Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Stallings Court Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia and no pressure injury on admission developed a right heel DTI after admission, and staff did not ensure ordered heel protectors were in place or that both heels were floated while she was in bed. Records and observations showed only one heel protector was being used at one point, both heels were touching the mattress, and the new heel injury was identified when no pressure-reducing devices were in place.
A resident with severe cognitive impairment, encephalopathy, and total dependence for toileting care received perineal care during which a CNA failed to follow the facility’s hand hygiene policy. The CNA cleaned the peri and rectal areas, handled a soiled brief, and then handled clean items such as a draw sheet and brief without performing hand hygiene between glove changes or after moving from contaminated to clean body sites, only washing hands after all care was completed.
Worn mechanical lift slings were left in use for three residents who required lift transfers. A resident with stroke-related hemiplegia and two residents with severe cognitive impairment were observed with slings underneath them that had faded loops, and one sling had an unreadable label. Staff stated faded colors, loose strings, rips, or tears could make a sling unsafe, while facility policy required worn or frayed slings to be discarded and the sling log directed inspection after each laundering.
Dish Machine Failed to Reach Required Sanitizing Temperature: A Dietary Aide observed the dish machine running below the manufacturer-required 120 degrees F wash-cycle temperature, reaching only 100 degrees F after multiple attempts. The Dietary Mgr and Maintenance Dir stated the hot water supply/heater was not keeping up with demand after laundry use, and the Administrator later confirmed the hot water heater had not been functioning properly. The machine later met the required wash temperature and 50 ppm chlorine rinse level.
The facility failed to ensure comprehensive care plans were developed by an interdisciplinary team, including a nurse aide and dietary staff, for four residents. Interviews revealed that the dietary manager often missed meetings due to staffing issues, and nurse aides did not participate. This lack of participation could hinder communication and collaborative goal-setting, as per the facility's care planning policy.
The facility failed to provide adequate hygiene and grooming care for several residents, including those with Parkinsonism, Alzheimer's, and dementia. A resident was found with wet linens, while others had unclean nails and teeth, and another had oily hair and body odor. Staff interviews revealed inconsistencies in care and documentation, highlighting a lack of proper attention to residents' daily living needs.
The facility failed to properly store and lock medications, including Fluticasone nasal spray found at a resident's bedside, and did not dispose of expired medications from carts and the medication room. Staff interviews revealed inconsistent checks for expired medications, and no residents were deemed safe to self-administer medications.
The facility failed to provide properly prepared pureed diets for three residents with dysphagia, leading to a deficiency. The residents required specific diet consistencies due to medical conditions, but the pureed food served was not of the necessary smooth texture. Observations and interviews revealed that the dietary staff did not adhere to the required standards, and the facility's policy on texture modification was not followed.
The facility failed to maintain a QAA Committee with required members and did not ensure quarterly meetings, as the Medical Director did not attend meetings in April, May, and July 2024, and no meeting was held in October 2024. The new Administrator was unaware of the policy for monthly meetings, leading to a risk of missing critical information for resident care.
A long-term care facility failed to maintain an effective infection prevention and control program. A CNA did not change gloves or perform hand hygiene during incontinent care for a resident, risking infection spread. Another CNA entered isolation rooms without PPE, misunderstanding the requirements for contact precautions. Despite training, these lapses in protocol adherence put residents at risk of exposure to infectious diseases.
A resident was not provided full privacy during incontinent care, as staff failed to pull the privacy curtain, leaving her exposed when a visitor entered the room. The resident, with moderately impaired cognition, expressed potential embarrassment. Staff interviews revealed oversight in maintaining privacy, despite facility policies emphasizing dignity and respect.
A resident with Parkinson's and limited mobility did not receive appropriate care to maintain mobility, as her prescribed hand splints were not applied. Despite a care plan and a list at the nurse's station, there was no system to ensure daily application of the splints, leading to a deficiency in care.
A resident with an indwelling catheter did not have the catheter secured with an anchor, as required by the facility's policy. This oversight occurred after the resident returned from the hospital, and staff acknowledged that securing devices were not routinely used unless requested. The resident's care plan did not address the need for catheter securement, leading to a deficiency in care.
