Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Walnut Place during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident in a LTC facility experienced a breach of dignity when a CNA tapped her nose and commented on her behavior, which was perceived as disrespectful. The resident, who was cognitively intact and had multiple health issues, felt upset by the CNA's actions. The incident was confirmed through interviews and a provider investigation, revealing a failure to adhere to the facility's policies on resident dignity and respect.
A resident at an LTC facility fell and sustained injuries after a CNA failed to use a gait belt during a transfer from a wheelchair to a bed. The resident, who was at risk for falls, was being assisted with incontinence care while standing, contrary to standard practice. The CNA admitted to not using a gait belt, despite being educated on its necessity. The facility's policy required gait belts for all transfers to prevent accidents.
A resident with a history of UTIs and other health issues was not promptly treated after lab results showing bacterial infection were not communicated to the physician. The urine sample, collected due to concerns about its color, revealed E.Coli and Providencia Stuartii. The results were available but not acted upon, leading to the resident's hospitalization for severe sepsis. Facility staff interviews indicated a lack of follow-up on the lab results, and the facility's policy for prompt physician notification was not adhered to.
A facility failed to coordinate PASARR assessments for two residents, resulting in inaccurate screenings that did not reflect their mental illness diagnoses. Both residents had comprehensive MDS assessments indicating moderately impaired cognition and care plans addressing psychotropic medication management. However, their PASARR Level I screenings were negative for mental illness, and no PASRR II evaluations were conducted. Interviews with staff revealed a lack of awareness and coordination in ensuring accurate PASARR screenings, placing the residents at risk of not receiving necessary services.
A facility failed to maintain accurate narcotic logs for three residents, leading to discrepancies between the narcotic administration records and actual pill counts. The issue was identified on a medication cart used by the 2 North Hall Nurses. An LVN admitted to not signing off on the narcotic log immediately after administering medications, which could lead to errors and drug diversion. The DON emphasized the importance of accurate documentation, and previous training had been conducted on this matter.
A facility failed to maintain an effective infection prevention and control program, as evidenced by an LVN not wearing required PPE when administering medication to a resident on enhanced barrier precautions, and an MA not disinfecting a blood pressure cuff between uses on two residents. Despite training, these oversights posed a risk of infection spread.
The facility failed to maintain the required eight consecutive hours of RN coverage daily over an 18-day period. The Staffing Coordinator was unaware of this requirement, and the DON and Administrator, who reviewed the schedules, also missed it. Despite the presence of LVNs, the absence of RNs for the required hours could impact assessments and pronouncements.
A resident's care plan was not updated to include the use of a Foley catheter, despite requiring substantial assistance with toileting and having an indwelling catheter. The resident was working with staff on catheter management, but the care plan was not revised to reflect these needs. The ADON admitted to removing catheter care from the plan when the resident was scheduled for removal, but forgot to add it back when the catheter was reinserted.
A facility failed to ensure proper administration of enteral feeding for a resident with a g-tube. The LVN did not check tube placement and used a syringe to force the feeding instead of allowing it to flow by gravity, risking complications like aspiration. The resident had a history of stroke and dysphagia, and the care plan required specific feeding protocols that were not followed.
A resident with a history of stroke and hemiplegia did not receive necessary restorative nursing services to maintain his range of motion and mobility. Despite being dependent on staff for daily activities, his care plan lacked restorative therapy, and there was no documentation of such services being provided. Interviews revealed that after surgeries, the resident did not receive the required therapy, and facility staff were unaware of the lack of services, indicating a breakdown in communication and care processes.
A resident at risk for falls was left unattended in bed without proper fall interventions, resulting in a fall. The CNA responsible left the resident to assist another and did not return, leading to the resident falling and sustaining an abrasion. The facility's fall prevention policy was not followed, as the bed was not in its lowest position and the fall mat was not properly placed.
