware of the medication's presence, and facility policy required all medications to be securely stored and accessible only to authorized personnel.
A resident with chronic respiratory failure was found to have a sleep apnea mask, nebulizer mask, and nasal cannula left unbagged and improperly stored when not in use, despite physician orders and facility policy requiring proper storage to prevent infection. Facility staff confirmed that these devices should have been bagged when not in use.
The facility failed to adhere to professional standards for food safety by not labeling opened food items with dates in the kitchen's walk-in refrigerator. Two jars of spaghetti sauce were found without open or discard dates, posing a risk of food-related illnesses to residents. Despite staff having up-to-date food safety certificates, this oversight occurred, highlighting a lapse in following the facility's food storage policy and FDA guidelines.
The facility reported a medication error rate of 13.33%, exceeding the acceptable 5% threshold. Three residents did not receive their medications within the prescribed timeframes, as observed on a specific date. The errors involved late administration of Glipizide, Benzonatate, Carvedilol, and Metformin. The staff acknowledged the delays, and the facility's policy requires medications to be administered as prescribed.
A LTC facility failed to protect a resident's personal and medical records when a resident's representative was mistakenly given another resident's face sheet containing sensitive information. The DON confirmed the breach, which likely occurred two years ago, and emphasized the importance of adhering to PHI management policies to prevent unauthorized disclosure.
The facility failed to maintain a clean and safe environment for 11 residents, with issues such as dirty air-condition units, soiled linens, and inadequate housekeeping services. Residents reported that their rooms were not cleaned regularly, and some faced health issues due to the lack of cleanliness. Housekeeping staff acknowledged oversight, and the Housekeeping Supervisor confirmed that daily checks were conducted, but these practices were not consistently followed.
The facility failed to ensure that three residents were free from unauthorized physical restraints, including scoop mattresses and a positioning wedge, without physician orders or assessments. This oversight involved residents with severe cognitive impairments and histories of falls, potentially putting them at risk of injury.
The facility failed to provide scheduled showers to two dependent residents, leading to concerns about personal hygiene and skin integrity. One resident with bilateral leg amputations and another with severe cognitive impairment received bed baths instead of showers, despite being scheduled for showers three times a week. Interviews revealed inconsistencies in documentation and communication among staff.
The facility failed to provide appropriate respiratory care for several residents, including not changing nebulizer tubing, not cleaning BiPAP machines, improperly storing nebulizer masks, and not maintaining humidifiers. These deficiencies were confirmed through observations and interviews with staff and residents.
The facility failed to re-order medications in a timely manner for four residents, resulting in low or depleted supplies of essential medications. This issue was observed during medication preparation and administration, and staff interviews revealed inconsistencies in following the re-ordering procedure. The DON and ADON acknowledged the problem and emphasized the importance of timely re-ordering to ensure residents receive necessary medications.
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards. Observations revealed rust on the ice machine's door hinges, improperly labeled dill pickle relish, and unsealed frozen chicken nuggets. Interviews confirmed these issues, and the facility's policy mandates proper storage and labeling.
The facility failed to obtain a signed informed consent for a resident before administering Lamictal, a medication for bipolar disorder. The resident was unaware of taking the medication or the diagnosis it was treating. The ADON admitted to overlooking the need for consent, and the DON confirmed that obtaining consent is required by facility policy.
The facility failed to ensure the call light system in the rooms of two residents was accessible, which could prevent them from obtaining assistance when needed. One resident's call light was found on the floor behind the headboard, and another's was hanging on the headboard out of reach. Staff acknowledged the issue and moved the call lights within reach.
A resident reported that staff had called her a liar but did not file a grievance because she did not know how. Interviews revealed that it was the Social Worker's responsibility to inform residents about the grievance process, but this was not effectively communicated to the resident.
The facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and a history of falls. The care plan required a low bed with a fall mat, but the mat was missing after the resident moved rooms. Both the ADON and DON confirmed the necessity of the fall mat to prevent injuries.
The facility failed to ensure a resident with a feeding tube had a clear physician order specifying the downtime, leading to potential risks of underfeeding, overfeeding, aspiration, and fluid overload. The nursing staff was confused about when to stop and resume the feeding due to the lack of a specific downtime order.
The facility failed to ensure proper hand hygiene practices were followed by staff, leading to potential infection risks for two residents. An ADON did not wash her hands before applying a splint, and a CNA did not perform hand hygiene during incontinence care. Both staff members acknowledged their lapses, and the DON emphasized the importance of handwashing in preventing infection transmission.
