Above 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 The Parks At Garland Healthcare And Rehab during CMS and state inspections, most recent first.
A facility failed to provide a private meeting space for Resident Council meetings. Residents stated their meetings were held in a Private Dining Room that opened to the Dining Room and did not have doors to ensure privacy, and some meetings were disrupted when staff entered the area. The ADON, SW, CNA, and Administrator acknowledged the lack of privacy and stated they were unaware the meetings needed a secured area with doors.
Grievance Forms Not Available for Anonymous Filing: The facility failed to ensure residents could file grievances anonymously. A resident with dementia and moderately impaired cognition stated grievance forms were kept at the Nurses’ Station and she did not know how to file anonymously. Other residents reported concerns about staff viewing grievances and feared retaliation, while staff confirmed forms were only available at the Nurses’ Station and completed forms were placed in the same basket as blank forms. The facility policy stated grievances may be filed anonymously.
Incomplete Discharge Summary: A resident admitted for hospice-arranged respite care and later discharged home did not have a discharge summary completed in PCC. The SW stated she was responsible for opening and closing the discharge summary and notifying the IDT, but confirmed it was not done and did not know why. The facility policy reviewed did not address the requirement for a discharge summary for routine discharge.
Staff failed to wear required gown and glove PPE while providing incontinent care and transferring a resident on EBP for wounds. The resident was incontinent, required max assist with toileting, and had multiple wounds. CNA A, CNA B, and an LVN did not use gowns during care and a hoyer lift transfer, despite the resident’s care plan and door posting indicating gown and glove use for high-contact care activities.
Staff failed to promptly deliver meal trays to residents, resulting in food being served at improper temperatures. Multiple residents and staff reported that meals were often cold, especially for those eating in their rooms. Observations confirmed that food lost its appropriate temperature during the delay between cart delivery and tray distribution, contrary to facility policy requiring prompt service.
A resident with severe cognitive impairment and multiple chronic conditions was found to have 11 missing Soma tablets from her prescribed medication supply. Staff discovered discrepancies and alterations in the medication count sheets, and the missing medication could not be accounted for after thorough checks. One agency nurse who had access during the relevant period could not be reached for clarification, and the resident was unable to provide information due to confusion.
A resident with multiple complex diagnoses and severe cognitive impairment continued to receive habilitation services, but the facility failed to submit required PASRR NFSS documentation in the LTC online portal within the mandated timeframe following IDT meetings. This lapse occurred during a change of ownership when staff lost portal access and did not seek timely resolution, resulting in noncompliance with regulatory requirements for PASRR service coordination and documentation.
The facility failed to ensure food safety standards were met as the Dietary Manager and Environmental Director did not wear beard coverings while handling food, risking contamination. Despite having beard coverings available, they were not used, violating both the facility's sanitation policy and the Federal Food Code.
Resident Council Meetings Held Without Private Space
Penalty
Summary
The facility failed to provide a private meeting space for residents attending the monthly Resident Council Meeting. During an interview, the Activities Director stated that the confidential Resident Council meeting with residents and the State Surveyor would not be held in the Private Dining Room where the monthly meetings were normally held, and instead would be held in an empty resident room for privacy. A confidential group meeting was then held in an empty resident room on the 100 Hall with 7 residents who regularly attended the monthly Resident Council meetings. During that confidential group meeting, the residents stated that their monthly Resident Council meetings were held in the Private Dining Room adjacent to the Dining Room. They described the area as a room connected to the Dining Room with one door opening to the 300 Hall, but with a large opening to the Dining Room that did not provide privacy. The residents stated that there were no interior or exterior doors separating the Private Dining Room from the Dining Room, and that staff had disrupted some of their previous meetings by entering the area. The residents stated they wanted the option to meet in a location with doors so staff or other residents could not overhear what was discussed. An observation confirmed that the Private Dining Room area had one door to the 300 Hall and shared common walls with the Dining Room, with no doors separating it from the Dining Room. Interviews with the SW, Administrator, CNA B, and Activities Director showed they were unaware the facility needed a private area for Resident Council meetings, and they acknowledged that the lack of doors meant residents did not have privacy during meetings. The Administrator stated the residents had not brought the concern to his attention, and the facility policy stated that Resident Council is intended to provide a forum for residents, families, and resident representatives to have input in facility operations and to discuss concerns and suggestions for improvement.