A resident with acute osteomyelitis did not receive Vancomycin as ordered due to the medication being unavailable. Despite procedures for verifying medication availability and contacting physicians for alternatives, the staff failed to administer the medication on time, resulting in a significant medication error.
A resident with multiple medical conditions was placed on a worn-out mattress that was peeling, leading to blue flakes covering their back. The facility failed to conduct regular inspections of bed equipment, resulting in this deficiency. The issue was identified by the resident's family and acknowledged by the ADON.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Resident Dignity Compromised by CNA's Actions
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, a cognitively intact female with a BIMS score of 13, was admitted to the facility with multiple diagnoses, including acute respiratory failure with hypoxia and end-stage heart failure. During the incident, the CNA tapped the resident on the nose and commented that the resident was being mean, which was perceived as disrespectful by the resident. The incident occurred while the CNA was assisting the resident with her cell phone. The CNA admitted to gently tapping the resident on the nose and making the comment, which was confirmed through interviews and a provider investigation report. The resident did not report any physical injuries or pain, but expressed feeling upset and disrespected by the CNA's actions. The CNA was an agency aide and had only worked a few shifts at the facility prior to the incident. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Social Worker (SW), confirmed the occurrence of the incident and the subsequent investigation. The facility's policy on abuse prohibition and protocol was reviewed, and it was noted that the CNA's actions were not in line with the facility's expectations for staff behavior. The incident highlighted a failure to adhere to the facility's policies on resident dignity and respect.
Failure to Use Gait Belt Results in Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received the necessary assistance devices to prevent accidents, specifically the use of a gait belt during transfers. A certified nursing assistant (CNA) did not apply a gait belt to a resident before transferring her from a wheelchair to a bed, resulting in the resident falling and sustaining a bruise and a small skin tear. The resident, who was cognitively intact and had a history of unsteadiness on her feet and muscle weakness, was at risk for falls and required a one-person assist with a gait belt for transfers and ambulation. The incident occurred when the CNA was performing incontinence care while the resident was standing, which was not the typical procedure as staff were expected to perform such care while the resident was sitting. The CNA briefly moved away from the resident to dispose of a brief, during which time the resident lost her balance and fell. The CNA admitted to not using a gait belt during the transfer, despite having been educated on fall prevention and the use of gait belts. The facility's policy required the use of gait belts during all transfers to ensure resident safety. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that the CNA did not follow the facility's policy and procedure, which led to the resident's fall and injury. The CNA was suspended pending an investigation and was eventually terminated. The facility conducted safe surveys and provided in-service training to staff on fall prevention and the use of gait belts following the incident.
Failure to Notify Physician of Lab Results Leads to Resident Hospitalization
Penalty
Summary
The facility failed to promptly notify the physician of laboratory results for a resident, leading to a serious health incident. The resident, a female with multiple health conditions including heart failure, hypertension, and chronic respiratory failure, was admitted to the facility in 2020. She had a history of urinary tract infections (UTIs) and was at risk due to a Foley catheter. On October 31, 2023, a urine sample was ordered by the physician at the request of the resident's family due to concerns about the urine's color. The sample was collected and sent to the lab, but the results, which showed the presence of Escherichia Coli (E.Coli) ESBL and Providencia Stuartii, were not communicated to the physician in a timely manner. The laboratory results were available on November 3, 2023, but the physician was not notified until after the resident experienced a change in condition on November 9, 2023. The resident became lethargic and was sent to the hospital, where she was diagnosed with severe sepsis due to a UTI. Interviews with the facility staff revealed a lack of follow-up on the lab results. LVN A, who initially collected the urine sample, reported the issue to the oncoming nurse, LVN J, but the results were not obtained from the computer system. The Director of Nursing (DON) and the Administrator were unaware of the resident's hospital admission and the lack of antibiotic treatment during the critical period. The facility's policy required prompt communication of lab results to the attending physician, especially when the resident's clinical status was unstable. However, this protocol was not followed, resulting in a delay in treatment and the resident's subsequent hospitalization. The deficiency was identified as an Immediate Jeopardy situation, indicating a high risk of serious injury or harm to the resident.
