Inspection Reports for Beacon Harbor Healthcare and Rehabilitation
TX, 75087
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 11, 2025, found deficiencies related to failure to notify a resident’s responsible party about a significant change in condition. Earlier inspections identified issues with resident privacy, safe transfers, food safety, medication errors, and environmental cleanliness. Complaint investigations substantiated failures in communication, medication administration, resident dignity, and supervision, including a serious injury from a resident fall during transfer. Enforcement actions such as staff termination and retraining were noted, but fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring themes in communication and care coordination issues, with some improvements following corrective actions, though deficiencies have persisted over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
114% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to immediately inform the resident, consult with the resident's physician, and notify the resident's representative of a significant change in the resident's condition.
Complaint Details
The complaint investigation found the facility failed to notify Resident #1's responsible party when the resident's midline IV was removed on 12/03/2025, despite the resident having a significant change in condition. Interviews with staff and the responsible party confirmed the failure to notify, which is against facility policy.
Findings
The facility failed to notify Resident #1's responsible party when the resident's midline IV was found removed from his arm, resulting in potential risk due to lack of timely communication about the resident's change in condition. Interviews and record reviews confirmed the failure to notify the responsible party despite policy requirements.
Deficiencies (1)
Failure to immediately inform the resident, consult with the resident's physician, and notify the resident's representative of significant changes in condition.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in findings related to failure to notify responsible party and documentation of resident's condition. |
| LVN A | Licensed Vocational Nurse | Interviewed regarding notification procedures and acknowledged failure to notify responsible party. |
| ADON C | Assistant Director of Nursing | Interviewed about assessment and notification procedures for changes in condition. |
| ADON D | Assistant Director of Nursing | Interviewed about notification procedures and resident communication. |
| NP E | Nurse Practitioner | Provided medical orders following notification from RN B about resident's condition. |
| DON | Director of Nursing | Stated expectations for notification of family and responsible party. |
| ADM | Administrator | Discussed staff education and policy enforcement regarding notification of changes in condition. |
| MD | Medical Doctor | Provided medical assessment and orders related to resident's condition. |
Inspection Report
Routine
Deficiencies: 3
Date: Dec 4, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, environment, care planning, and clinical record accuracy at Beacon Harbor Healthcare and Rehabilitation.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment as evidenced by stained bed sheets for Resident #1, failure to review and revise the comprehensive care plan quarterly for Resident #1, and inaccurate nursing documentation regarding new bruises for Resident #2. These deficiencies posed minimal harm or potential for actual harm to a few residents.
Deficiencies (3)
Failed to ensure Resident #1's sheets were clean and free of stains.
Failed to ensure the comprehensive care plan was reviewed and revised quarterly by the interdisciplinary team for Resident #1.
Failed to maintain clinical records accurately; nursing notes incorrectly documented bruises as old when they were new for Resident #2.
Report Facts
Residents affected: 1
Residents affected: 1
BIMS score: 10
BIMS score: 7
Fall dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Interviewed regarding bed sheet changes for Resident #1 | |
| Director of Nursing | Director of Nursing | Interviewed regarding bed linens and nursing documentation |
| Social Worker | Interviewed regarding care plan conferences and scheduling | |
| Administrator | Administrator | Interviewed regarding care plan updates and documentation issues |
| LVN B | Licensed Vocational Nurse | Authored nursing notes and incident report with inaccurate documentation for Resident #2 |
| LVN C | Licensed Vocational Nurse | Authored incident report dated 08/12/2024 for Resident #2 |
| LVN D | Licensed Vocational Nurse | Authored incident report dated 08/11/2024 for Resident #2 |
| LVN E | Licensed Vocational Nurse | Authored nursing note dated 08/12/2024 for Resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 22, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to ensure resident privacy during incontinent care and failure to ensure safe resident transfers using a Hoyer lift, as well as concerns about food safety in the facility's kitchen.
Complaint Details
The complaint investigation substantiated that the facility failed to maintain resident privacy during personal care for four residents due to broken blinds and inadequate window coverings. It also substantiated a serious incident where a resident fell from a Hoyer lift due to improper transfer technique by a physical therapist, resulting in multiple fractures and brain hemorrhage. The physical therapist was terminated and the facility implemented staff training and competency checks. Additionally, food safety violations were identified related to improper labeling, storage, and sanitation in the kitchen.
