Inspection Reports for Advanced Health and Rehabilitation Center of Garland
TX, 75403
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
349% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 5
Nov 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and infection control at Advanced Health & Rehab Center of Garland.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans with measurable objectives, inadequate pressure ulcer care, insufficient supervision during resident transfers, unsafe respiratory care practices, and lapses in infection prevention and control practices such as hand hygiene.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan including measurable objectives and timeframes, specifically lacking hydraulic lift and transfer interventions for Resident #2. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers, including uncovered stage IV sacral pressure ulcer for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure nursing home area is free from accident hazards and provide adequate supervision, specifically failure to use two staff members during hydraulic lift transfer for Resident #2. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate respiratory care, including oxygen tubing positioned on the floor and zip-tied to bedside table for Resident #3, and failure to perform hand hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an infection prevention and control program, including multiple staff failing to perform proper hand hygiene during resident care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care plans: 6
Residents reviewed for wound care: 5
Residents reviewed for accidents and supervision: 5
Residents reviewed for respiratory care: 4
Residents reviewed for infection control: 6
BIMS score: 0
BIMS score: 0
Braden Scale score: 6
Skills checkoffs frequency: 2
Skills checkoffs frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in hydraulic lift transfer deficiency for Resident #2 | |
| ADON | Assistant Director of Nursing | Interviewed regarding hydraulic lift use and care plan deficiencies for Resident #2 |
| DON | Director of Nursing | Interviewed regarding hydraulic lift use and care plan deficiencies for Resident #2 |
| CNA B | Named in pressure ulcer care and infection control deficiencies for Resident #1 | |
| CNA C | Named in infection control deficiencies related to hand hygiene | |
| LVN E | Licensed Vocational Nurse | Named in infection control and pressure ulcer care deficiencies |
| LVN F | Licensed Vocational Nurse | Named in respiratory care and infection control deficiencies for Resident #3 |
| LVN G | Licensed Vocational Nurse | Named in infection control deficiencies related to hand hygiene |
| Treatment Nurse | Named in pressure ulcer care deficiencies for Resident #1 | |
| Administrator | Provided staffing records and interviewed regarding infection control and care plan deficiencies | |
| Hospice Aide | Named in pressure ulcer care deficiency for Resident #1 |
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 25, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident care, medication administration, call system accessibility, and restraint use at Advanced Health & Rehab Center of Garland.
Findings
The facility was found deficient in ensuring residents were free from physical restraints without physician orders, accurate medication administration documentation, and accessible call light systems for residents. Deficiencies were noted in restraint use without physician orders for a bolster mattress, inaccurate medication administration records for a resident who refused medication, and call lights being out of reach for several residents, posing risks to resident safety and care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1 was free from physical restraints without physician orders for the bolster mattress. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide pharmaceutical services including accurate medication administration documentation for Resident #5, who refused medication but was documented as receiving it. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a working call system was accessible and within reach for Residents #1, #2, #3, and #4. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN O | Licensed Vocational Nurse | Named in medication administration finding for prematurely coding medication as administered |
| ADON A | Assistant Director of Nursing | Interviewed regarding physical restraint and call light deficiencies |
| ADON S | Assistant Director of Nursing | Interviewed regarding medication administration documentation |
| Administrator | Interviewed regarding physical restraint and medication administration findings | |
| LVN E | Charge Nurse | Interviewed regarding medication administration documentation |
| CNA M | Certified Nursing Assistant | Interviewed and observed repositioning call lights for residents |
| CNA C | Certified Nursing Assistant | Interviewed and observed repositioning call lights for residents |
| RN O | Registered Nurse | Interviewed regarding call light accessibility |
| LPN A | Licensed Practical Nurse | Interviewed regarding call light accessibility |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 12, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to establish and implement proper admission policies and to ensure safe and appropriate transfer/discharge procedures for residents, specifically focusing on Resident #1's admission and subsequent transfer to the ER.