The facility failed to remove worn mechanical lift slings from service, posing a risk of injury to two residents with cognitive and physical impairments. Observations showed that slings with faded loops were used during transfers, despite staff acknowledging that such wear indicated potential hazards. The facility's policy lacked guidance on inspecting slings for wear, contributing to the deficiency.
Failure to Offload Heels and Prevent a Right Heel Pressure Injury
Penalty
Summary
The facility failed to ensure a resident with a right heel pressure injury received the ordered pressure-relieving interventions and heel offloading while in bed. The resident was admitted with dementia, hypertension, and a history of deep vein thrombosis, and her admission skin assessment showed intact skin with no pressure injuries. Her care plan later identified an unstageable deep tissue injury to the right heel and included heel protectors as an intervention. The physician’s wound orders also directed daily wound care for the right heel wound. On observation, the resident was found in bed with a pillow under her knees, one heel protector on her right foot, and both heels touching the mattress. The resident’s RP stated the wound had been present since the heel injury was identified. The CNA assigned to the resident said the facility instructed staff to place heel protectors on both feet and keep the heels floating, but only one heel protector was in use because the other had been thrown away after becoming dirty. The Treatment Nurse confirmed the resident was supposed to have two heel protectors and that her heels should not be on the mattress. The facility also failed to prevent the development of the right heel deep tissue injury after admission. The weekly skin assessment documented a new open area to the right heel on the date the injury was first identified, with no pressure-reducing devices in place at that time. Subsequent records showed the wound persisted and was later described as an unstageable wound of the right heel. The facility’s policy stated that when a resident is in bed, every attempt should be made to float the heels by placing a pillow from knee to ankle or with other devices as recommended and prescribed.
Improper Hand Hygiene and Glove Use During Perineal Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper infection prevention and control practices during incontinent and perineal care for one resident. The resident was an elderly female with encephalopathy, severely impaired cognition (BIMS score of 7), and total dependence on staff for toileting hygiene, with continuous bowel and bladder incontinence. During an observation of perineal care, the CNA entered the room and washed her hands, then donned gloves and unfastened the resident’s brief to clean the peri-area. After cleaning the peri-area, the CNA rolled the resident, removed the soiled brief, and disposed of it in a trash bag while still wearing the same contaminated gloves. The CNA then removed those gloves and applied new gloves without performing hand hygiene. She proceeded to clean the resident’s rectal area and, without removing those now-contaminated gloves, retrieved a clean draw sheet and placed it under the resident along with a clean brief, then repositioned and refastened the brief while still wearing the same gloves used for rectal care. Hand hygiene was only performed after all care was completed, when the CNA removed her gloves, tied the trash bag, and washed her hands before exiting the room. In an interview, the CNA acknowledged she did not perform hand hygiene between glove changes, was unsure if she changed gloves between cleaning the rectal area and handling clean items, and stated she knew she was supposed to use sanitizer when changing gloves. Facility policy required hand hygiene before moving from a contaminated body site to a clean body site and after removing gloves, which was not followed in this instance.
Worn mechanical lift slings left in use
Penalty
Summary
The facility failed to ensure the residents’ environment remained as free of accident hazards as possible when worn and damaged mechanical lift slings were left in use for 3 of 17 residents reviewed. Resident #19 was a cognitively intact male with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and he was dependent for transfers with assistance of 2 staff members using a mechanical lift. Resident #38 was a female with acute and chronic respiratory failure with hypercapnia and severe cognitive impairment, and she required substantial to maximum assistance for transfers. Resident #40 was a female with intracranial injury without loss of consciousness, had severe cognitive impairment, and was dependent for transfers. Their care plans each identified the need for 2 staff members and a mechanical lift for transfers. During observations, Resident #19 was seen in a geri-chair with a mechanical lift sling underneath him with loops that were faded in color. Resident #38 was seen in a wheelchair with a mechanical sling underneath her with faded loops and an unreadable label. Resident #19 and Resident #40 were later observed in activities, both up in geri-chairs with mechanical slings underneath them with loops that were faded in color. CNA B stated that faded colors or loose strings could make a sling unsafe and could cause a resident to fall and get hurt. The DON stated residents could get hurt if transferred using an unsafe sling and said she looked for faded colors, loose strings, rips, and tears. The Laundry Aide stated she would set aside any sling with rips, tears, fading, or loose strings for possible removal from service, and the Administrator stated the laundry supervisor was responsible for checking the slings and removing them from service. The facility policy required equipment to be in good condition and directed staff to discard worn, frayed, or ripped slings, and the sling log stated the Laundry Aide should inspect for rips, tears, frays, or discoloration after each laundering.
