Average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Renaissance At Kessler Park during CMS and state inspections, most recent first.
Food safety standards were not followed in Kitchen #1 when a plate of meatloaf was left on the prep table overnight instead of being discarded or refrigerated, and a staff member’s personal drink was also left on the prep table. Staff stated leftover food was supposed to be labeled, dated, and stored properly, and personal cups were supposed to be kept in a designated area away from food prep. The DON stated there was no policy for personal drinks or food for kitchen staff, and employee records showed missing training documentation.
A resident with schizophrenia and dementia, who had exit-seeking behavior and was placed on 1:1 supervision, was transferred to another facility without written notice to the RP and without notice to the LTC ombudsman. The RP said she learned of the transfer from the receiving facility and did not receive the required written discharge notice, while the ombudsman confirmed no notification was received. The facility policy required written notice to the resident, RP, and ombudsman before a non-emergency transfer or discharge.
Failure to update a resident’s person-centered care plan for exit-seeking behavior. A resident with schizophrenia, dementia, and moderate cognitive impairment was documented as attempting to go to doors and later pushing open an exit door and triggering the alarm, yet the care plan did not reflect a history of elopement. The DON stated the elopement assessment was for residents who left the facility, not exit-seeking behavior, and the Administrator stated the care plan needed to be specific to the resident’s care.
A resident receiving hospice care had Morphine Sulfate concentrate and MS Contin ordered for shortness of breath and pain. A parcel company delivered the medication package directly to the resident after hours, it was not labeled as medication, and a CNA took it from the room but left it on a linen cart and forgot about it. Facility leadership stated the package later went missing and that the delivery process did not follow the usual pharmacy receipt process for controlled substances.
Staff failed to follow Enhanced Barrier Precautions by not wearing gowns during high-contact care activities for two residents with complex medical needs, and feeding pump poles used for these residents were observed to be dirty. PPE supplies were not consistently available, and there was confusion among staff regarding responsibility for cleaning equipment and restocking PPE, resulting in lapses in infection prevention practices.
A resident who was fully dependent on staff for ADLs and had significant medical needs was found with a soiled brief and bedding, including a brown ring and strong ammonia odor, after reporting that incontinent care had not been provided since the previous night. Staff interviews confirmed delays in care, and family members reported similar past incidents. The facility's care plan required frequent checks and changes, but staff failed to ensure timely hygiene and incontinence management.
A resident receiving enteral nutrition via a gastrostomy tube was found lying flat in bed while the feeding pump was running, despite care plans and physician orders requiring the head of the bed to be elevated between 30 to 45 degrees during feedings. Staff interviews indicated a lack of awareness about who lowered the bed, and the resident's family reported repeatedly finding the bed flat during visits. Facility leadership confirmed the expectation for bed elevation during tube feeding, but this was not consistently followed for the resident.
A facility failed to prevent resident-to-resident abuse, resulting in two separate altercations in the dining room. In one incident, a resident with no cognitive impairment scratched another resident with moderate cognitive impairment. In another, a resident with behavioral issues threw orange juice at another resident, leading to a physical confrontation. Both incidents occurred due to a lack of staff presence, violating the facility's abuse prevention policy.
The facility did not follow food service safety standards by using the same tongs for different food items during lunch, risking cross-contamination. A staff member used the same tongs for pork loin, beef patties, and French fries due to a lack of utensils. The Dietary Manager confirmed the risk of cross-contamination and the facility's policy emphasized the importance of sanitary conditions to prevent food-borne illnesses.
A resident with a tracheostomy did not have complete and accurate tracheostomy care orders documented in the EMR, despite receiving care. The facility's process of deleting previous orders upon readmission may have contributed to this oversight. Staff documented care in progress notes, but it was not reflected in the MAR, leading to concerns about potential inappropriate care.
A resident with a history of falls and cognitive impairment experienced a delay in receiving an x-ray for a painful and swollen left wrist and hand, resulting in a 14-day delay in treatment. Despite an initial x-ray order, the procedure was not completed before the resident was transferred to the hospital for seizure activity. Upon return, the resident continued to report pain, but follow-up on the x-ray order was not conducted until the pain worsened, revealing an acute displaced fracture.
