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 Rowlett Health And Rehabilitation Center during CMS and state inspections, most recent first.
Unsanitary resident rooms and dining room serving table. Multiple resident rooms on one hall had dirty AC vents, dust, stained shower floors, dirt buildup in bathrooms, stained privacy curtains, and unclean furniture, while the dining room serving table had visible black and brown stains. Housekeeping and the HS acknowledged the areas were their responsibility, and the Administrator stated the conditions did not present a homelike environment.
Food storage and kitchen sanitation deficiencies were identified in the facility's only kitchen. Surveyors observed unlabeled frozen chicken nuggets and dry goods, expired honey mustard dressing that had not been discarded, an uncovered tea dispenser, and dirt/stains in the ice machine and ice scoop holder. The Dietary Mgr stated labeling, dating, discarding expired food, and cleaning equipment were her responsibility, and the Admin stated he expected the kitchen to follow state guidelines.
Call lights were not kept within reach for two residents with severe cognitive impairment and significant mobility needs. One resident with Alzheimer's disease and unsteadiness on feet had her call light on the floor beside the bed, and another resident with hemiplegia after a stroke had her call light on the floor behind the roommate's bed. CNAs, the ADON, and the DON stated the call lights should have been within reach.
Respiratory equipment was left uncovered for two residents who needed suctioning and oxygen therapy. One resident’s yankauer suction tip was sitting on a nightstand instead of being stored in a bag, and another resident’s oxygen tubing was looped over the concentrator rather than bagged. An LVN, ADON, and DON all stated the items should have been covered when not in use to prevent contamination.
A resident with dementia and total bowel and bladder incontinence was observed receiving incontinent care when a CNA used gloves from her scrub pocket, failed to change gloves and perform hand hygiene between tasks, and blew on her hands to dry sanitizer before putting on clean gloves. The CNA later acknowledged the improper practices, and the DON and LVN stated the care should have followed infection control measures to prevent contamination.
The facility's kitchen failed to meet professional standards for food service safety, with unlabeled and undated food items in the refrigerator and freezer, and unsanitary conditions observed in the ice machine scoop holder and storage bins. These deficiencies could risk cross-contamination and airborne illnesses.
The facility failed to provide a clean and safe environment in several resident rooms, with issues such as dirty air conditioning units, dusty air filters, and grime in bathrooms. Interviews revealed a lack of coordination between housekeeping and maintenance staff regarding cleaning responsibilities.
A resident with mobility and cognitive impairments was unable to access her call light due to it being pinned between the bed and the wall, contrary to her care plan and facility policy. Staff interviews revealed a lack of awareness and adherence to ensuring call lights are within reach, resulting in the resident relying on her roommate's call light for assistance.
Two residents with COPD and respiratory failure experienced deficiencies in respiratory care due to improper storage of nebulizer masks and nasal cannulas, and lack of physician's orders for oxygen administration. Observations showed equipment was left unbagged, risking contamination, while interviews confirmed the absence of necessary orders and care plans, violating facility policies.
A CNA in an LTC facility failed to follow proper infection control procedures while providing incontinent care to two residents with hemiplegia and cognitive impairments. The CNA did not wash hands before donning gloves, failed to change gloves or sanitize hands after cleaning the residents, and used a brief that fell on the floor. These actions were against the facility's infection control policies, which emphasize hand hygiene to prevent cross-contamination.
A resident with severe cognitive impairment was found to have a scoop mattress without physician orders or assessment, contrary to facility policy. Staff interviews revealed the mattress was left in place after the resident changed rooms, and the oversight was acknowledged by the DON.