Findings
The facility failed to ensure privacy for residents during personal care due to broken blinds and inadequate window coverings, placing residents at risk of embarrassment and loss of dignity. Additionally, the facility failed to follow safe transfer protocols resulting in a resident falling from a Hoyer lift and sustaining serious injuries. The facility also failed to maintain proper food labeling, storage, and sanitation in the kitchen, risking foodborne illness.
Deficiencies (3)
Failure to ensure personal privacy during incontinent care due to broken blinds and inadequate window coverings.
Failure to ensure safe resident transfers using Hoyer lift, resulting in resident fall and serious injuries.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including improper labeling, expired items, and unsanitary conditions.
Report Facts
Residents reviewed for privacy: 15
Residents affected by privacy deficiency: 4
Date of resident fall: Feb 1, 2024
Duration of Immediate Jeopardy: 2
Staff in-service date: Feb 2, 2024
Number of bowls with expired cereals: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PT K | Physical Therapist | Named in the finding related to improper Hoyer lift transfer causing resident fall and injuries. |
| LVN C | Licensed Vocational Nurse | Observed providing incontinent care without adequate privacy due to broken blinds. |
| DON | Director of Nursing | Provided statements regarding staff responsibilities for resident privacy and investigation of the Hoyer lift incident. |
| RN L | Registered Nurse | Assessed resident after fall from Hoyer lift and reported injuries. |
| DM | Dietary Manager | Provided information about food storage practices and acknowledged deficiencies. |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident privacy, physical environment safety, food service safety, and infection prevention and control in the facility.
Findings
The facility failed to ensure resident privacy during incontinent care due to broken or missing window blinds, failed to maintain a safe and homelike environment including clean vents, intact baseboards, and safe handrails, failed to properly label and store food items in the kitchen, and failed to ensure staff performed hand hygiene during meal service, placing residents at risk for privacy violations, unsafe environment, foodborne illness, and infection transmission.
Deficiencies (4)
Failed to ensure personal privacy during incontinent care due to broken or missing window blinds exposing residents to view.
Failed to provide a safe, clean, comfortable, and homelike environment including unclean intake vents, missing blinds, detached baseboards, and broken handrails.
Failed to store, prepare, distribute, and serve food in accordance with professional standards including unlabeled food items, expired or improperly stored food, and unclean eyewash station.
Failed to implement an infection prevention and control program by staff failing to perform hand hygiene after resident contact during meal service.
Report Facts
Residents reviewed for privacy: 15
Residents affected by privacy deficiency: 4
Resident halls reviewed for physical environment: 3
Resident rooms with missing blinds: 3
Staff members failing hand hygiene: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Observed providing incontinence care and interviewed about privacy concerns. |
| CNA B | Certified Nursing Assistant | Reported broken blinds and privacy practices. |
| Resident #3 | Reported broken blinds and privacy concerns. | |
| Resident #38 | Reported blinds did not cover window and privacy curtain use. | |
| MA A | Medical Assistant | Reported privacy practices during personal care. |
| CNA D | Certified Nursing Assistant | Reported privacy practices and dignity issues. |
| LVN E | Licensed Vocational Nurse | Reported need for window coverings to ensure privacy. |
| CNA F | Certified Nursing Assistant | Reported privacy practices including closing blinds and curtains. |
| DON | Director of Nursing | Reported expectations for privacy and maintenance plans. |
| RN G | Registered Nurse | Reported expectations for privacy during personal care. |
| LVN H | Licensed Vocational Nurse | Reported privacy procedures during personal care. |
| CNA I | Certified Nursing Assistant | Reported maintenance reporting practices. |
| LVN J | Licensed Vocational Nurse | Reported maintenance reporting practices. |
| Maintenance Director | Reported maintenance and renovation activities. | |
| DM | Dietary Manager | Reported food storage and labeling practices. |
| CNA M | Certified Nursing Assistant | Observed failing hand hygiene during meal service. |
| CNA P | Certified Nursing Assistant | Observed failing hand hygiene during meal service. |
| CNA Q | Certified Nursing Assistant | Observed failing hand hygiene during meal service. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2024
Visit Reason
The inspection was conducted due to a complaint regarding a medication error where Resident #1 was provided the incorrect medications when going on therapeutic leave on 06/02/24.