The facility did not have a governing body responsible for establishing and implementing management policies, and the administrator's license was expired. This was discovered through an internet search, indicating a failure to ensure the administrator's license was current, potentially affecting resident health and safety.
A facility failed to report allegations of neglect related to falls for a resident within required timeframes. The resident, with severe cognitive impairment, experienced two unwitnessed falls. The first fall resulted in a skin tear, and the second led to pain and swelling in the left hand. The facility did not report these incidents to the State Agency as required, citing unawareness of injuries and the resident being sent to the hospital before an x-ray could be completed.
A facility failed to provide proper respiratory care for a resident with chronic respiratory failure by not dating the oxygen tubing as required. The resident was observed with a nasal cannula, but the tubing lacked a date, which is necessary to prevent infection. Interviews with staff confirmed the oversight, and the facility's policy mandates weekly changes and labeling of disposable parts.
Food Left Unlabeled on Prep Table and Staff Drink Left in Food Prep Area
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in Kitchen #1. During observation, a plate of meatloaf covered with saran wrap was found on the prep table next to a disposable cup containing water and ice. The meatloaf was observed on the prep table during the morning survey and was reported by kitchen staff to have been left there overnight rather than discarded or refrigerated. Interviews with dietary staff showed that the meatloaf was an extra order for a resident and had been in the line for delivery, but it was not delivered and remained on the prep table. Staff stated leftover food was supposed to be discarded at the end of the night or labeled, dated, and placed in the refrigerator with a use-by date. The temporary Dietary Manager also stated all items in the kitchen were supposed to be labeled and dated with a use-by date, and the Administrator stated the meatloaf should not have remained on the prep table all night and should have been refrigerated. The disposable cup on the prep table was identified as belonging to a new kitchen employee. Staff stated personal drinks were not supposed to be on the prep table and were supposed to be kept in a designated area near the office or in the break room. The employee who owned the cup stated she was not sure where personal cups were supposed to be placed and said she had not received any training prior to being hired. Record review showed one dietary aide file contained no training documentation and another employee file contained no trainings, and the facility’s policy required ready-to-eat food and commercially prepared PHF/TCS food to be clearly labeled with dates and use-by dates.
Failure to Provide Required Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide written notification to the resident’s representative and to the Office of the State Long-Term Care Ombudsman regarding the resident’s transfer/discharge. The resident had diagnoses of schizophrenia and unspecified dementia with moderate cognitive impairment, with a BIMS score of 10 on the admission MDS. The resident’s face sheet identified a resident representative, and the record also showed an elopement assessment with a score of 0.0 indicating low risk and no plan of care needed. Progress notes documented that the resident had exit-seeking behavior and was moved to a room away from the doors, later placed on 1:1 supervision after attempting to leave through an exit door. The social worker documented discussions with the representative about the resident’s behavior and placement needs, and noted that a local facility accepted the resident and that transfer arrangements were made. However, the resident’s representative stated she did not receive written notification about the discharge and did not want the resident transferred until she had looked at the other facility. Interviews showed the representative learned of the transfer from another facility rather than from the facility, and the facility ombudsman and volunteer ombudsman stated they were not notified of the transfer. The administrator stated the social worker was expected to email the ombudsmen about the discharge, but no such email could be found. The facility policy required the social services director to notify the resident and representative in writing at least 30 days before transfer or discharge and to provide a copy of the notice to a representative of the State Long-Term Care Ombudsman.
Failure to Update Care Plan for Exit-Seeking Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1 that included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs. Resident #1 was an [AGE]-year-old male admitted with diagnoses of schizophrenia and unspecified dementia with behavioral disturbance, and his admission MDS reflected a BIMS score of 10, indicating moderate cognitive impairment. An elopement assessment dated 01/16/26 rated the resident at 0.0 and indicated low risk with no plan of care needed, and the discharge MDS reflected wandering as not exhibited. Progress notes dated 03/26/26 documented that staff met with the resident’s RP to discuss exit-seeking behavior, noting the resident attempted to go to doors and was easily redirected, and that he had been moved to a room away from the doors. The care plan dated 03/27/26 did not reflect a history of elopement, even though the record also documented that on 03/21/26 the resident was observed pushing open an exit door, causing the alarm to sound, and was redirected back into the facility before being placed on 1:1 supervision until secure unit placement. During interviews, the DON stated the elopement assessment was done when a resident left the facility and not for exit-seeking behaviors, and the Administrator stated the care plan needed to be person centered and specific to the resident’s care.