Dish Machine Failed to Reach Required Sanitizing Temperature
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed because the dish machine did not reach the required wash-cycle temperature of 120 degrees Fahrenheit during operation on 02/04/2026. During an initial observation at 09:00 a.m., a Dietary Aide was running the dish machine after breakfast and checked the gauge for compliance with the manufacturer’s requirement. After 4 attempts, the temperature reached only 100 degrees Fahrenheit. The aide stated the machine had been tested earlier that morning and had reached 120 degrees Fahrenheit for the wash cycle and 50 ppm hypochlorite in the final rinse. During interviews, the Dietary Manager stated he would contact Maintenance because the morning load at the facility was pulling down the hot water supply, and the facility would use disposable products until the dish machine reached the required temperature. The Maintenance Director stated he had adjusted the hot water heater and the dish machine after laundry had been done that morning and that the heater was not keeping up with demand. Later that morning, at 11:30 a.m., the dish machine met the required 120 degrees Fahrenheit during the wash cycle and 50 ppm hypochlorite in the final rinse. The Administrator later stated the hot water heater had not been functioning properly and a new part had been ordered to repair it.
Deficiency in Interdisciplinary Care Planning
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was prepared by an interdisciplinary team for four residents, which included the participation of a nurse aide responsible for the resident and a member of the food and nutrition services staff. This deficiency was identified during a review of care plans for residents with varying degrees of cognitive impairment and medical conditions such as senile degeneration of the brain and cerebral infarction. The care plan conferences for these residents lacked evidence of attendance by the dietary manager and the responsible nurse aide. Interviews with facility staff revealed that the dietary manager did not consistently attend care plan meetings due to staffing challenges, often working in the kitchen during these times. The MDS Coordinator and the Director of Nursing confirmed that the dietary manager attended only about half of the meetings, and certified nurse aides did not participate in the care conferences. The Director of Nursing and the Social Worker acknowledged that the absence of these team members could hinder communication of changes in residents' conditions and the collaborative goal-setting process. The facility's policy on care planning, revised in September 2013, mandates that the care plan be developed by an interdisciplinary team, including the dietary manager and nursing assistants responsible for the resident's care. The Administrator recognized the risk of not having all required team members present, as it could impede effective communication and the ability to maintain residents' highest level of functioning.
Deficiencies in Resident Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide adequate care for residents who were unable to perform activities of daily living, resulting in deficiencies in personal hygiene and grooming. Resident #37, who had diagnoses including Parkinsonism and major depressive disorder, was found with wet and yellow-stained linens, indicating a lack of proper incontinence care. Despite being scheduled for a shower, the resident reported frequent occurrences of being left on wet linens, which were not changed promptly by the staff. Interviews with staff revealed inconsistencies in the care provided, with some staff unaware of the incident and others acknowledging the risk of skin breakdown from such neglect. Resident #34, diagnosed with Alzheimer's, was observed with long, dirty fingernails and unbrushed teeth, despite requiring maximum assistance with personal hygiene. The resident expressed a desire for her nails to be cleaned and her teeth brushed, highlighting a failure in the facility's responsibility to maintain her grooming and oral hygiene. Similarly, Resident #48, who had dementia, was found with long, dirty fingernails and reported infrequent cleaning by the staff. Interviews with CNAs and LVNs confirmed that nail and mouth care were not consistently provided, which could lead to infections and other health issues. Resident #69, with a history of cerebral infarction and dementia, was noted to have oily hair and body odor, indicating a lack of regular bathing. Although the resident was scheduled for showers, there was no documentation of refusals, and staff interviews revealed a lack of proper documentation and follow-up on the resident's care. The facility's failure to ensure proper hygiene and grooming for these residents could result in poor care outcomes and health risks, as noted by the staff and administration during interviews.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls. This deficiency was observed in two of three medication carts, one medication room, and involved one resident. Specifically, the facility did not properly store and lock Fluticasone nasal spray for a resident, as it was found at her bedside without being in a box or locked compartment. The resident, who had Alzheimer's Disease and other health conditions, was not care planned to self-administer her nasal spray, yet it was left accessible in her room. Additionally, the facility failed to dispose of expired medications from the medication aide and nurse medication carts, as well as the medication room. Expired items included Juven nutrition powder, Glucerna, phenylephrine hcl, I-caps, gas relief, and Geri Lanta. These expired medications were found during observations and interviews with staff, who acknowledged the oversight and the potential risk of sickness if residents consumed expired medications. Interviews with various staff members, including the ADON, RN, and DON, revealed that there was a lack of consistent checks on medication carts and rooms for expired medications. The staff admitted that medications should not be stored at the bedside and that no residents were deemed safe to self-administer medications. The facility's policy on medication storage was not adhered to, as it requires drugs and biologicals to be stored in a safe, secure, and orderly manner, and prohibits the use of outdated or deteriorated drugs.