Medications Left Accessible in Resident Rooms
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in a safe and secure manner and were not accessible to residents. During observation, an open tube of Clear Moisture Barrier Ointment was seen on Resident #17’s bedside table in plain view, and an unopened packet of Essentials Prevent Ointment was seen on Resident #21’s bedside table in plain view. The report states that both items were in resident rooms and not stored in a locked or designated medication area. Resident #17 was admitted with diagnoses including cirrhosis of the liver, thrombocytopenia, type 2 diabetes mellitus, protein-calorie malnutrition, cellulitis, irritant contact dermatitis related to incontinence, neuromuscular dysfunction of the bladder, and cognitive communication deficit. The resident’s MDS assessment showed a BIMS score of 15, indicating cognitively intact status. The care plan directed staff to observe the peri-area during cares for redness or excoriation and notify the nurse or physician if present, and the active physician’s orders did not include self-administration of medications. Resident #21 was admitted with diagnoses including unspecified dementia, cerebral infarction, chronic kidney disease stage 4, anemia, peripheral vascular disease with history of vascular intervention, blindness, and immobility. The resident’s MDS assessment showed a BIMS score of 14, indicating cognitively intact status. Staff interviews confirmed that creams and topical treatments should not remain in resident rooms, that residents were not supposed to keep medications at bedside, and that medications should be stored on the medication cart or in a designated storage area. The DON stated no residents had assessments or authorizations for bedside medication storage or self-administration, and that medications or treatments found in resident rooms were expected to be removed immediately.
Call Lights Left Out of Reach for Two Residents
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences when the call light systems in two residents’ rooms were not positioned within reach. Resident #93, a female with dementia and anxiety, was dependent on staff for eating, hygiene, showers, dressing, and bed mobility, and her care plan identified her as at risk for falls with an intervention to keep the call light within reach. During observation, she was in bed awake and her call light was found on the floor; when asked where it was, she did not respond. The MDS Nurse then retrieved the call light from the floor and placed it where the resident could reach it. Resident #95, a cognitively intact female with an acquired absence of the left leg below the knee, required assistance with hygiene, showers, dressing, bed mobility, and transfers, and her care plan also directed that the call light be kept in reach. During observation, she was in bed awake, her call light was on the floor, and her bed was soaking wet after she reported spilling coffee. She stated she did not have her call light and had no way to call staff. A CNA observed the call light on the floor, placed it within reach, and noted the resident’s bedding was wet. Facility leadership later stated that call lights should always be within residents’ reach and that staff were responsible for ensuring this before leaving the room.
Open Buttock Wounds Left Uncovered During Incontinent Care
Penalty
Summary
The facility failed to ensure that Resident #17’s open wounds on the left and right buttocks were covered with dressings during incontinent care. Resident #17 was an [AGE]-year-old female admitted to the facility with irritant contact dermatitis due to fecal, urinary, or dual incontinence. Her MDS assessment reflected that she was cognitively intact with a BIMS score of 15 and had moisture associated skin damage. Her care plan identified skin integrity impairment related to shear and MASD on the right and left buttocks, with an intervention to administer treatments as ordered. The physician’s orders directed cleansing the left buttock wound and the right buttock wound with NS, applying Triad paste, and covering each with a foam dressing on Mon, Wed, and Fri and as needed for dislodgement or soiling. During observation, CNA F and CNA G were providing incontinent care and transferring the resident when loose, unformed stool was seen scattered on both buttocks. The resident’s open wounds on both buttocks were observed without dressings and had feces on them. The brief removed from the resident’s bottom also had no dressings on it. CNA F left the room to call the nurse after cleaning the resident’s bottom. CNA G stated she was not sure why the wounds did not have dressings. CNA F said he went to notify LVN H about whether cream or dressings were needed, and the Treatment Nurse said she would do the wound care. ADON B later cleaned the wounds and placed dressings on them, and stated she had no idea why the wounds were uncovered. LVN H said nobody had notified her earlier that the dressings were soiled or dislodged or that the wounds had no dressings. The facility policy stated that residents with pressure injuries receive necessary treatment and services to promote healing and prevent infection, and that if a resident is incontinent, the skin should remain clean and dry with regular pericare and toileting when appropriate.