Failure to Coordinate PASARR Assessments for Residents
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program for two residents, leading to a deficiency in ensuring accurate PASARR Level One screenings that reflected their diagnoses of mental illness. Resident #13, a female with a history of stroke, hypertension, depression, and bipolar disorder, was admitted and readmitted to the facility without a new PASARR Level I screening that accurately reflected her mental illness diagnosis. Her comprehensive MDS assessment indicated moderately impaired cognition, and her care plan included interventions for managing psychotropic medications. However, her PASARR Level I screening was negative for mental illness, and there was no documentation of a PASRR II evaluation. Similarly, Resident #69, a female with end-stage renal disease, hypertension, type II diabetes, and bipolar disorder, was admitted to the facility with a PASARR Level I screening that also inaccurately showed a negative result for mental illness. Her comprehensive MDS assessment indicated moderately impaired cognition, and her care plan addressed the risk of adverse reactions to psychotropic medications. Despite these diagnoses, there was no new PASARR Level I screening conducted after her admission, nor was there a PASRR II evaluation from the local authority. Interviews with facility staff, including the MDS Coordinator, Social Worker, and DON, revealed a lack of awareness and coordination in ensuring accurate PASARR screenings. The MDS Coordinator acknowledged the responsibility to review and update PASARR screenings and alert the Social Worker if discrepancies were found. The Social Worker confirmed that no request for a new PASARR screening had been completed for Resident #69, and the DON was unaware of the negative PASARR readings for both residents. The facility's Admission Criteria policy outlined the process for conducting PASARR screenings, but the failure to adhere to these procedures placed the residents at risk of not receiving necessary specialized services.
Inaccurate Narcotic Logs Found in Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in maintaining accurate narcotic logs for three residents. The discrepancies were found on one of the medication carts used by the 2 North Hall Nurses. The narcotic logs for pregabalin, hydrocodone, lorazepam, and tramadol did not match the actual pill counts in the blister packs, indicating a failure in the documentation process. This discrepancy was observed during a review of the medication cart and narcotic administration records. The residents involved were all receiving medications for pain management, with one resident also receiving medication for anxiety. The residents had varying levels of cognitive impairment, with BIMS scores indicating moderate impairment for two residents and intact cognition for one. The discrepancies in the narcotic logs were identified during an observation and record review, where it was noted that the logs did not reflect the actual number of pills remaining in the blister packs. An interview with LVN G revealed that she had administered the medications but failed to sign off on the Narcotic Administration Record log immediately after administration. She acknowledged that this failure could lead to medication errors and drug diversion. The Director of Nursing (DON) confirmed that staff are expected to document medication administration accurately to prevent discrepancies. The facility had previously conducted training on medication administration and documentation, which LVN G had attended, but the issue persisted despite this training.