Grievance Forms Not Available for Anonymous Filing
Penalty
Summary
The facility failed to ensure that residents had access to file grievances anonymously. The deficiency involved Resident #75 and confidential group members, and the report also stated that the facility failed to ensure that the 93 residents at the facility had access to file a grievance anonymously. Resident #75’s record reflected diagnoses including stage 3A chronic kidney disease, Alzheimer’s disease, dementia, and muscle wasting and atrophy. Her MDS Quarterly Assessment reflected a BIMS score of 12, indicating moderately impaired cognition. Record review of the facility’s grievance logs for October 2025 and March 2026 showed no grievances completed for Resident #75. During interview, Resident #75 stated she kept a personal notebook for complaints and usually did not complete a grievance because she verbally told staff about her concerns. She stated the grievance forms were located at the Nurses’ Station and that she did not like that location. She also stated she would like the option to file a grievance anonymously but did not know how. In a confidential group meeting, residents stated the grievance forms were kept in a black wire basket at the Nurses’ Station and that they had completed grievances on several occasions, with concerns addressed after filing. They also stated they were uncertain whether staff could view their grievances and share the concerns with others after filing, and that they had not filed grievances about some concerns because they feared retaliation from caregivers and staff. Observation confirmed blank grievance forms in a black wire basket at the Nurses’ Station desk. Staff interviews reflected that the grievance forms were only available at the Nurses’ Station, that there was no anonymous filing area, and that completed forms were placed in the same black wire basket as blank forms. The facility policy stated grievances may be submitted anonymously and that residents, family, and representatives have the right to voice or file grievances without discrimination or reprisal.
Incomplete Discharge Summary
Penalty
Summary
The facility failed to complete a discharge summary for Resident #2, a [AGE]-year-old female admitted with a primary diagnosis of Alzheimer's disease and discharged home after a respite stay arranged through hospice. Record review showed that the resident's discharge MDS was completed, but the discharge summary in PCC had not been completed. The record also showed progress notes documenting the resident's admission for respite care and discharge home on 03/21/2026. During interview, the Social Worker stated she was responsible for opening and closing the discharge summary and for notifying the IDT when it was open so the rest of the team could complete their parts. She confirmed in PCC that the discharge summary had not been completed and stated it should have been done. She also stated she completed a trauma assessment and social history, but did not know why she did not complete the discharge summary. Review of the facility's Transfer or Discharge, Emergency policy dated August 2018 did not address the requirement to complete a discharge summary for a resident discharge, and the facility could not provide a policy for scheduled or routine transfers or discharges that addressed this requirement.
Failure to Use Required PPE During Resident Care and Transfer
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for one resident reviewed for infection control. Resident #1 was re-admitted with diagnoses including muscle wasting and atrophy, generalized muscle weakness, morbid obesity, depression, and anxiety, and was always incontinent of bowel and bladder, required maximum assistance with toileting, and had more than one wound. Her care plan indicated she was on enhanced barrier precautions because of wounds, with instructions to use gowns and gloves during dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. During observation, CNA A provided incontinent care after LVN C completed wound care, but CNA A did not wear a gown even though the resident was on enhanced barrier precautions. After the care was completed, CNA A, CNA B, and LVN C assisted the resident from bed to chair using a hoyer lift, and none of the staff wore gowns during the transfer. A later observation showed a sign on the resident’s door indicating gloves and gown were required, with gowns, masks, and gloves available at the door. In interviews, CNA A stated she forgot to put on the gown and did not think a gown was required for the transfer, CNA B stated she was not aware she needed a gown for the transfer, and LVN C stated the gown was not required during transfer and that she only used it for wound care. The DON stated staff were expected to wear gown and gloves while caring for the resident, including during transfers.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that residents received food that was palatable, attractive, and served at a safe and appetizing temperature during a lunch meal. Multiple staff members, including CNAs, reported receiving complaints from residents about cold food, particularly for those eating in their rooms. Observations revealed that food temperatures were initially within safe ranges when checked in the kitchen, but by the time trays were delivered to residents, the food was no longer at an appetizing temperature. A test tray provided to the state surveyor showed that the barbeque meat was only lukewarm in the center, the okra was cold, and the potato salad was no longer cold, indicating a loss of appropriate temperature during tray delivery. Interviews with residents confirmed that food was often not hot when received, with trays sometimes sitting on the hall for several minutes before being distributed. Dietary staff delivered food carts to the halls on time and notified nursing staff, but there were delays in passing out trays, sometimes up to 13 minutes after arrival. Facility policy required prompt delivery of room service trays upon reaching the floor, but this procedure was not consistently followed, leading to dissatisfaction among residents regarding meal temperature and palatability.