Unsanitary resident rooms and dining room serving table
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for 10 resident rooms on the 500 hall and for the dining room serving table. During observation, the dining room serving table used for drinks and condiments had black and brownish stains along the front, side, and bottom portions of the table. Multiple resident rooms also showed unsanitary conditions, including dark dirt stains on and between air conditioning vents, dust in air filters, dirt buildup in bathroom corners and behind toilets, stained shower floors, and stained or dusty furniture surfaces. Additional observations in the resident rooms included a bathroom wastebasket with no trash bag and brownish stains and dried dirt inside, a privacy curtain with large brownish stains on both sides, a roll of tissue paper lodged between bathroom lights, and a shower wall with dried cement plastered along the bottom and corner. One room also had a slightly separated air conditioning unit cover. The observations were made across rooms #1 through #10 on the 500 hall, with the noted conditions documented in several of those rooms. Housekeeping staff stated they were responsible for cleaning the resident rooms, bathrooms, air conditioning units, furniture, and privacy curtains, but they did not use a checklist when cleaning the rooms. The housekeeping supervisor stated staff were responsible for cleaning the floors, wiping surfaces, and cleaning the bathrooms, and acknowledged the observed concerns. The Administrator stated the areas should have been cleaned by housekeeping and said the concerns did not present a homelike environment. The facility policy stated resident rooms are to be cleaned regularly and includes sweeping and mopping, disinfecting high-touch surfaces, properly cleaning and disinfecting restrooms, and changing or picking up trash from receptacles.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. During observation on 07/22/25, surveyors found one zip lock bag of frozen chicken nuggets in the freezer that was not labeled with the date stored, packages of hot dog buns, hamburger buns, and white bread in the dry storage area that were not labeled with the date stored, and a large container of honey mustard dressing in the refrigerator with a disposal date of 6/17/25 that had not been discarded. A large tea dispenser in the kitchen area contained tea but did not have a lid placed on top to avoid airborne contaminants. Surveyors also observed the ice machine had stains and dirt particles along the door openings and inside the door, and the ice scoop holder hanging on the wall had brown dirt particles on the inside bottom. During interview, the Dietary Manager stated she was responsible for ensuring food was labeled and dated and that expired food was discarded, but the items noted had been overlooked. She also stated the ice machine was cleaned at least once a week by the night team and that they should have cleaned the ice scoop holder as well. The Administrator stated he had been briefed on some of the concerns and expected the kitchen to follow state guidelines.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure the call light system was within reach for two residents, Resident #76 and Resident #79, both reviewed for reasonable accommodation of needs. Resident #76 was a female with diagnoses including Alzheimer's disease and unsteadiness on feet. Her quarterly MDS reflected severely impaired cognition with a BIMS score of 0, and her care plan identified her as at risk for falling related to impaired mobility and impaired cognition. During an observation, she was lying in bed with the bed in the lowest position, her recliner was beside the bed, and her call light was on the floor on the opposite side of the recliner and not within reach. She was unable to answer further questions because of her cognitive status, and a CNA stated the call light should have been placed within reach. Resident #79 was a female with diagnoses including hemiplegia following a stroke, cognitive communication deficit, and need for assistance with personal care. Her quarterly MDS reflected severely impaired cognition with a BIMS score of 0, and her care plan identified her as at risk for falling related to reduced mobility and a stroke with hemiplegia. During an observation, she was lying in bed asleep with the bed in the lowest position, and her call light was on the floor behind the roommate's bed and not within reach. A CNA stated all residents should have their call light within reach, and the ADON and DON both stated the call light should have been in reach for these residents.
Respiratory equipment left uncovered when not in use
Penalty
Summary
The facility failed to ensure that respiratory care equipment was stored appropriately when not in use for two residents who required respiratory support. One resident had diagnoses including cerebral infarction, dysphagia, and hemiplegia, was receiving hospice services, and had an order for oral suction as needed for increased secretions. During an observation, the resident’s suction machine was on the nightstand, and the yankauer suction tip was lying on the nightstand behind the machine rather than being stored in a bag. During interview, an LVN stated the suction tip should have been covered and explained that if it were touched or sneezed on, it could become contaminated and place the resident at risk for infection. The DON later stated the yankauer suction tip should have been stored in a bag and that, if it was not frequently used, staff could have placed a new sealed yankauer suction tip next to the machine in case it was needed. The resident’s care plan reflected hospice services and interventions to work with hospice to meet physical needs, control symptoms, and provide maximum comfort. A second resident had diagnoses including COPD, hypertension, acute respiratory failure, and difficulty walking, and had an order for oxygen at 3 liters continuous via nasal cannula. During observation, the resident was receiving oxygen through a nasal cannula, the concentrator was set at 3 liters, and the wheelchair beside the bed had a portable oxygen tank on the back. The oxygen tubing was connected to the concentrator and looped over the top of it rather than being bagged. An LVN stated the tubing should have been stored in a bag because it was not in use, and the ADON and DON both stated respiratory tubing should be bagged when not in use to prevent contamination and infection.