Infection Control Deficiencies in PPE Use and Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving staff members not adhering to established protocols. In the first incident, a Licensed Vocational Nurse (LVN) did not wear the required personal protective equipment (PPE) when administering medication to a resident on enhanced barrier precautions due to a gastrostomy tube. Despite being aware of the need for PPE and having completed training on enhanced barrier precautions, the LVN only donned gloves and neglected to wear a gown, which was necessary to prevent the spread of infection. In the second incident, a Medical Assistant (MA) failed to disinfect a blood pressure cuff between uses on two residents during medication administration. The MA did not clean the cuff after checking the blood pressure of the first resident and proceeded to use the same cuff on the second resident without disinfection. Although the MA performed hand hygiene, the lack of equipment disinfection posed a risk of cross-contamination. The MA acknowledged the requirement to disinfect reusable equipment between residents but did not provide a reason for the oversight. Interviews with the Director of Nursing (DON) and a review of training records confirmed that the facility had conducted training on infection control and enhanced barrier precautions. However, the MA had not attended the specific training on disinfecting items between residents. The facility's policies emphasized the importance of PPE use and equipment disinfection to prevent the transmission of infections, but these protocols were not consistently followed by the staff involved in these incidents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, during a review period from July 20, 2024, to October 17, 2024. Specifically, on 18 days within this period, the facility did not have RN coverage for the required duration, with RNs working only around six hours on those days. The Staffing Coordinator, responsible for scheduling, was unaware of the requirement for eight consecutive hours of RN coverage, believing that the 12-hour shifts covered the requirement. The Director of Nursing (DON) and the Administrator, who reviewed the schedules, also missed this requirement. Interviews with the Staffing Coordinator, DON, and Administrator revealed a lack of awareness and oversight regarding the RN coverage requirement. The DON stated she was aware of the requirement but was unsure of the specific days she worked to cover the shortfall. The Administrator believed there was no risk due to the presence of Licensed Vocational Nurses (LVNs), although RNs are required for assessments and pronouncements. The facility's policy, revised in May 2019, clearly stated the need for eight hours of RN coverage daily, which was not adhered to during the specified period.
Failure to Update Care Plan for Catheter Use
Penalty
Summary
The facility failed to revise and review the care plan for a resident who was using a Foley catheter. This oversight was identified during a survey where it was found that the resident's care plan did not include his use of a Foley catheter or the need for catheter care, despite the resident requiring substantial assistance with toileting and having an indwelling catheter. The resident, who was admitted for rehabilitation following a fall, had intact cognition and was working with staff on catheter management as part of his discharge goal to be independent. Interviews with the resident and staff revealed that the resident had been practicing catheter care with the help of therapy and was receiving regular incontinence care checks. However, the care plan was not updated to reflect these needs. The Physical Therapist and RN involved in the resident's care were aware of the catheter use but did not ensure the care plan was updated. The Assistant Director of Nursing (ADON) admitted to removing the catheter care from the care plan when the resident was scheduled to have it removed, but forgot to add it back when the catheter was reinserted due to fluid retention issues. The Director of Nursing (DON) confirmed that the resident had a catheter prior to entering the facility and that attempts to remove it were unsuccessful, necessitating its reinsertion. The facility's policy requires that care plans be revised as residents' conditions change, but this was not adhered to in this case, leading to a lack of documented catheter care in the resident's care plan.
Failure to Properly Administer Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding through a gastrostomy tube (g-tube) was provided with appropriate treatment and services to prevent complications. Specifically, the facility did not ensure that the Licensed Vocational Nurse (LVN) checked the g-tube placement before administering the bolus feeding formula. The LVN used a syringe to plunge 120 mL of formula into the g-tube instead of allowing it to flow by gravity, which is against the prescribed procedure. This action placed the resident at risk for complications such as aspiration and pneumonia. The resident involved was a female with a history of stroke, dysphagia, and hypertension, who was admitted to the facility with a mechanically altered diet. Her care plan indicated she was at risk for aspiration related to tube feeding and required specific interventions, including checking tube placement and allowing feeding to flow by gravity. However, during an observation, the LVN did not follow these protocols and instead used a syringe to force the feeding, which could introduce air into the stomach and increase the risk of aspiration. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the nursing staff was expected to follow the protocol for administering bolus feedings, which includes checking for tube placement and allowing the feeding to flow by gravity. The ADON and DON acknowledged that the failure to adhere to these procedures placed the resident at risk for complications. The facility's policy on maintaining the patency of a feeding tube also emphasized the importance of confirming tube placement and allowing fluids to flow by gravity, which was not followed in this instance.