Missing Hospice Pain Medication Package
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate dispensing and administration of drugs and biologicals for one resident receiving hospice care. The resident had end stage heart disease, dementia, and major depressive disorder, and her physician orders included Morphine Sulfate concentrate for shortness of breath and MS Contin for pain. Her care plan stated that dignity would be maintained and that she would be kept comfortable and pain free. During an observation and interview, the resident stated she had recently received a package of pain medication in the mail, opened it, and later gave it to a staff member to take to her nurse. She did not recall telling staff that the package contained medication. The package was delivered directly to the resident by a parcel company after hours and was not labeled as medication. CNA A took the package from the resident’s room without knowing what it contained, placed it on a linen cart, then became occupied with another resident and forgot about it. The package was later reported missing. Facility leadership stated that medications were typically delivered through the pharmacy and received by licensed staff, but this hospice delivery was separate and not anticipated by the facility. The ADON stated the package was taken to the resident’s room like normal mail, and the Administrator stated she initially was not sure what was in the package. The record also showed CNA A received verbal counseling for failing to deliver the package to the nurse, and the facility in-serviced staff on misappropriation of property. The facility policy required controlled substances to be received by licensed personnel, inspected on delivery, and immediately secured, with discrepancies and losses investigated.
Failure to Implement Infection Control Program and Maintain Clean Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) and by the presence of unclean medical equipment in the care environment. Specifically, staff members including LVNs and a CNA did not wear gowns as required during high-contact care activities such as incontinent care and linen changes for a resident on EBP. Observations revealed that no gowns were available in the resident's room or on the isolation cart, and staff interviews confirmed that the omission was due to forgetfulness, lack of supply, and unclear responsibility for restocking PPE. Additionally, both residents reviewed for infection control were observed to have feeding pump poles that were visibly dirty, with yellow and brown sticky substances present on the poles and the floor beneath them. Staff interviews indicated confusion regarding responsibility for cleaning the equipment, with nursing staff believing it was housekeeping's duty and housekeeping staff stating they only cleaned equipment upon request. The facility's policy required that portable equipment be kept clean to prevent the spread of infection, but this was not consistently followed. The residents involved had significant medical histories, including sepsis, pneumonia, pressure ulcers, dysphagia, stroke, and the use of feeding tubes and catheters. Care plans for both residents included EBP to reduce the transmission of multidrug-resistant organisms, with specific instructions for PPE use during high-contact activities. Despite these documented precautions, staff failed to consistently implement the required infection control measures, as evidenced by direct observation and staff admissions during interviews.
Failure to Provide Timely Incontinent Care and Maintain Resident Hygiene
Penalty
Summary
A deficiency was identified when a resident who was fully dependent on staff for all activities of daily living (ADLs) was not provided timely and adequate incontinent care. The resident, who had multiple diagnoses including sepsis, pneumonia, a pressure ulcer, dysphagia, stroke, and was dependent on a feeding tube, was observed on the morning of 06/18/25 to be lying in bed with a soiled brief and bedding. The bedding had a brown ring and a strong ammonia odor, and the resident reported not having received incontinent care since the previous night, describing discomfort and itchiness. Staff interviews confirmed that the resident was changed at 6:00 AM, but by 9:12 AM, the resident was already found to be wet and soiled, indicating a lack of timely care. Further observations showed that the resident remained wet later in the morning, though without the brown ring or strong odor. The care plan for the resident specified that she was to be checked frequently for wetness and soiling and changed as needed, with the goal of maintaining cleanliness, dryness, and dignity. Staff interviews revealed that while CNAs were primarily responsible for providing ADL care, nurses were expected to monitor and assist as needed. However, the nurse on duty admitted to not checking if the resident was wet during her morning rounds, despite administering medications and checking blood sugar. Family interviews corroborated the findings, with reports of repeated incidents where the resident was found soiled, including during a previous hospitalization for pneumonia and a staph infection. The facility's policy required essential ADL services to maintain hygiene but did not specify the frequency of incontinent care. The Director of Nursing and the Administrator both stated that the expectation was for ADL and incontinent care to be provided every two hours or as needed, and acknowledged that the observed condition indicated a failure to meet these standards.