Infection Control Lapses During Incontinent Care
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident observed for infection control. Resident #78 was a female with diagnoses including dementia and a need for assistance with personal care. Her quarterly MDS assessment reflected severely impaired cognition with a BIMS score of 0, and she was always incontinent of bowel and bladder. Her care plan identified her as at risk for pressure ulcer related to bowel and bladder incontinence and directed staff to immediately notify the nurse of any new area of skin breakdown noted during bath or daily care. During an observation of incontinent care, CNA E prepared to provide care to Resident #78, explained the care, and pulled the curtain for privacy. She used hand sanitizer, removed two gloves from her scrub top pocket, and put them on before beginning care. While cleaning the resident, she did not change gloves or perform hand hygiene after cleaning the front of the brief and before continuing care. She then placed the resident's right hand, which had been used during cleaning, on the bed rail while turning the resident. After cleaning the resident's bottom, she removed her gloves, used hand sanitizer, pulled gloves from her pocket again, softly blew on her hands to dry the sanitizer, and put on the clean gloves. CNA E later stated she should have removed her gloves and used hand sanitizer after cleaning the resident, should not have blown on her hands to dry the sanitizer, and should not carry gloves in her pockets because they can get contaminated.
Deficiencies in Food Storage and Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. During an inspection, it was noted that food items in the refrigerator and freezer were not labeled and dated according to guidelines. Specifically, a large bag of breadsticks and a bag of pretzels were found with incomplete labeling, missing the year, which is against the facility's policy. Additionally, ten large frozen tubes of meat were found unlabeled and undated, lacking any visible indication of the type of meat or the date they were received. Further observations revealed unsanitary conditions in the kitchen, including an ice machine scoop holder with black stains and storage bins for sugar and flour with black dirt stains and black particles in the sugar. Medium storage bins for brown sugar and rice also had black dirt stains. These deficiencies in food storage, labeling, and kitchen sanitation could potentially place residents at risk for cross-contamination and airborne illnesses.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in several rooms, as observed during a survey. Specifically, rooms #511, #513, #515, #517, #519, and #522 were found to have air conditioning units with dirt particles and grime, thick layers of dust on air filters, and bathroom floors with built-up dirt and grime. Additionally, some rooms had other issues such as non-functional lights, calcium deposits on faucets, and stained nightstands. These conditions were identified through observations and interviews with staff, indicating a lack of proper cleaning and maintenance. Interviews with housekeeping and maintenance staff revealed a lack of clarity and coordination regarding responsibilities for cleaning air conditioning units and filters. Housekeeping staff mentioned that they were instructed to clean the outer parts of the units, while maintenance was responsible for changing air filters quarterly. However, both departments acknowledged the need for better coordination to ensure thorough cleaning. The facility's policy on maintaining a safe and comfortable environment was not effectively implemented, as evidenced by the unsanitary conditions observed in the resident rooms.