Complaint Details
The complaint was substantiated. Resident #1's family reported that on 06/02/24, Resident #1 was given another resident's medications and not his insulin. The facility confirmed the error and took corrective actions including staff re-training.
Findings
The facility failed to provide pharmaceutical services to meet the needs of Resident #1 by giving him the medications of Resident #2 during therapeutic leave, placing residents at risk of harm. The error was identified and reported promptly, and staff involved were re-trained on medication administration and leave of absence medication procedures.
Deficiencies (1)
Failed to provide pharmaceutical services to meet the needs of Resident #1, resulting in the resident being given another resident's medications during therapeutic leave.
Report Facts
Residents reviewed for medications: 5
Residents affected: 1
Inservice dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Nurse who administered incorrect medications to Resident #1 and reported the error |
| MA B | Medication Aide | Prepared the incorrect medications for Resident #1 |
| LVN C | Supervisor | Supervisor who took over the situation after the medication error was reported |
| DON | Director of Nursing | Conducted one-on-one inservices and facility-wide staff training following the medication error |
| ADMIN | Administrator | Investigated the medication error and ensured corrective actions were taken |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 28, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to immediately notify the hospice agency about significant changes in the condition of a resident receiving hospice care, specifically falls and changes in condition on 02/22/24 and 02/25/24.
Complaint Details
The complaint investigation found that the facility did not notify the hospice agency immediately of Resident #1's falls and change in condition on 02/22/24 and 02/25/24. The hospice supervising nurse confirmed not being informed by the facility. The Director of Nursing stated hospice was verbally notified on 02/26/24 but not documented. The complaint was substantiated with minimal harm.
Findings
The facility failed to notify the hospice agency immediately about Resident #1's falls and change in condition, which could place residents at risk of health decline. Interviews and record reviews confirmed the lack of timely notification and documentation despite notification of the physician and family. Facility policies on significant change in condition and end-of-life care were reviewed.
Deficiencies (1)
Failure to immediately notify hospice agency about significant change in resident's condition including falls on 02/22/24 and 02/25/24.
Report Facts
Date of falls: Falls occurred on 02/22/2024 and 02/25/2024
Time of nursing note: Nursing notes dated 02/22/24 at 3:45 PM and 02/25/24 at 8:33 PM and 9:01 PM
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Authored nursing notes documenting Resident #1's fall and condition on 02/22/24 | |
| LVN B | Authored nursing notes and incident report regarding Resident #1's falls on 02/25/24 | |
| LVN C | Interviewed regarding hospice notification procedures | |
| LVN D | Interviewed regarding hospice notification procedures | |
| DON | Director of Nursing | Interviewed regarding failure to document hospice notification and notification timeline |
| Hospice Supervising Nurse | Interviewed and confirmed not being notified by facility of falls |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 16, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to honor a resident's right to choose their attending physician.
Complaint Details
The complaint investigation found that Resident #1's appointments were not scheduled and the facility assigned a physician not familiar with her care needs. The resident's responsible party (RP) expressed concerns about lack of continuity of care and transportation. The facility staff acknowledged the issues and noted that a grievance should have been filed but was not initiated.
Findings
The facility failed to honor Resident #1's right to choose her primary care physician as her attending physician upon readmission, resulting in concerns about continuity of care and appointment scheduling. Interviews and record reviews confirmed that Resident #1 was assigned a facility physician instead of her chosen PCP, and follow-up appointments were not scheduled as per hospital discharge instructions.
Deficiencies (1)
Failed to honor the resident's right to choose his or her attending physician.
Report Facts
Residents reviewed for resident rights: 5
BIMS score: 10
Oxygen flow rate: 1
Follow-up appointment date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marketing Specialist | Admissions Director | Discussed admission process and resident rights, including the right to choose a primary care physician. |
| LSW | Licensed Social Worker | Responsible for scheduling follow-up appointments and discussed resident rights and grievance process. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 7, 2023
Visit Reason
The inspection was conducted based on complaints and observations regarding housekeeping deficiencies, failure to provide timely incontinent care, inadequate treatment and monitoring of a resident's change in condition, and medication administration issues.