Failure to Provide Properly Prepared Pureed Diets
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of three residents who required pureed diets. The deficiency was identified during an observation, interview, and record review process. The residents involved had medical conditions such as dysphagia, aphasia, and cerebral infarction, which necessitated a pureed diet to prevent choking and ensure adequate nutritional intake. Despite these requirements, the facility did not prepare the pureed diet to the necessary consistency for these residents. Resident #27, a female with moderate cognitive impairment and dysphagia, was on a low sodium, dysphagia pureed level 1 regular diet. Resident #12, a male with severe cognitive impairment and dysphagia, was on a 2 Gram sodium, dysphagia pureed level 1 regular diet with honey consistency. Resident #24, a female with moderate cognitive impairment and dysphagia, was on a regular, dysphagia pureed level 1 diet. During a test tray observation, the pureed pork served was found to be chewy and not of the smooth, pudding-like consistency required for a pureed diet. Interviews with the facility's dietary staff revealed a lack of adherence to the required pureed food consistency. The Dietary District Manager and Dietary Manager acknowledged the issue and stated that an in-service training was initiated to address the correct preparation of pureed foods. The Administrator, who had been in her position for one month, also recognized the need for proper consistency in pureed diets and planned to involve speech therapists and dieticians in monitoring the situation. The facility's policy on texture modification emphasized that all foods must be pureed to a mousse-like texture, which was not followed in this instance.
Failure to Maintain QAA Committee and Conduct Meetings
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) Committee with the required members and did not ensure that the committee met quarterly as mandated. Specifically, the Medical Director did not attend the QAA and Quality Assurance and Performance Improvement (QAPI) meetings for the months of April, May, and July 2024. Additionally, there was no record of a QAA/QAPI meeting for October 2024. This lack of attendance and failure to hold meetings could lead to quality deficiencies going unidentified and no appropriate plans of action being developed or implemented. The facility's policy, dated July 2016, required the establishment and maintenance of a QAPI Committee that oversees the implementation of the QAPI program, with the Medical Director as a member. However, the review of the facility's QAA/QAPI meeting signature logs revealed that the Medical Director or their designee did not sign the attendance sheets for the specified months, nor was there any indication of their participation via remote means. Furthermore, the newly appointed Administrator, who started in October 2024, was unaware of the facility's policy for monthly meetings and had not conducted any meetings since taking over. This oversight in maintaining the committee and conducting regular meetings poses a risk of missing critical information necessary for resident care.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA C and CNA H. CNA C did not change gloves or perform hand hygiene during the provision of incontinent care for a resident with bowel and bladder incontinence. This resident, who had moderately impaired cognition and was dependent on staff for toileting, was at risk of infection due to the improper handling of soiled materials. Despite being recently trained and checked off on infection control procedures, CNA C acknowledged the mistake and the potential for spreading infections. Additionally, the facility did not ensure that CNA H adhered to proper infection control protocols when entering isolation rooms. CNA H entered the rooms of two residents on contact isolation precautions without donning the required personal protective equipment (PPE). One resident was on isolation due to an intraspinal abscess and sepsis, while the other had infective endocarditis and sepsis. CNA H mistakenly believed PPE was only necessary for direct care, not for tasks like delivering meal trays, which led to potential cross-contamination. The facility's policies on infection prevention and control, as well as isolation procedures, were not effectively implemented by the staff. Despite having received training, both CNAs failed to follow the established protocols, putting residents at risk of exposure to infectious diseases. The Director of Nursing and the Assistant Director of Nursing were responsible for ensuring staff competency in infection control, yet lapses in adherence to these protocols were observed.