Missing physician order for scoop mattress used for fall prevention
Penalty
Summary
The facility failed to ensure Resident #24’s environment remained free of hazards as possible when the resident was observed lying in bed on a scoop mattress, which features raised sides and a concave center. Resident #24 was an [AGE] year-old female admitted to the facility with a diagnosis of reduced mobility, and her MDS assessment reflected a BIMS score of 5, indicating severe cognitive impairment. Her comprehensive care plan identified her as a fall risk, but it did not include any intervention for the use of a scoop mattress. Record review showed there was no physician order for the scoop mattress, even though the mattress was in use. During interview, the ADON stated she did not know whether the resident had an order for the mattress and acknowledged that the resident needed a physician order because it was part of her care. The DON and Clinical Resource Nurse were informed of the scoop mattress without an order, and the DON stated the resident had an order for a wedge and assumed that was for the scoop mattress; they also stated it was used for fall prevention. The facility policy stated residents should be provided an environment as free of accident hazards as possible and receive appropriate assessment and interventions to prevent falls.
G-tube Not Flushed as Ordered Before Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one resident with a g-tube. The resident had dysphagia, gastrostomy status, and a memory problem, and the care plan reflected the need for tube feeding and reference to current feeding orders. The physician’s order required the g-tube to be flushed with 30 to 50 mL of water before and after medication administration. During observation, an LVN prepared crushed medications for g-tube administration, checked tube placement, and checked residuals, but did not flush the g-tube before giving the medications. After the medications were administered, he flushed the tube with 15 mL of water, which was less than the ordered amount. In interview, the LVN acknowledged he did not flush before medication administration and did not use the ordered amount after administration. The ADON and DON stated the tube should be flushed before medication administration and that staff were expected to follow the ordered procedure and amount. The facility policy also required flushing before and after giving any medication by tube.
Infection Control Lapses With Uncapped IV Port and Missing Gown During EBP Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents. One resident, who was cognitively intact and had bowel and bladder incontinence, was receiving antibiotics through a midline for a UTI. During an observation, the resident’s IV pole was in the room and the midline port was observed uncovered. The resident said she was not sure whether staff were putting a cover on the IV port. The LVN who had administered and disconnected the IV said he was not sure if he had covered the midline port after disconnecting it and then saw that the port did not have a cover. A second resident, who had end stage renal failure, was undergoing dialysis and had a central venous catheter to the right upper chest. The resident’s care plan directed use of enhanced barrier precautions because of the permacath, and the physician’s order required PPE for high-contact care activities. During an observation, a CNA entered the room and began incontinent care after washing her hands and putting on gloves, but she did not wear a gown. The CNA stated this was an oversight and acknowledged that a gown was required for residents on enhanced barrier precautions. During interviews, the ADON stated the IV port should be covered after disconnecting IV bags and that staff must wear a gown when PPE is required, including for residents on enhanced barrier precautions. The DON stated that when a resident is on enhanced barrier precautions, staff should wear a gown and gloves during handling to prevent transfer of MDROs, and that residents with indwelling medical devices such as dialysis ports were on enhanced barrier precautions. The facility’s infection control policy identified gown and glove use for high-contact care activities, including changing briefs or assisting with toileting and device care or use for central vascular lines, but the facility did not have a specific policy for capping the IV port.
Resident-to-Resident Abuse During Dining
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from abuse by another resident when one resident threw an empty plastic bowl at another during a meal. Resident #1 was an 85-year-old female with dementia, reduced mobility, chronic pain, and multiple other medical conditions, and required setup assistance for all ADLs and was dependent for mobility. Her MDS indicated she was unable to complete the interview and had no documented physical or verbal behaviors. Her care plan identified her as at risk for impaired cognitive function/dementia and included interventions such as consistent routines, step-by-step instructions, and monitoring for changes in cognitive status. Resident #2 was a female with a history of nontraumatic intracerebral hemorrhage, hemiplegia/hemiparesis, schizoaffective disorder, bipolar disorder, generalized anxiety disorder, and other medical conditions. Her MDS showed a BIMS score of 12 (moderate cognitive impairment), dependence or need for setup with all ADLs, and no documented physical or verbal behaviors. Her care plan identified risk for impaired cognitive function related to CVA, schizophrenia, and bipolar disorder, and a potential for mood problems related to schizophrenia and bipolar disorder, with interventions focused on communication, psychosocial support, and monitoring mood and cognitive changes. On the morning of 03/03/26 during dining, Resident #2 threw an empty plastic cup/bowl at Resident #1, striking Resident #1 on the upper body/shoulder after Resident #1 reportedly reached for or attempted to take food from Resident #2’s tray and coughed over her food. Staff interviews indicated that Resident #2 told staff she threw the cup because Resident #1 tried to take food from her tray and did not stop when told to. The nurse’s progress note documented a resident-to-resident incident in which Resident #1 was struck by a cup thrown by Resident #2, with no injuries or distress observed and Resident #1 denying pain. The facility’s policy stated that each resident has the right to be free from abuse, neglect, exploitation, and mistreatment by anyone, including other residents. Despite this policy, the incident occurred, and the facility failed to ensure Resident #1 was free from abuse by Resident #2.