Findings
The facility failed to provide Resident #1 and his representative with required admission documentation and disclosures, placing residents at risk of uninformed care and financial obligations. Additionally, the facility failed to ensure safe transfer/discharge practices, sending Resident #1 to the ER without staff supervision, adequate clinical information, or proper coordination with the resident's representative, resulting in an Immediate Jeopardy that was later removed but with ongoing compliance issues.
Complaint Details
The complaint investigation focused on Resident #1, who was admitted without proper admission documentation and was transferred to the ER unsafely without staff supervision or adequate communication with the resident's representative. The Immediate Jeopardy was identified due to unsafe transfer practices and lack of clinical information provided to the ER. The facility submitted a Plan of Removal addressing transport protocols and staff education.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide Resident #1 and his representative with a written admission agreement, consent to treat, resident rights notification, Medicare/Medicaid information, or disclosure of services and charges at admission. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure safe transfer/discharge of Resident #1, including lack of supervision during transport to the ER, failure to notify and coordinate with the resident's representative, and failure to provide clinical information to the receiving hospital. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents reviewed for admissions: 3
Residents reviewed for hospital transfers: 5
Plan of Removal education completion date: Specific completion dates mentioned but redacted
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Admitting Nurse | Conducted nursing assessment on Resident #1 during admission and documented resident's agitation and need for supervision |
| BOM | Business Office Manager | Responsible for admission documentation and acknowledged lack of required admission paperwork for Resident #1 |
| DON | Director of Nursing | Made decisions regarding Resident #1's transfer to ER, communicated with EMS and private transport, and acknowledged lack of supervision during transfer |
| LVN A | Licensed Vocational Nurse | Provided care to Resident #1 during agitation, coordinated transport, and communicated with DON and RP |
| NP G | Nurse Practitioner | Gave verbal order for ER transfer and provided clinical oversight |
| Staff C | CNA and Facility Van Driver | Assisted with arranging transport for Resident #1 to ER |
| CNA D | Certified Nursing Assistant | Provided care to Resident #1 during agitation and noted lack of abdominal binder |
| Receptionist E | Receptionist | Notified about Resident #1's transfer and communicated with RP |
| ADM | Administrator | Provided oversight and interviews regarding Resident #1's admission and transfer |
| Driver H | Private Transport Driver | Transported Resident #1 to ER and reported on arrival and supervision |
Inspection Report
Routine
Deficiencies: 6
Apr 10, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident rights, environment, care planning, pharmaceutical services, food safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, inadequate cleaning of resident rooms and kitchen, incomplete care planning for a resident's dermatitis treatment, expired medication storage, and lapses in infection control practices such as improper glove use and hand hygiene.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure call light systems were accessible to residents in 5 of 34 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure 10 of 15 resident rooms in the memory care unit were thoroughly cleaned and sanitized. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a comprehensive care plan for Resident #17's dermatitis treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to dispose of expired medication (Magnesium Oxide) found on medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain food service safety including unclean ice machine, dirty cooking equipment, uncovered food and storage bins, and uncovered tea dispenser. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper infection prevention and control practices including removal of gloves and hand hygiene before using medication cart laptops. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for call light accessibility: 34
Residents affected by call light deficiency: 5
Resident rooms reviewed for environment: 15
Expired medication found: 1
Residents reviewed for care plan deficiency: 6
Residents reviewed for infection control: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Stated importance of call light accessibility and proper glove removal | |
| CNA B | Stated call lights should be within reach for residents | |
| Medication Aide H | Emphasized importance of call light placement | |
| CNA I | Placed call light within reach of Resident #17 | |
| CNA J | Placed call light near Resident #107 | |
| ADON E | Stated expectations for call light accessibility and infection control | |
| ADON G | Stated importance of call light accessibility and glove removal | |
| ADON D | Stated importance of call light accessibility, care plan updates, and medication cart checks | |
| DON | Stated expectations for call light accessibility, care plan updates, medication cart checks, and infection control training | |
| Housekeeping Supervisor | Discussed cleaning responsibilities and risks of unclean rooms | |
| Housekeeping D | Responsible for cleaning memory care unit rooms and notifying maintenance | |
| Maintenance Director | Responsible for cleaning air vents and air condition units | |
| Medication Aide F | Observed with expired medication and improper glove use | |
| RN C | Observed with improper glove use and hand hygiene | |
| Dietary Manager | Discussed kitchen cleanliness and food safety practices | |
| Administrator | Discussed expectations for cleanliness and infection control | |
| LVN O | Discussed care planning for dermatitis treatment |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 16, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to immediately inform the resident, consult with the resident's physician, and notify the resident's durable power of attorney when the resident missed a scheduled dialysis appointment on 03/07/25.