Failure to Prevent Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to ensure the right to be free from misappropriation of property for a resident who was prescribed Soma, a muscle relaxant. The resident, a severely cognitively impaired female with multiple diagnoses including congestive heart failure, schizoaffective disorder, panic disorder, dementia, diabetes, and chronic pain, was unable to make decisions and required assistance from two staff members for activities of daily living. Despite having a physician's order for Soma 325mg to be administered three times daily and at bedtime, it was discovered that 11 Soma tablets were missing from her blister pack. The medication administration record indicated that no doses were missed during the relevant period, and the pharmacy manifest confirmed delivery of the correct quantity of medication. The deficiency was identified when staff noticed discrepancies in the medication count sheets, including numbers that had been written over and skipped, as well as signatures at times when the nurse was not assigned to the resident. Interviews with staff revealed that the count was correct at one point, but later counts did not match the actual number of pills present. The count sheet for the Soma had been altered from one date to another, and the missing medication could not be located after checking medication carts, rooms, and other areas. One agency nurse who had access to the medication during the relevant period could not be reached for an interview despite multiple attempts by facility staff, the agency, and the police. The resident was unable to provide information due to confusion and forgetfulness. The facility's abuse prevention policy states that residents have the right to be free from misappropriation of property. The investigation involved notifying the police, the family, the pharmacy consultant, and the medical director, but the facility was unable to confirm who was responsible for the missing medication.
Failure to Timely Submit PASRR NFSS Documentation
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident's assessment, care planning, and transition of care for one resident reviewed for PASRR services. Specifically, the facility did not submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC online portal within 20 days after the Interdisciplinary Team (IDT) meeting, as required by policy. This lapse was identified through interviews and record reviews, which showed that although the resident continued to receive habilitation services such as speech, occupational, and physical therapy, the necessary documentation and portal submissions were not completed in a timely manner. The resident involved was a male with multiple diagnoses, including intellectual disabilities, schizophrenia, Parkinson's disease, and severe cognitive impairment, requiring significant assistance with activities of daily living. The care plan indicated that the resident was PASRR positive and required ongoing coordination of PASRR services, including quarterly care plan meetings and individualized service plans. Despite these documented needs and ongoing therapy services, the facility did not ensure that the NFSS forms were submitted within the required timeframe following IDT meetings, particularly during a period of change of ownership when access to the portal was disrupted. Interviews with facility staff, including the Director of Rehabilitation (DOR), MDS nurse, and Administrator, confirmed that while habilitation services were continuously provided, there was a breakdown in the administrative process for submitting required documentation. The MDS nurse and Administrator both acknowledged issues with portal access during the change of ownership and admitted that no one contacted the appropriate parties to resolve the issue at the time. As a result, the facility did not meet the regulatory requirement to submit the NFSS form within 20 business days of the IDT meeting, as outlined in their own policy.
Failure to Use Hair Restraints in Food Service
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an observation of the kitchen, it was noted that the Dietary Manager (DM) had facial hair on his chin and was not wearing a beard covering while checking the temperatures of the food prepared for the lunch meal service. Additionally, the Environmental Director was observed taking food off the tray stand and delivering it to residents without wearing a beard covering. This lack of proper hair restraint could lead to food contamination and foodborne illness. The facility's Employee Sanitation policy, dated October 1, 2018, requires that hairnets, headbands, caps, beard coverings, or other effective hair restraints be worn to prevent hair from coming into contact with food and food-contact surfaces. The Federal Food Code 2022 also mandates the use of effective hair restraints. Despite having beard coverings available in the kitchen, the DM acknowledged the importance of wearing them to prevent hair from contaminating the food, yet failed to comply with this requirement.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,037 citations issued within 25 miles in the last 12 months — including the 17 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) |
|---|---|---|---|---|
| Legend Oaks Healthcare And Rehabilitation Garland | 1 mi | ★★★★★ | 10 | 0 |
| Beltline Healthcare Center | 1.7 mi | ★★★★★ | 4 | 0 |
| Avir At Garland | 2.6 mi | ★★★★★ | 15 | 1 |
| Pleasant Valley Healthcare And Rehabilitation Cent | 2.8 mi | ★★★★★ | 7 | 0 |
| Lindan Park Care Center Lp | 3 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Parks At Garland Healthcare And Rehab.
100% money-back within 48 hours.
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.