Failure to Provide Timely Incontinent Care and ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinent care and assistance with activities of daily living (ADLs) to a resident who was dependent on staff for toileting and hygiene. The resident was an older female with multiple diagnoses, including COPD, dementia with mood disturbance, type 2 diabetes, morbid obesity, chronic kidney disease, overactive bladder, and bowel and bladder incontinence. Her MDS assessment showed moderate cognitive impairment, substantial assistance needs for most ADLs, wheelchair use, and dependence on all mobility tasks. Her care plan identified bowel/bladder incontinence related to decreased mobility, deconditioning, activity intolerance, weakness, unsteady gait, and impaired cognition, with interventions that included use of disposable briefs, checking for incontinence as required, washing and drying the perineum, changing clothing as needed after incontinence episodes, monitoring for UTI, and observing the peri-area for redness or excoriation. On the day of the incident, the resident used her call light to request assistance with changing her clothes and a soiled brief. A CNA responded, and the resident requested to be changed. The CNA reported that when she checked the resident’s closet, only smaller briefs were available and not the XXXL size the resident preferred, so she went to a storage area on another hall to obtain the correct size. The CNA stated that when she returned to the resident’s room, the resident was asleep, and the CNA decided not to wake her and did not change the soiled brief at that time. The CNA acknowledged that she made the decision not to change the resident and that the expectation was to wake the resident to change her if requested. The resident and her responsible party reported that the resident remained in a soiled brief for several hours despite repeated attempts to obtain assistance. The responsible party stated she received a call from the resident crying and reporting she had been waiting since early morning for her soiled brief to be changed. The responsible party described multiple unsuccessful attempts to reach facility staff by phone and reported that, during follow-up calls with the resident over the next several hours, the resident stated she still had not been changed and had fallen asleep while waiting. The resident later stated that staff told her they had not changed her because she was asleep when they returned, and she expressed confusion and upset because staff routinely woke her for other reasons and she wanted to be awakened to be changed. The facility’s policies on Quality of Care and Resident Rights required that residents unable to perform ADLs receive necessary services for toileting and hygiene and that residents be treated with dignity and be appropriately groomed and in clean clothing.
Failure to Secure Medications and Lock Emergency Cart
Penalty
Summary
Surveyors observed that the facility failed to store all drugs and biologicals in locked compartments as required by state and federal regulations. On the morning of the survey, a crash cart containing emergency supplies, equipment, and medications was found unlocked and unattended in a hallway outside the nurse's station. The drawers of the cart, which were accessible to passing residents, contained items such as scissors, syringes, tubing, and a first aid kit. Staff interviews confirmed that the crash cart should have been locked when not in use, and that its contents could be harmful if accessed by residents. Additionally, a tube of topical analgesic cream was found on the overbed table of a resident diagnosed with dementia, depression, and low back pain. The resident had a severe cognitive impairment and no physician order for the analgesic cream. There was no assessment for self-administration of medications, nor any documentation indicating the resident was competent to manage her own medications. Staff were unaware of the presence of the cream in the resident's room and acknowledged that it should have been stored securely and administered by nursing staff. Facility policy required that all drugs and biologicals be stored in locked compartments and accessible only to authorized personnel. The policy also specified that medication rooms, carts, and supplies must be locked or attended by authorized staff. The observed failures to lock the crash cart and to prevent unauthorized medications from being present in a resident's room were in direct violation of these policies and regulatory requirements.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure who required multiple respiratory devices, including a sleep apnea mask, nebulizer mask, and nasal cannula. On the date of observation, all three respiratory devices were found unbagged and not properly stored when not in use, contrary to professional standards of practice and the facility's own policy. The resident's care plan included oxygen therapy, and physician orders specified the use of oxygen, nebulizer treatments, and BiPAP/CPAP at night. During observations and interviews, the DON and an RN confirmed that all breathing devices should have been bagged when not in use to prevent infection. The failure to properly store these respiratory devices was directly observed and acknowledged by facility staff. The resident involved had an intact cognitive status and a diagnosis of chronic respiratory failure, requiring consistent adherence to respiratory care protocols.