Failure to Maintain Head-of-Bed Elevation During Enteral Feeding
Penalty
Summary
A deficiency occurred when a resident receiving enteral feeding via a gastrostomy tube was observed lying flat in bed while the feeding pump was running. The resident's care plan and physician orders specifically required the head of the bed to be elevated between 30 to 45 degrees during tube feeding and for at least 30 minutes afterward to prevent aspiration. Despite these documented requirements, the resident was found with the bed flat and the feeding pump actively delivering nutrition. Interviews with staff, including a CNA and an LVN, revealed that neither was aware of who had lowered the bed, and both stated they were trained to keep the head of the bed elevated during tube feeding. The staff also confirmed that the risk of aspiration was well known, and the facility's policy required the head of the bed to be elevated during feedings. The resident's family reported that on multiple occasions, they found the bed flat during visits and had to request staff to raise it, indicating a recurring issue. Further interviews with facility leadership, including the DON and ADM, confirmed the expectation that the head of the bed should be elevated during tube feedings. The ADM acknowledged that the resident had a tendency to lay the bed flat and that this behavior was known among staff but had not been specifically care planned. The facility's policy and staff statements consistently supported the need for bed elevation during enteral feeding, but this was not consistently implemented for the resident in question.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving four residents. In the first incident, a resident with no cognitive impairment and a history of verbally abusive behavior was involved in an altercation with another resident who had moderate cognitive impairment. The altercation occurred in the dining room when the first resident refused to move her wheelchair, leading to a physical confrontation where she scratched the other resident's face. Both residents were separated, and assessments showed no new injuries. In a separate incident, two residents with cognitive impairments were involved in a physical altercation in the dining room. One resident, who had a history of behavioral problems, threw orange juice at another resident, prompting a retaliatory hit to the face. The altercation was witnessed by staff, and both residents were separated and assessed. The resident who was hit had some redness on his face, but no other injuries were noted. Interviews with staff and residents revealed that during both incidents, there was a lack of staff presence in the dining room, which contributed to the escalation of the situations. The facility's policy on abuse and neglect emphasizes the prevention of such incidents, but the absence of staff during meal times allowed these altercations to occur without immediate intervention. The facility's failure to ensure adequate supervision and adherence to its abuse prevention policy led to these deficiencies.
Failure to Use Separate Utensils for Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not using separate utensils for each food item during lunch service. Observations revealed that a staff member, identified as [NAME] D, used the same tongs to serve both pork loin and beef patties, and later used the same tongs to serve French fries. An interview with [NAME] D confirmed that there was only one pair of tongs available during lunch service, acknowledging the risk of food transfer. Further interview with the Dietary Manager confirmed that each food item was supposed to have its own serving utensil, but there were not enough tongs available. The Dietary Manager recognized that using the same utensil for multiple food items posed a risk of cross-contamination. A review of the facility's Food Safety and Sanitation Plan highlighted the serious complications nursing home residents could face from food-borne illnesses due to their compromised health status, emphasizing the need for sanitary conditions in food service settings.
Incomplete Documentation of Tracheostomy Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the documentation of tracheostomy care orders in the electronic medical record (EMR). The resident, who had a tracheostomy and was dependent on staff for all care due to severe cognitive and physical impairments, did not have documented orders for tracheostomy care in the EMR. This oversight was discovered during a review of the resident's records, which showed that while tracheostomy care was being provided and documented in progress notes, it was not reflected in the medication administration record (MAR) for the month of August 2024. The resident's care plans indicated the need for specific tracheostomy care, including maintaining clear airways, preventing infection, and providing suctioning as needed. However, the EMR only contained an order for Albuterol Sulfate via trach, with no comprehensive tracheostomy care orders. Interviews with staff revealed that the absence of these orders in the EMR was unexpected, as they believed the orders had been entered and were investigating the cause of their disappearance. The Assistant Director of Nursing (ADON) and the Administrator both expressed concern over the missing orders, acknowledging that this could lead to inappropriate care. The facility's policy on medication reconciliation outlines the process for verifying and transcribing orders upon a resident's admission or readmission. It was noted that the resident had been readmitted from the hospital, and the facility's practice involved deleting previous orders to accommodate new ones from the hospital. This process may have contributed to the oversight, as the admitting nurse is responsible for entering all necessary orders, including those for tracheostomy care. Despite the lack of orders in the EMR, the nursing staff documented tracheostomy care in progress notes, indicating that care was being provided, albeit not in accordance with the facility's documentation standards.