Complaint Details
The complaint investigation was triggered by multiple resident and family member reports of inadequate housekeeping, delayed or missed incontinent care, failure to administer prescribed pain medication, and failure to properly assess and treat a resident's pain and injury.
Findings
The facility failed to maintain a sanitary environment in resident rooms, ensure timely incontinent care for residents, accurately assess and treat a resident's change in condition resulting in fractures, and administer prescribed medications as ordered. Documentation and communication deficiencies were also noted.
Deficiencies (5)
Failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 7 of 10 resident rooms.
Failure to ensure timely incontinent care for 3 of 5 residents reviewed for ADL care.
Failure to ensure a resident was accurately assessed, monitored, and treated for a change of condition resulting in fractures.
Failure to provide pharmaceutical services including accurate administration of medications for 1 of 5 residents.
Failure to maintain complete, accurate, and accessible medical records for 1 of 5 residents.
Report Facts
Resident rooms with housekeeping deficiencies: 7
Residents reviewed for ADL care: 5
Residents reviewed for pharmacy services: 5
Residents reviewed for medical records: 5
Missed medication doses: 2
Resident's BIMS score: 2
Resident's BIMS score: 0
Resident's BIMS score: 13
Resident's BIMS score: 5
Date of survey completion: Sep 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Involved in assessment and communication regarding Resident #1's missed medication and Resident #7's pain assessment |
| CNA B | Certified Nursing Assistant | Assigned to Resident #1's hall and involved in missed incontinence care |
| CNA C | Certified Nursing Assistant | Reported Resident #7's pain and condition, assisted with care |
| LVN F | Licensed Vocational Nurse | Assessed Resident #7's pain and injury, called physician and emergency services |
| CNA H | Certified Nursing Assistant | Reported Resident #7's pain and grimacing, assisted with care |
| LVN I | Licensed Vocational Nurse | Performed head-to-toe assessment on Resident #7 but failed to document findings |
| OT K | Occupational Therapist | Worked with Resident #7 and reported no pain at lunch |
| OT J | Occupational Therapist | Observed Resident #7's leg deformity and pain on 09/11/23 |
| Med Aide E | Medication Aide | Missed administering Resident #1's tramadol medication |
| DON | Director of Nursing | Provided statements on expectations for pain assessment, medication administration, and documentation |
| SC | Staffing Coordinator | Reported staffing issues and complaints about CNA availability |
| Administrator | Reported housekeeping staffing issues and corrective actions | |
| HK Manager | Housekeeping Manager | Reported housekeeping staffing and cleaning procedures |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 5, 2023
Visit Reason
The inspection was conducted as an annual survey of Beacon Harbor Healthcare and Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 30, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide a safe, sanitary, and homelike environment, inadequate supervision to prevent elopement, improper medication storage, food safety violations, infection control lapses, and pest control issues.
Complaint Details
The complaint investigation revealed multiple issues including environmental sanitation failures affecting Resident #82, an elopement incident involving Resident #133 due to inadequate supervision and elopement prevention, medication storage security lapses, food safety violations, infection control breaches, and pest control deficiencies.
Findings
The facility failed to maintain a safe and sanitary environment for Resident #82, including pest control and housekeeping deficiencies. Resident #133 eloped from the facility due to inadequate supervision and lack of effective elopement prevention measures. Medication carts were left unlocked, risking unauthorized access. Food service staff failed to follow sanitation protocols. Infection control practices were not followed, including failure to sanitize equipment between residents. Pest control was inadequate, allowing spider infestation in a resident's room.
Deficiencies (6)
Failed to provide a safe, sanitary, and homelike environment for Resident #82, including spider infestation and unsanitary conditions in the resident's room.
Failed to ensure adequate supervision and interventions to prevent elopement of Resident #133, resulting in the resident leaving the facility unnoticed.
Medication carts #1 and #2 were left unlocked and unattended, risking unauthorized access to medications.