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide necessary restorative nursing services to a resident, identified as Resident #42, to maintain or improve his range of motion and mobility. Resident #42, a male with a history of stroke, heart failure, and hemiplegia, was dependent on staff for various activities of daily living. His care plan did not include restorative therapy, and there was no documentation of restorative nursing services being provided, despite his need for such services following surgeries. Interviews with the resident's family member and the resident himself revealed that after his surgery in August 2023, Resident #42 did not receive the restorative therapy he required. The family member expressed concerns that the facility had neglected to provide necessary exercises and therapy, leaving the resident without support for six months. The resident also confirmed that he had not received restorative therapy after his first surgery and was awaiting physical therapy following a second surgery. Interviews with facility staff, including the Director of Rehabilitation and the Restorative Aide, indicated a lack of communication and follow-through in providing restorative services. The Restorative Aide admitted to not attempting restorative therapy for a long time and was unaware of any recent requests for such services for Resident #42. The Director of Nursing was also unaware that the resident had not been receiving restorative therapy, highlighting a breakdown in the facility's processes to ensure residents receive necessary care.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident identified as being at risk for falls. The resident, who was admitted with diagnoses including unspecified dementia and was totally dependent on staff for daily activities, was left unattended in bed without the necessary fall interventions in place. Specifically, the bed was not in its lowest position, and the fall mat was not properly positioned, leading to the resident experiencing a fall. The incident occurred when a CNA left the resident unattended to assist another resident and subsequently began passing breakfast trays, neglecting to return to the resident. The fall resulted in an abrasion on the resident's forehead, which was assessed and treated by the ADON. The facility's policy on fall prevention was not adhered to, as the environmental factors such as bed positioning and the use of fall mats were not properly managed, contributing to the resident's fall.
Failure to Administer Vancomycin as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Vancomycin. The resident, a male with multiple diagnoses including acute osteomyelitis, was admitted to the facility with a physician's order for Vancomycin 750 mg to be administered every 12 hours. However, the medication was not administered as ordered on the specified date due to the drug being unavailable, resulting in the resident missing a scheduled dose. Interviews with facility staff revealed that there was a process in place for handling medication orders upon a resident's admission. The Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON) stated that the expectation was to verify medication availability and contact the physician if the medication was not available. Despite these procedures, the medication was not administered on time, and the staff involved did not follow the protocol to ensure the resident received the medication as prescribed. The Director of Nursing (DON) confirmed that the facility's expectation was for medication to be ordered within one hour of a resident's admission and that the pharmacy could deliver medications within a few hours. The DON also stated that if the medication was unavailable, staff were to contact the physician for alternative orders. The failure to administer the medication as ordered was identified as a medication error, highlighting a lapse in the facility's medication management process.
Failure to Inspect and Maintain Bed Equipment
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which led to a deficiency in the care provided to a resident. The deficiency was identified through observation, interview, and record review, revealing that the facility did not have a regular maintenance program to identify potential risks and problems with the beds. This failure was specifically noted in the case of a resident who was placed on a worn-out mattress that was peeling, causing blue flakes to cover the resident's back. The lack of a flat sheet and the presence of only a disposable bed pad further contributed to the issue. The resident involved was a male with multiple medical conditions, including acute osteomyelitis, overactive bladder, dysphagia, and Parkinsonism, among others. Despite having intact cognitive skills for daily decision-making, as indicated by a BIMS score of 14, the resident required assistance with mobility in bed. The incident was brought to the attention of the facility staff by the resident's family member, who noticed the peeling mattress and the absence of proper bedding. The Assistant Director of Nursing (ADON) acknowledged the issue and noted that the peeling was due to the breakdown of the mattress from cleaning chemicals.
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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) |
|---|---|---|---|---|
| The Meadows Health And Rehabilitation Center | 0.3 mi | ★★★★★ | 8 | 0 |
| The Legacy Midtown Park | 0.7 mi | ★★★★★ | 3 | 0 |
| Pure Health Transitional Care At Texas Health Pres | 0.9 mi | ★★★★★ | 0 | 0 |
| Presbyterian Village North Special Care Ctr | 1.8 mi | ★★★★★ | 1 | 0 |
| The Highlands Guest Care Center | 2 mi | ★★★★★ | 19 | 0 |
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