Delayed X-ray Order Leads to Untreated Fracture
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan. The deficiency involved a delay in obtaining an x-ray for a resident's left wrist and hand, which resulted in a delay of treatment for a period of 14 days. The resident, who had a history of falls and cognitive impairment, reported pain and swelling in her left hand to a CNA, which was then communicated to an RN. An x-ray order was received, but the x-ray was not completed before the resident was transferred to the hospital due to seizure activity. Upon the resident's return to the facility, there was no follow-up to ensure the x-ray was completed, despite the resident's continued complaints of pain in the left wrist and hand on multiple occasions. The resident's pain was documented, and pain medication was administered, but the x-ray was not ordered until the resident's pain increased significantly. The x-ray eventually revealed an acute displaced fracture of the distal metaphysis of the left radius. Interviews with facility staff revealed a lack of follow-up on the pending x-ray order and a failure to reassess the resident's condition upon her return from the hospital. Staff were aware of the protocols for handling falls and changes in condition, but the necessary steps were not taken in this case, leading to a delay in diagnosis and treatment of the resident's fracture.
Expired Administrator License and Lack of Governing Body
Penalty
Summary
The facility failed to establish a governing body or designate persons functioning as a governing body that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. Additionally, the governing body did not ensure that the administrator appointed was properly licensed by the state. Specifically, the administrator's license was found to be expired, as revealed by an internet search of the Texas Health and Human Services public search website. This deficiency indicates that the facility did not ensure the administrator's license was current, which could potentially affect the health and safety of all residents.
Failure to Report Alleged Neglect Timely
Penalty
Summary
The facility failed to report allegations of neglect related to falls for a resident within the required timeframes to the State Agency. The resident, an elderly female with severe cognitive impairment and multiple medical conditions, experienced two unwitnessed falls. The first fall resulted in a skin tear and was not reported because the facility did not know of any injuries at the time. The second fall led to pain and swelling in the resident's left hand, and although an x-ray was ordered, the resident was sent to the hospital before it could be completed. The facility's administrator acknowledged that the falls were not reported to the State Agency as required. The administrator stated that the facility's policy mandates reporting all incidents with injuries immediately after they occur. However, the falls were not reported because the facility was unaware of any injuries at the time of the incidents. The administrator also mentioned that the resident was sent to the hospital before the x-ray could be completed, which contributed to the failure to report. The facility's policy on abuse, neglect, and exploitation requires reporting all alleged violations to the appropriate authorities within specified timeframes. This includes reporting within two hours if the events involve abuse or result in serious bodily injury, or within 24 hours if they do not. The failure to report the falls as required placed residents at risk of ongoing neglect, as the facility did not adhere to its own policy and regulatory requirements.
Failure to Date Oxygen Tubing for Resident with Respiratory Needs
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required tracheostomy care and tracheal suctioning, as well as consistent oxygen therapy. The resident, an elderly female with a primary diagnosis of dementia and chronic respiratory failure, was observed with a nasal cannula in place, but the oxygen tubing was not dated as required by the facility's policy. This oversight was noted during an observation, and it was confirmed that the responsibility for changing and dating the nasal cannula tubing fell to the night nurse scheduled on Sundays. Interviews with the LVN and the DON confirmed that the nasal cannula tubing was not labeled and dated, which is a necessary practice to prevent infection. The facility's policy mandates that disposable parts should be changed weekly and labeled with the date and initials. The failure to adhere to this policy placed the resident at risk of not receiving the necessary respiratory care services.
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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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakewest Rehabilitation And Skilled Care | 2.3 mi | ★★★★★ | 25 | 1 |
| Skyline Nursing Center | 3.2 mi | ★★★★★ | 14 | 0 |
| The Villa At Mountain View | 4.1 mi | ★★★★★ | 6 | 0 |
| Ventana By Buckner | 4.4 mi | ★★★★★ | 3 | 0 |
| Forest Park Nursing & Rehabilitation | 4.8 mi | ★★★★★ | 13 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.