Findings
The facility failed to notify Resident #1's durable power of attorney for healthcare about the missed dialysis appointment, and there was no transportation arranged for the resident. Staff interviews confirmed the failure to notify the family member, despite notifying the Administrator, Director of Nursing, and Assistant Director of Nursing. The resident refused dialysis, but the facility did not follow proper notification procedures as outlined in their Patient Refusal of Care policy.
Complaint Details
The complaint investigation found that the facility did not notify the durable power of attorney for healthcare when Resident #1 missed dialysis on 03/07/25. Interviews confirmed the family was not notified, although the Administrator, Director of Nursing, Assistant Director of Nursing, and Medical Doctor were notified. The Nurse Practitioner confirmed the resident had not refused dialysis care in the past. The facility's Patient Refusal of Care policy requires notification of the physician and family about refusal of care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately inform the resident, consult with the resident's physician, and notify the resident representative when there was a significant change in the resident's status, specifically missing a scheduled dialysis appointment. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 5
Residents affected: Few
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Wrote progress note dated 03/08/25 and reported missing dialysis appointment |
| RN B | Registered Nurse | Interviewed and stated Resident #1 refused dialysis and notified Administrator, Director of Nursing, Assistant Director of Nursing, and Medical Doctor |
| Assistant Director of Nursing | Interviewed regarding scheduling transportation and notification procedures | |
| Administrator | Involved in notification and follow-up interviews | |
| Director of Nursing | Involved in notification and follow-up interviews | |
| Nurse Practitioner | Interviewed and confirmed resident had not refused dialysis care in the past |
Inspection Report
Complaint Investigation
Deficiencies: 5
Dec 2, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide safe and appropriate respiratory care to residents, including failure to obtain physician orders for oxygen administration, improper oxygen dispensing, inadequate monitoring, and infection control issues related to respiratory care.
Findings
The facility failed to ensure residents received necessary respiratory care according to professional standards, care plans, and resident choices, resulting in immediate jeopardy to resident health or safety. Specific failures included lack of physician orders for oxygen, inappropriate oxygen levels administered, inadequate supervision and monitoring leading to a resident's death, and poor infection control practices with respiratory equipment.
Complaint Details
The complaint investigation was triggered by a 911 call for an unresponsive resident (Resident #1). Video evidence and interviews revealed that the night nurse did not check on Resident #1 every two hours or provide required respiratory care. Resident #1 was found unresponsive and later pronounced dead. The investigation found multiple failures in respiratory care and monitoring, placing residents at risk of harm.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to obtain a physician's order to administer oxygen to Resident #1 upon readmission. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide appropriate oxygen levels to Resident #1, administering oxygen at levels higher than prescribed. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to adequately supervise or monitor Resident #1 during an eight-hour shift, resulting in resident found unresponsive and subsequent death. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to safely handle and perform infection control practices for Resident #2's tracheostomy tubing. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide consistent oxygen therapy for Resident #3. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Oxygen flow rates: 7
Oxygen flow rates: 10
Critical CO2 lab value: 45
Time of death: 5.23
Shift duration: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Named in findings for failure to obtain physician orders, inadequate monitoring, and failure to respond appropriately to Resident #1's respiratory condition. | |
| RN H | Documented admitting diagnosis and care for Resident #1; involved in care and documentation related to respiratory treatment. | |
| NP N | Nurse Practitioner | Provided physician progress notes and orders related to Resident #1's respiratory care and treatment. |
| CNA U | Found Resident #1 unresponsive and initiated emergency response. | |
| MOD | RN Weekend Supervisor | Interviewed regarding Resident #1's condition and care during the weekend. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Sep 3, 2024
Visit Reason
The inspection was conducted to investigate complaints related to trust fund management, discharge planning, medication administration, laboratory services, wound care documentation, and infection control at the facility.