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure that Resident #11 was treated with respect and dignity by not providing full privacy during incontinent care. On November 18, 2024, CNA C and the ADON entered Resident #11's room to provide care but did not pull the privacy curtain on the door side, leaving the resident exposed. A visitor entered the room during this time, further compromising the resident's privacy. Resident #11, who has moderately impaired cognition and is dependent on staff for toileting, expressed that she would feel embarrassed if someone saw her naked. Interviews with the staff involved revealed that CNA C, who had been at the facility for one year, did not notice the curtain was not pulled, acknowledging that this oversight could lead to the resident being exposed and embarrassed. The ADON, responsible for staff competency checks, admitted that the privacy curtain should have been pulled to ensure the resident's dignity. The DON and the Administrator both emphasized the importance of maintaining resident privacy and dignity, stating that all staff are responsible for ensuring these rights are upheld. The facility's policy on dignity, dated October 2009, mandates that residents be treated with dignity and respect, including maintaining bodily privacy during personal care.
Failure to Ensure Use of Hand Splints for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited mobility, specifically in ensuring the use of hand splints to prevent contractures. Resident #14, an elderly female with Parkinson's disease and moderately impaired cognition, was observed without her prescribed hand splints on multiple occasions. The resident's care plan required the application of a hand splint and palm protector, but these were not in place during observations. Interviews with staff revealed a lack of clarity and responsibility regarding who should apply the splints, with CNAs, nurses, and restorative aides all mentioned as responsible parties. The facility's Director of Nursing (DON) and other staff acknowledged the absence of a system to ensure the daily application of necessary devices like splints. Despite a list at the nurse's station indicating which residents required such devices, there was no oversight to confirm their use. The facility's policy on contracture management emphasized the importance of splinting devices to prevent further contractures, yet this was not adhered to, leading to the deficiency noted in the report.
Failure to Secure Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, which could lead to urinary tract infections and other complications. The resident, a male with moderately impaired cognition, had an indwelling catheter and was always incontinent of bowel. The comprehensive care plan for the resident did not include securing the catheter with an anchor, which is a necessary intervention to prevent the catheter from pulling and causing potential harm. During observations and interviews, it was noted that the resident's catheter was not secured with a device, and staff members acknowledged the oversight. The Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) admitted that the use of anchors was not standard practice unless requested by residents, and the oversight occurred because the resident had recently returned from the hospital. The facility's policy on catheter care, which includes securing the catheter with a leg band, was not followed, leading to the deficiency.
Failure to Remove Worn Lift Slings Poses Risk
Penalty
Summary
The facility failed to ensure the residents' environment was free from accident hazards by not removing worn and damaged mechanical lift slings from service. Observations revealed that two residents, both with significant cognitive and physical impairments, were using mechanical lift slings with faded colored loops, indicating wear and tear. These slings were used during transfers, posing a risk of injury to the residents. Interviews with CNAs confirmed that faded slings were a sign of wear and should not be used, as they could lead to falls. The facility's policy did not address the inspection of slings for wear and tear before use. The Director of Nursing (DON) and other staff acknowledged that unsafe slings could result in residents falling. The facility's in-service training and skills validation forms indicated that staff had been trained on the use of mechanical lifts, but the policy lacked specific guidance on inspecting slings. The guidance from an external source emphasized the importance of inspecting slings for signs of wear, such as color fading, which was not adequately addressed in the facility's practices.
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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 Nacogdoches
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willowbrook Nursing Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Westward Trails Nursing And Rehabilitation | 2.4 mi | ★★★★★ | 1 | 0 |
| Garrison Nursing Home & Rehabilitation Center | 15 mi | ★★★★★ | 0 | 0 |
| Wells Ltc Nursing & Rehabilitation | 20.5 mi | ★★★★★ | 17 | 4 |
| Southland Rehabilitation And Healthcare Center | 21.7 mi | ★★★★★ | 9 | 0 |
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