Inaccessible Call Light System
Penalty
Summary
The facility failed to ensure that the call light system in a resident's room was accessible, which is a violation of the resident's right to reasonable accommodation of needs and preferences. The resident, an elderly female with difficulty walking, unsteadiness, and weakness, was observed to have her call light pinned between the bed and the wall, making it inaccessible. Despite the resident's limited range of motion and moderate cognitive impairment, the call light was not repositioned to be within her reach, as required by her care plan. Interviews with staff, including a CNA and the DON, revealed that the staff did not notice the call light's inaccessibility, and the CNA admitted responsibility for ensuring call lights are accessible. The facility's policy mandates that call devices be within the resident's reach before leaving the room, but this was not adhered to, leading to the deficiency. The resident expressed reliance on her roommate's call light due to the inaccessibility of her own, highlighting the oversight in ensuring her needs were met.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the storage and administration of respiratory equipment. Resident #321, a female with chronic obstructive pulmonary disease (COPD) and acute respiratory failure, had her nebulizer mask and nasal cannula improperly stored. Observations revealed that the mask was left unbagged on a side table, and the nasal cannula was hanging from the back of her wheelchair, touching potentially contaminated surfaces. Interviews with staff confirmed that these items should have been bagged to prevent contamination and infection. Resident #322, also diagnosed with COPD and chronic respiratory failure, had no physician's order for oxygen administration, which is necessary for ensuring proper respiratory care. The resident's nasal cannula was found hanging unbagged on an oxygen concentrator, and there was no care plan in place for oxygen administration. Interviews with the LVN and DON highlighted the lack of a physician's order, which is crucial for meeting the resident's respiratory needs and ensuring staff are aware of the required care. The facility's policies on oxygen administration and physician's orders were not followed, as evidenced by the improper storage of respiratory equipment and the absence of necessary physician's orders. These failures could lead to respiratory infections and unmet respiratory needs for the residents involved. The staff, including the DON, acknowledged the importance of proper storage and the need for physician's orders to ensure consistent and safe respiratory care.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA D during the provision of incontinent care to two residents. Resident #49, a male with hemiplegia and severe cognitive impairment, was observed during a transfer from a shower chair to bed. CNA D did not wash his hands before putting on gloves, failed to change gloves or sanitize hands after cleaning the resident's bottom, and handled clean items such as a new brief without proper hand hygiene. This lack of adherence to infection control protocols could lead to cross-contamination and infection. Similarly, Resident #89, also a male with hemiplegia and severe cognitive impairment, was observed during a transfer to a wheelchair. CNA D again did not wash his hands before donning gloves, failed to change gloves or sanitize hands after cleaning the resident, and used a brief that had fallen on the floor. These actions were contrary to the facility's infection control policies, which emphasize hand hygiene as a primary means to prevent the spread of infections. Interviews with CNA D, the DON, and LVN A confirmed the lapses in infection control practices. CNA D acknowledged the failure to follow proper procedures, while the DON and LVN A reiterated the importance of hand hygiene and glove changes to prevent cross-contamination. The facility's policies clearly outline the necessity of hand hygiene before and after resident contact, after glove removal, and when transitioning from contaminated to clean areas during care.
Failure to Obtain Physician Orders for Scoop Mattress
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not obtain physician orders or assess a resident for the use of a scoop mattress before its installation. This oversight was identified during a record review and observations, which revealed that the resident, who had severe cognitive impairment and required moderate assistance for activities of daily living, was using a scoop mattress without the necessary physician orders. Interviews with facility staff, including an LVN and the DON, confirmed that the resident had been moved to a new room, and the scoop mattress was inadvertently left in place without proper assessment or orders. The LVN acknowledged that the resident was independent in bed mobility and should not have had a scoop mattress, while the DON admitted that the mattress was not changed when the resident was relocated. The facility's policy on physician orders emphasizes that physical restraints, such as a scoop mattress, should only be used to treat medical symptoms and require prior assessment and orders, which were not obtained in this case.
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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 Rowlett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beacon Harbor Healthcare And Rehabilitation | 0.3 mi | ★★★★★ | 2 | 0 |
| Rockwall Nursing Care Center | 3.2 mi | ★★★★★ | 10 | 1 |
| Broadmoor Medical Lodge | 4.2 mi | ★★★★★ | 5 | 0 |
| Highland Meadows | 4.9 mi | ★★★★★ | 10 | 0 |
| Pleasant Valley Healthcare And Rehabilitation Cent | 5.6 mi | ★★★★★ | 1 | 0 |
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