Findings
The facility failed to properly manage residents' trust funds, complete discharge summaries, administer medications as ordered, provide timely laboratory services, document wound care treatments, and maintain effective infection control protocols, including COVID-19 isolation procedures.
Complaint Details
The investigation was complaint-driven, focusing on allegations of mismanagement of resident funds, inadequate discharge planning, medication errors, delayed lab testing, incomplete wound care documentation, and infection control breaches.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to hold, safeguard, manage and account for the personal funds of Resident #3, including failure to ensure trust fund was spent down to avoid Medicaid over-resourcing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a discharge summary for Resident #6 including diagnoses, treatment course, and medication reconciliation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer medications and take vital signs as ordered for Residents #7 and #9, including failure to document blood pressure and blood glucose readings and medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide or obtain timely laboratory services for Resident #1, including failure to complete a C-diff stool test as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete, accurate, and accessible medical records for Residents #4 and #5, including failure to document wound care treatments on multiple occasions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to establish and maintain an infection prevention and control program, including failure to isolate COVID positive Resident #2 appropriately for the required 10 days. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Trust fund balance: 6306.04
Trust fund monthly credits: 30
Trust fund monthly credits: 45
Trust fund monthly interest: 15
Medication doses missed: 3
Blood glucose checks missed: 28
Wound care treatments undocumented: 29
Wound care treatments undocumented: 36
COVID isolation days: 10
COVID isolation days breached: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Charge nurse involved in medication administration and lab specimen collection for Resident #1, #7, and #9 |
| LVN C | Licensed Vocational Nurse | Nurse who documented Resident #2's COVID positive status and observed Resident #2 outside isolation |
| LVN E | Licensed Vocational Nurse | Nurse who described medication administration documentation and wound care responsibilities |
| LVN F | Wound Care Nurse | Responsible for wound care treatments and documentation |
| BOM | Business Office Manager | Interviewed regarding trust fund management and notification processes |
| SW | Social Worker | Interviewed regarding Resident #3's trust fund spend down efforts |
| DON | Director of Nursing | Interviewed regarding medication administration, wound care, and infection control policies |
| ADM | Administrator | Interviewed regarding oversight of trust funds and infection control protocols |
| ADON B | Assistant Director of Nursing | Interviewed regarding discharge summary responsibilities and wound care audits |
Inspection Report
Routine
Deficiencies: 6
Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, infection control, activities of daily living, and call system functionality at Advanced Health & Rehab Center of Garland.
Findings
The facility failed to ensure effective communication for a Spanish-speaking resident, maintain clean and good condition privacy curtains for multiple residents, provide timely incontinence and personal care, maintain infection control practices, and ensure working call light systems for residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Resident #54 was not provided sufficient modes of communication, resulting in inadequate assessment and unmet needs due to language barriers. | Level of Harm - Minimal harm or potential for actual harm |
| Privacy curtains for Residents #4, #51, #76, #97, and #107 were visibly soiled and in poor condition, risking infection control and dignity. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #24 did not receive incontinence care every two hours as required. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #29 had long, dirty fingernails that were not properly cleaned and trimmed. | Level of Harm - Minimal harm or potential for actual harm |
| CNA failed to perform hand hygiene before and during incontinence care for Resident #89, risking infection transmission. | Level of Harm - Minimal harm or potential for actual harm |
| Resident #69's call light was not always working, preventing timely assistance and increasing risk of harm. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for environment: 10
Residents affected by privacy curtain issue: 5
Residents reviewed for ADLs: 8
Residents affected by ADL deficiencies: 2
Residents observed for infection control: 8
Residents affected by infection control deficiency: 1
Residents reviewed for call system: 7
Residents affected by call system deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Interviewed about communication with Resident #54 | |
| DON | Director of Nursing | Interviewed about communication methods, incontinence care, infection control, and call light system |
| ADON | Assistant Director of Nursing | Interviewed about communication with Resident #54 and call light system |