Improper Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety in its only kitchen. During an observation, two 48-ounce plastic jars of opened spaghetti sauce were found on a shelf in the walk-in refrigerator without any dates indicating when they were opened or when they should be discarded. The Dietary Manager confirmed that all food in the walk-in refrigerator should have an open and discard date, acknowledging that foods past their discard dates could become spoiled and potentially expose residents to food-related illnesses. Despite the staff having up-to-date food safety certificates, this oversight occurred. Interviews with staff, including a dietary aide and the Director of Nursing (DON), highlighted the importance of proper food storage practices. The dietary aide emphasized the necessity of labeling leftover foods with opened and discard dates to prevent residents from consuming spoiled foods, which could lead to illness. The DON also noted that ingesting spoiled foods could cause food-borne illnesses or discomfort to residents. The facility's policy on frozen and refrigerated food storage, as well as the FDA Food Code, requires that refrigerated, ready-to-eat foods be clearly marked with the date they were opened and a discard date if held for more than 24 hours, which was not adhered to in this instance.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 13.33% due to four errors out of 30 opportunities. These errors involved three residents who did not receive their medications within the prescribed timeframes. Resident #28, a female with diabetes and chronic respiratory failure, did not receive her Glipizide and Benzonatate as ordered between 7:00 a.m. and 10:00 a.m. Resident #74, a male with hypertension and coronary artery disease, did not receive his Carvedilol within the scheduled timeframe. Resident #89, a male with diabetes, did not receive his Metformin as prescribed. The medication administration errors were observed on 2/18/2025, when MA A administered medications to the residents outside the scheduled timeframes. The medications appeared in red on the Medication Administration Record (MAR), indicating they were late. MA A acknowledged the delay, attributing it to running behind schedule, and expressed an understanding that medications should not be given too close together. The Assistant Director of Nursing (ADON) and Clinical Resource Nurse confirmed that medications should be administered within the designated window or the physician should be contacted to adjust the timing. Interviews with the Director of Nursing (DON) and the Medical Doctor (MD) highlighted the expectation that medications be administered within the scheduled window to avoid potential adverse events. The facility's policy, revised in 2015, mandates that medications be administered as prescribed by the attending physician. However, the medication error policy was not provided at the time of the survey exit, indicating a possible gap in policy adherence or availability.
Breach of Resident Confidentiality in LTC Facility
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records, specifically for one resident involved in a privacy investigation. The incident occurred when a resident's representative, assisting with the discharge of another resident, was inadvertently handed a document containing another resident's personal information. This document, identified as a face sheet, included sensitive details such as the resident's name, birthdate, social security number, and medical diagnoses. The Director of Nursing (DON) confirmed the breach after reviewing the documents in question, acknowledging that the incident likely occurred two years prior. Despite the DON's assertion that no similar incidents had occurred in the past 12 months, the facility's policy on Protected Health Information (PHI) management emphasizes the responsibility of all personnel to prevent unauthorized disclosure of resident information. The facility's failure to adhere to these policies resulted in the potential risk of exposure and misuse of the resident's personal information.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 11 residents. Observations revealed that multiple rooms had air-condition units with black dirt stains and thick dust build-up on the filters. Additionally, some rooms had stained mini-fridges, heavily soiled linens, and missing air filters. Interviews with residents indicated that housekeeping services were inadequate, with some residents reporting that their rooms had not been cleaned for several days. One resident mentioned that the lack of cleanliness exacerbated their sinus and allergy problems. Another resident reported that their sleep apnea machine was not being cleaned properly, despite previous complaints to the Director of Nursing (DON). Housekeeping staff acknowledged that certain areas might have been overlooked and that they faced challenges cleaning rooms of residents who exhibited aggressive behavior. The Housekeeping Supervisor confirmed that staff were trained to clean thoroughly, including air-condition units and mini-fridges, and that he conducted daily checks known as Angel rounds to ensure cleanliness. However, the observations indicated that these practices were not consistently followed, leading to an environment that could pose infection control concerns.