Dietary staff failed to wear required beard and hair coverings in the kitchen, risking food contamination.
Failed to sanitize blood pressure equipment between use on different residents, risking cross-contamination and infection.
Failed to maintain an effective pest control program to keep the facility free of pests, resulting in spider infestation in Resident #82's room.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication carts unsecured: 2
Pest control visit date: Jun 23, 2023
Elopement date: Jun 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN K | Licensed Vocational Nurse | Left medication cart unlocked while assisting hospice patient |
| MA A | Medication Aide | Failed to sanitize blood pressure equipment between residents |
| HSK B | Housekeeper | Responsible for cleaning Resident #82's room; reported spider presence |
| LVN F | Licensed Vocational Nurse | Provided interview regarding elopement incident and monitoring |
| DON | Director of Nursing | Provided multiple interviews regarding elopement, infection control, and medication cart policies |
| ADM | Administrator | Provided interviews regarding environmental concerns, medication cart security, and kitchen sanitation |
| Cook H | Cook | Failed to wear hair and beard coverings in kitchen |
| Dishwasher M | Dishwasher Aide | Failed to wear beard and hair coverings in kitchen |
| HSK Supervisor | Housekeeping Supervisor | Reported staffing issues and inability to deep clean Resident #82's room |
| LVN D | Licensed Vocational Nurse | Provided interview regarding elopement procedures and assessments |
| CNA E | Certified Nursing Assistant | Reported on elopement incident and alarm functioning |
| CNA C | Certified Nursing Assistant | Participated in elopement drill and provided interview about elopement day |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 11, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to treat residents with dignity and respect, failure to provide timely incontinence care, and failure to serve food at safe and appetizing temperatures.
Complaint Details
The complaint investigation was substantiated based on observations, interviews, and record reviews showing failures in resident dignity, incontinence care, and food service temperature.
Findings
The facility failed to treat Resident #2 with dignity during incontinence care, leaving the resident uncovered. Resident #1 did not receive timely incontinence care, resulting in poor hygiene and skin issues. Additionally, food served to Residents #1 and #3 was not at an appetizing temperature, posing risks to nutritional status.
Deficiencies (3)
Facility left Resident #2 uncovered during incontinence care, risking dignity and quality of life.
Failed to assist Resident #1 with timely incontinence care, risking poor hygiene and skin integrity.
Failed to serve food at safe and appetizing temperature to Residents #1 and #3.
Report Facts
Deficiencies cited: 3
Food temperature: 171
Food temperature: 174
Food temperature: 170
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in Resident #2 incontinence care incident |
| RN J | Registered Nurse | Involved in Resident #2 incontinence care incident |
| DON | Director of Nursing | Responded to Resident #2 incontinence care incident and interviewed |
| CNA C | Certified Nursing Assistant | Responsible for Resident #1 care and interviewed regarding toileting assistance |
| SC | Staff Coordinator | Assisted with Resident #1 incontinence care and interviewed |
| CNA F | Certified Nursing Assistant | Interviewed about Resident #1 care needs |
| LVN H | Licensed Vocational Nurse | Interviewed about Resident #1 care and incontinence orders |
| DM | Dietary Manager | Interviewed about food temperature and service |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 25, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Beacon Harbor Healthcare and Rehabilitation.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 12
Deficiencies: 2
Date: May 12, 2022
Visit Reason
The inspection was conducted to evaluate the facility's pharmaceutical services, specifically the accurate acquiring, receiving, dispensing, administering, and securing of medications and related supplies.
Findings
The facility failed to ensure proper pharmaceutical services, including failure to report a damaged blister pack of medication and the presence of expired blood glucose control solutions on a nurse's medication cart. These issues posed risks of medication errors, drug diversion, and inaccurate blood sugar readings.
Deficiencies (2)
Failure to report a damaged blister pack of Resident #47's tramadol HCL tablet 50 mg.
Expired blood glucose control solutions found on the A-hall, station I nurse cart.
Report Facts
Residents on blood sugar check: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Interviewed regarding the damaged blister pack and expired blood glucose control solutions | |
| DON | Director of Nursing | Interviewed regarding policies on medication blister packs and expired blood glucose control solutions |
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