| LVN C | Interviewed regarding Resident #54 hospital transfer and communication issues | |
| CNA A | Certified Nursing Assistant | Observed failing to perform hand hygiene during incontinence care for Resident #89 |
| CNA F | Certified Nursing Assistant | Interviewed about incontinence care for Resident #24 |
| CNA G | Certified Nursing Assistant | Interviewed about incontinence care for Resident #24 |
| LVN J | Interviewed about fingernail care responsibilities | |
| CNA R | Certified Nursing Assistant | Interviewed about Resident #29 fingernail care |
| LVN O | Interviewed about Resident #29 fingernail care | |
| CNA H | Certified Nursing Assistant | Interviewed about call light system for Resident #69 |
| CNA I | Certified Nursing Assistant | Interviewed about call light system for Resident #69 |
| RN J | Registered Nurse | Interviewed about call light system for Resident #69 |
| Maintenance Director | Interviewed about call light system maintenance and monitoring | |
| Administrator | Interviewed about call light system and facility policies | |
| OT K | Occupational Therapist | Interviewed about privacy curtain condition |
| Activity Director | Interviewed about Resident #54 activities and communication | |
| Family Member | Interviewed about concerns with Resident #54 care | |
| DO | Doctor | Interviewed about inability to assess Resident #54 due to language barrier |
Inspection Report
Routine
Deficiencies: 5
Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, environment, activities of daily living, infection control, and call system functionality.
Findings
The facility was found deficient in ensuring effective communication for a Spanish-speaking resident, maintaining clean and good condition privacy curtains for multiple residents, providing timely assistance with activities of daily living including incontinence care and fingernail hygiene, maintaining infection control practices during care, and ensuring call light systems were functional for resident safety.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure Resident #54 was fully informed and understood health status due to language barrier and lack of sufficient communication modes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain privacy curtains in clean and good condition for five residents (Resident #4, #51, #76, #97, #107). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary assistance for activities of daily living for Resident #24 (incontinence care every 2 hours) and Resident #29 (fingernails cleaned and trimmed). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection control practices; CNA failed to perform hand hygiene during incontinence care for Resident #89. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure call light system was always working for Resident #69, placing resident at risk of not obtaining assistance. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for environment: 10
Residents affected by privacy curtain deficiency: 5
Residents reviewed for ADLs: 8
Residents affected by ADL deficiencies: 2
Residents observed for infection control: 8
Residents affected by infection control deficiency: 1
Residents reviewed for call system: 7
Residents affected by call system deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Named in incident involving Resident #54's hospital transfer and communication issues |
| DON | Director of Nursing | Interviewed regarding communication issues, infection control, and ADL care |
| ADON | Assistant Director of Nursing | Interviewed regarding communication and care for Resident #54 |
| CNA A | Certified Nursing Assistant | Failed to perform hand hygiene during incontinence care for Resident #89 |
| Maintenance Director | Responsible for call light maintenance and interviewed about call light issues | |
| Housekeeping and Laundry Manager | Interviewed regarding privacy curtain cleaning and maintenance | |
| Administrator | Interviewed regarding facility policies and awareness of deficiencies | |
| CNA H | Certified Nursing Assistant | Interviewed regarding call light system for Resident #69 |
| CNA R | Certified Nursing Assistant | Interviewed regarding Resident #29's fingernail care |
| LVN O | Licensed Vocational Nurse | Interviewed regarding Resident #29's fingernail care |
| RN J | Registered Nurse | Interviewed regarding call light system for Resident #69 |
| CNA I | Certified Nursing Assistant | Interviewed regarding call light system for Resident #69 |
| CNA F | Certified Nursing Assistant | Interviewed regarding incontinence care for Resident #24 |
| CNA G | Certified Nursing Assistant | Interviewed regarding incontinence care for Resident #24 |
| CNA V | Certified Nursing Assistant | Observed and interviewed regarding infection control during care for Resident #89 |
| OT K | Occupational Therapist | Interviewed regarding observation of privacy curtain conditions |
| Activity Director | Interviewed regarding Resident #54's activity participation and communication | |
| DO | Doctor | Interviewed regarding inability to assess Resident #54 due to language barrier |
Inspection Report
Routine
Census: 38
Deficiencies: 3
Sep 21, 2023
Visit Reason
The inspection was conducted to assess the accuracy of resident assessments, comprehensive care plans, and to evaluate the facility's ability to prevent accidents and elopements, including a review of a recent elopement incident involving Resident #50.