Failure to Ensure Residents Were Free from Unauthorized Physical Restraints
Penalty
Summary
The facility failed to ensure that three residents were free from physical restraints that were not required to treat their medical symptoms. Resident #14, who has quadriplegia and a history of falls, was observed with a scoop mattress without a physician's order or assessment. The Licensed Vocational Nurse (LVN) was unaware of the need for a physician's order or assessment for the scoop mattress, which was intended to assist with fall prevention. The Assistant Director of Nursing (ADON) also confirmed the absence of a physician's order and assessment for the scoop mattress, which was provided at the family's request without proper documentation or evaluation. Resident #63, who has Alzheimer's disease and severe cognitive impairment, was also observed with a scoop mattress without a physician's order or assessment. The LVN and ADON were unsure of the need for a physician's order or assessment, and the mattress was provided based on a family request. The Director of Nursing (DON) confirmed the lack of physician orders and assessments for the scoop mattress, indicating a misunderstanding of the facility's policy on restraint use. Resident #49, who has a history of repeated falls and severe cognitive impairment, was observed with a positioning wedge without a physician's order or assessment. The ADON and DON both confirmed the absence of proper documentation and evaluation for the use of the positioning wedge. The facility's policy on restraints requires a physician's written order and assessment, which were not followed in these cases, potentially putting the residents at risk of injury.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, two residents, one with bilateral leg amputations and another with severe cognitive impairment, did not receive their scheduled showers consistently. Records for January 2024 and December 2023 showed that both residents were scheduled to receive showers three times a week but were instead given bed baths on multiple occasions. Interviews with staff revealed inconsistencies in documentation and communication regarding the residents' refusal of showers and the subsequent actions taken by the nursing staff. Resident #1, a cognitively intact female with bilateral leg amputations, was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays. However, records indicated that she only received bed baths on the scheduled days. The resident expressed concerns about not receiving proper care and mentioned a fear of retaliation if she complained. Interviews with CNAs and LVNs revealed that the resident had refused showers on some occasions, but there was confusion about the proper documentation and follow-up procedures. The ADON confirmed that the resident was at risk of skin breakdown due to not receiving her scheduled showers. Resident #36, a male with severe cognitive impairment and on hospice care, was also scheduled to receive showers three times a week. However, records showed that he only received bed baths. The resident's family expressed concerns about the lack of showers and were told that a special shower chair was needed, which contradicted the facility's available resources. Interviews with hospice staff and facility administrators revealed a breakdown in communication and documentation, leading to the resident not receiving his scheduled showers. The DON acknowledged the issue and mentioned that the resident was at risk of skin breakdown due to the lack of proper hygiene care.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, leading to deficiencies in their treatment. Resident #14's nebulizer tubing was not changed within the facility's policy of 7 days, and there was no date indicating the last change. This oversight was confirmed during an observation on January 17, 2024, and was acknowledged by the Assistant Director of Nursing (ADON), who admitted that the tubing should have been changed on Wednesday nights by the night nurse and checked by the staff on Thursdays. The ADON also noted that missing the scheduled change could result in an infection. Resident #15's BiPAP machine was not properly cleaned and sanitized. The mask and tubing lacked a date indicating the last cleaning, and the resident's family member had previously raised concerns about the machine's maintenance. The Licensed Vocational Nurse (LVN) and ADON both confirmed that the machine should be cleaned nightly, and the lack of proper cleaning could lead to infection. Additionally, the resident's humidifier was found empty, which could cause nasal irritation. Resident #55's nebulizer mask was improperly stored and not dated, as observed during an interview with the resident. The mask was left on top of the nebulizer machine, which was not always clean. The Registered Nurse (RN) and ADON both acknowledged that the mask should be cleaned, bagged, and dated to prevent contamination. Similarly, Resident #67's humidifier was found without water, which could lead to nasal dryness and irritation. The Director of Nursing (DON) and ADON both confirmed that the humidifier should have water to moisten the nasal linings and prevent dryness. These deficiencies highlight the facility's failure to adhere to professional standards of practice and the residents' comprehensive care plans.
Failure to Re-Order Medications Timely
Penalty
Summary
The facility failed to ensure that four residents were provided medications and pharmaceutical services to meet their needs. Specifically, the facility did not re-order medications in a timely manner for Resident #3 (Clopidogrel Bisulfate 75 mg), Resident #12 (Gabapentin capsule 100 mg), Resident #56 (Oxcarbazepine 300 mg), and Resident #58 (Levothyroxine Sodium 25 mcg). This failure was observed during medication preparation and administration, where it was noted that the blister packs for these medications were either completely out or running low, indicating a lack of timely re-ordering by the staff responsible for medication management. Resident #3, a female with hemiplegia and hemiparesis following a cerebral infarction, was found to have no remaining Clopidogrel Bisulfate 75 mg tablets in her blister pack. Resident #12, a female with severe cognitive impairment and chronic pain due to osteoporosis and neuropathy, had only three Gabapentin capsules left. Resident #56, a female with major depressive disorder and bipolar disorder, had only one Oxcarbazepine 300 mg tablet left. Resident #58, a female with chronic kidney disease and hypothyroidism, had only two Levothyroxine Sodium 25 mcg tablets left. Interviews with CMA B and LVN N revealed that medications should be re-ordered when they reach the blue portion of the blister pack, but this procedure was not consistently followed. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the issue, stating that medications must be re-ordered in a timely manner to ensure residents have the necessary medications. The facility's policy requires medications to be re-ordered seven days in advance to maintain an adequate supply. The DON and ADON emphasized the importance of following this procedure to prevent residents from running out of essential medications, which could adversely affect their health. The facility planned to audit the medication carts and in-service the staff to reinforce the importance of timely medication re-ordering.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed that the ice machine in the facility's kitchen had rust on and inside the door hinges. Additionally, a gallon container of dill pickle relish in the walk-in refrigerator was dated but lacked a visible expiration date, and a large box of frozen chicken nuggets in the walk-in freezer was not sealed, exposing it to air-borne contaminants. These issues were identified during a survey conducted on 01/19/24 from 09:17 AM to 09:21 AM. Interviews with the Dietary Manager, Dietician, and Housekeeping Supervisor confirmed the deficiencies. The Dietary Manager and Dietician acknowledged the issues with the ice machine and food storage, stating that the cleaning of the ice machine was the responsibility of maintenance. The Housekeeping Supervisor confirmed that maintenance was responsible for cleaning the ice machine and admitted uncertainty about how to address the rust issue. The facility's policy on food storage and supplies, dated 2012, mandates that all storage areas be maintained in an orderly manner, with air-tight containers or bags for all opened packages of food, and accurate labeling with the item and date opened. The U.S. Food and Drug Administration (FDA) Code (2022) also requires that packaged food be labeled as specified in law and protected from contamination.
Failure to Obtain Informed Consent for Medication
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not obtain a signed informed consent for Resident #28 before administering Lamictal, a medication used to treat seizures and bipolar disorder. The resident, an [AGE] year-old female with Alzheimer's disease, was alert and oriented but was unaware that she was taking Lamictal or that it was being used to treat bipolar disorder. This oversight was identified during a review of the resident's medical records and confirmed through interviews with the resident and facility staff. The Assistant Director of Nursing (ADON) responsible for reviewing pharmacy recommendations admitted to overlooking the need for consent for Lamictal. The Director of Nursing (DON) confirmed that residents are supposed to give consent for medications and that it is the ADONs' responsibility to ensure these consents are obtained. The facility's policy on psychoactive medications consent, dated July 2014, requires that the use of such medications be explained to the resident or their legal representative and that consent be obtained. However, this policy was not followed in the case of Resident #28, leading to a violation of the resident's rights to be informed and to participate in their treatment decisions.
Failure to Ensure Call Lights Were Accessible
Penalty
Summary
The facility failed to ensure the call light system in the rooms of two residents was accessible, which could prevent them from obtaining assistance when needed. Resident #68, a male with secondary Parkinsonism and ataxic gait, was found with his call light on the floor behind the headboard, covered by a box. A CNA who entered the room did not notice the misplaced call light until it was pointed out, after which she cleaned it and placed it within the resident's reach. The resident's care plan specifically mentioned the importance of having the call light within reach due to his risk of falls and unsteady gait. Resident #236, a female with osteoarthritis and idiopathic neuropathy, was found with her call light hanging on the headboard, out of her reach. The resident was unaware of the call light's location. An ADON who observed the situation acknowledged that the call light was not accessible and moved it within the resident's reach. The resident's care plan also emphasized the need for the call light to be within reach due to her fall risk and muscle weakness. Interviews with the DON and ADON confirmed that the facility's policy required call lights to be within residents' reach to ensure they could communicate their needs. The DON stated that all staff were responsible for ensuring call lights were accessible and mentioned plans to audit the call light system. The facility's policies on accommodation of needs and call light procedures were reviewed, both of which mandated that call lights be within residents' reach before staff left the room.