Findings
The facility failed to ensure accurate and complete Minimum Data Set (MDS) assessments for multiple residents, failed to develop and implement comprehensive individualized care plans addressing behaviors and interventions for some residents, and failed to provide adequate supervision and environmental controls to prevent elopement of Resident #50. The facility corrected the elopement issue prior to the survey and implemented additional safety measures.
Deficiencies (3)
| Description |
|---|
| Failed to ensure accurate MDS assessments for 5 of 13 residents, missing documentation of mood, behaviors, anxiety, and oxygen use. |
| Failed to develop and implement comprehensive care plans addressing behaviors and interventions for Residents #10, #20, and #50. |
| Failed to provide adequate supervision and environmental controls to prevent elopement of Resident #50 on 08/23/23. |
Report Facts
Residents reviewed for MDS accuracy: 13
Residents reviewed for comprehensive care plans: 9
Census: 38
Elopement incident date: Aug 23, 2023
Elopement monitoring duration: 72
Generator test announcement time: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided statements on expectations for assessment accuracy, care plan development, and elopement incident response | |
| Director of Nursing (DON) | Responsible for monitoring assessments, care plans, and staff education; updated care plans after findings | |
| Assistant Director of Nursing (ADON) | Involved in monitoring, education, and response to elopement incident | |
| MDS Coordinator | Responsible for conducting timely MDS assessments and care plan updates | |
| Social Worker (LMSW) | Responsible for updating MDS and care plans during open assessment periods | |
| Licensed Vocational Nurse (LVN E) | Last observed Resident #50 before elopement; provided statements on protocols and training | |
| Certified Nursing Assistant (CNA C) | Provided statements on elopement drills and resident supervision | |
| Licensed Vocational Nurse (LVN A) | Provided statements on elopement drill procedures and staff responsibilities | |
| Licensed Vocational Nurse (LVN G) | Provided statements on staff supervision and elopement prevention protocols | |
| Certified Nursing Assistant (CNA D) | Observed and reported on elopement incident and subsequent staff actions | |
| Medical Director (MDD) | Conducted generator test, investigated elopement incident, and implemented corrective actions |
Inspection Report
Routine
Deficiencies: 5
Jan 27, 2023
Visit Reason
The inspection was conducted to assess compliance with care planning, accident prevention, and food service safety standards at the Advanced Health & Rehab Center of Garland.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #27, specifically failing to place a fall mat alongside the bed as required. Additionally, the facility did not ensure the resident environment was free from accident hazards and adequate supervision was provided to prevent accidents. The kitchen failed to comply with food safety standards, including improper labeling and dating of food items and staff not wearing proper head and face coverings.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to develop and implement a complete care plan that meets all the resident's needs, including measurable objectives and timeframes, for Resident #27. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure Resident #27's fall mat was placed alongside the resident's bed as per care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the nursing home area was free from accident hazards and provided adequate supervision to prevent accidents for Resident #27. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper labeling and dating of all foods stored in the refrigerator, freezer, and dry food storage areas. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff wore proper head and face coverings when serving food. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Food items: 15
Hamburger buns: 24
Hot dog buns: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Observed and interviewed regarding fall mat placement for Resident #27 |
| DON | Director of Nursing | Interviewed about Resident #27's care plan and fall mat placement |
| Administrator | Interviewed about Resident #27's care plan and kitchen safety concerns | |
| Interim Dietary Manager | Observed not wearing beard covering and interviewed about food safety compliance | |
| Culinary Regional Dietary Manager | Observed not wearing beard covering and interviewed about food safety compliance | |
| Dietary Manager | Interviewed about food labeling and kitchen safety responsibilities | |
| Culinary Regional Director | Interviewed about food labeling and kitchen safety responsibilities |
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