Failure to Inform Resident on Grievance Filing Process
Penalty
Summary
The facility failed to ensure that Resident #71 knew how to file a grievance. Resident #71, a [AGE] year-old female with intact cognitive status and diagnoses including stroke and diabetes, reported that staff had called her a liar. She did not file a grievance about the issue because she did not know how to do so. This indicates that the facility did not provide adequate information to the resident on how to file a grievance, as required by their policy. Interviews with the Social Worker (SW) and the Operations Manager revealed that it was the SW's responsibility to ensure residents knew how to file grievances. The SW stated that she completed quarterly assessments with residents to inform them about the grievance process but was unaware of why Resident #71 did not know how to file a grievance. The facility's policy indicated that residents and/or families are informed of the grievance policy during the admission process, but this was not effectively communicated to Resident #71.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #44, who had severe cognitive impairment and a history of falls. The care plan, dated 05/16/23, specified that the resident should have a low bed with a fall mat due to her poor balance, unsteady gait, and poor safety awareness. However, during an observation and interview on 01/17/24, it was noted that while the resident's bed was low, there was no fall mat present. The resident was confused and unable to answer questions coherently. Further interviews revealed that the fall mat was left behind when the resident moved rooms. Both the ADON and DON confirmed that the fall mat was necessary to prevent injuries and that its absence posed a risk of increased severity of injury in the event of a fall. The DON mentioned that the facility was in the process of ordering a new mat as the one provided by Hospice was dirty. The facility's policy on care plans was reviewed, but it was not dated and did not provide specific guidance on ensuring the presence of fall mats as per individual care plans.
Failure to Ensure Clear Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that Resident #76, who required enteral feeding due to dysphagia following a cerebrovascular accident, had a clear physician order specifying the downtime for the feeding tube. The resident's care plan indicated the need for tube feeding, but the physician order only specified the duration of feeding (16 hours) without mentioning the specific downtime. This omission led to confusion among the nursing staff, as they were unsure when to stop and resume the feeding, potentially risking underfeeding, overfeeding, aspiration, and fluid overload for the resident. During an observation and interview, LVN N confirmed the absence of a downtime order and highlighted the risks associated with this lack of clarity. The Director of Nursing (DON) acknowledged the issue, stating that a clear order for downtime was necessary to ensure consistent care and prevent complications. The facility's policies on gastrostomy tube care and physician orders were reviewed, revealing that the orders should be accurately transcribed and verified, which was not adhered to in this case.
Failure to Follow Hand Hygiene Protocols
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff, leading to potential infection risks for two residents. In the first instance, the Assistant Director of Nursing (ADON) did not wash or sanitize her hands before applying a resting hand splint to a resident's right hand. The resident, a male with a history of cerebral infarction and hemiplegia, confirmed that he was supposed to wear the splint. The ADON acknowledged the lapse in hand hygiene and admitted that being busy was not an excuse for neglecting this critical practice. The Director of Nursing (DON) emphasized the importance of handwashing in preventing infection transmission and stated that staff are expected to wash their hands before and after every care activity. In the second instance, a Certified Nursing Assistant (CNA) failed to perform hand hygiene during incontinence care for a female resident with dementia and chronic kidney disease. The CNA did not change her gloves or wash her hands after cleaning the resident's peri-area and buttocks, and before applying cream and handling a clean brief. When questioned by the surveyor, the CNA admitted she should have performed hand hygiene but did not. The DON confirmed that staff are required to perform hand hygiene and change gloves during incontinence care to prevent infection spread. The facility's policy on hand hygiene underscores its importance in infection prevention and control.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,140 citations issued within 25 miles in the last 12 months — including the 22 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 Garland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Parks At Garland Healthcare And Rehab | 1 mi | ★★★★★ | 13 | 0 |
| Avir At Garland | 2.1 mi | ★★★★★ | 15 | 1 |
| Beltline Healthcare Center | 2.2 mi | ★★★★★ | 4 | 0 |
| Lindan Park Care Center Lp | 2.4 mi | ★★★★★ | 11 | 0 |
| Remington Transitional Care Of Richardson | 3.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.