Deficiencies (last 4 years)
Deficiencies (over 4 years)
16.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
366% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 3
Dec 3, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory standards related to resident dignity, accommodation of resident needs and preferences, and respiratory care.
Findings
The facility was found deficient in treating residents with dignity by failing to conceal a catheter bag, ensuring call lights were accessible to residents, and providing proper respiratory care by not storing breathing devices in bags when not in use. These deficiencies posed risks to residents' dignity, safety, and health.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to treat Resident #6 with respect and dignity by not concealing the catheter bag from public view. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to reasonably accommodate the needs and preferences of Residents #3, #4, and #5 by not ensuring call light systems were accessible. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate respiratory care for Residents #1 and #2 by not properly storing nasal canulas and CPAP masks in bags when not in use. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity: 6
Residents reviewed for call systems access: 10
Residents reviewed for respiratory care: 7
BIMS score: 99
BIMS score: 99
BIMS score: 4
BIMS score: 15
BIMS score: 8
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN H | Interviewed regarding catheter bag privacy and call light accessibility; shown breathing devices unbagged | |
| RN F | Interviewed regarding call light accessibility and respiratory device storage | |
| DON | Director of Nursing | Interviewed about catheter bag privacy, call light accessibility, and respiratory device storage |
| CNA R | Certified Nursing Assistant | Interviewed about call light accessibility and care provision on 600-hall |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 13, 2025
Visit Reason
The inspection was conducted following a complaint related to a fall incident involving Resident #1, who was injured during an improper transfer by a Certified Nurse Aide (CNA). The visit aimed to investigate the circumstances and compliance with transfer protocols.
Findings
The facility failed to ensure adequate supervision and proper transfer techniques for Resident #1, resulting in a fall causing a traumatic brain hemorrhage and bruising. The CNA attempted a one-person sliding board transfer instead of the required two-person Hoyer lift transfer, leading to immediate jeopardy. The facility implemented corrective actions including staff suspension, in-services, and audits.
Complaint Details
The complaint investigation was substantiated. Resident #1 fell during a transfer on 11/07/2025 due to CNA A's failure to request assistance and improper use of a sliding board instead of a two-person Hoyer lift. The fall caused a traumatic brain hemorrhage and bruising. The facility self-reported the incident and took corrective actions including suspension of CNA A and staff training.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that each resident received adequate supervision and assistance devices to prevent accidents, resulting in a fall with serious injury to Resident #1. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Care staff check for Appropriate Transfer in-service: 33
Care staff check for Abuse and Neglect training: 43
Care staff check for Gait Belts and Transfers: 30
Care staff check for Mechanical Lift Competency: 29
Therapy staff check for Sliding Board Transfers: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Attempted improper transfer causing Resident #1's fall and injury; suspended pending investigation |
| RN D | Registered Nurse | Notified of fall, assessed Resident #1, documented incident |
| CNA C | Certified Nurse Aide | Witnessed fall, notified charge nurse immediately |
| Therapy Assistant B | Therapy Assistant | Informed CNA A to make bed and was working with Resident #1 in therapy |
| Administrator E | Administrator | Reported incident, confirmed suspension and corrective actions |
| Therapy Director F | Therapy Director | Stated nursing staff should not use sliding board for Resident #1; confirmed training |
| Attending Physician G | Physician | Notified of fall; stated fall posed mild to severe risk of injury |
| Director of Nurses H | Director of Nursing | Conducted in-services and corrective actions |
Inspection Report
Routine
Deficiencies: 7
Mar 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, privacy, assessment accuracy, care planning, respiratory care, medication storage, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, failure to maintain resident privacy during medical treatments, inaccurate resident assessments, incomplete care plans, improper respiratory care and equipment storage, improper medication storage, and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure call lights were within reach and accessible for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide privacy during assessment and flushing of Resident #50's midline catheter. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #43's Quarterly MDS assessment accurately reflected use of an external catheter (Purewick). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive care plans for Resident #50's smoking and Resident #11's breathing treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate respiratory care including improper storage of respiratory equipment and empty humidifier bottles for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure probiotics requiring refrigeration were stored properly. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper infection prevention and control practices including improper glove use and hand hygiene by staff during incontinence care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for Reasonable Accommodation of Needs: 18
Residents affected: 5
Residents reviewed for Privacy: 9
Residents affected: 1
Residents reviewed for Accuracy of Assessments: 8
Residents affected: 1
Residents reviewed for Care Plans: 8
Residents affected: 2
Residents reviewed for Respiratory Care: 10
Residents affected: 5
Residents reviewed for Infection Control: 12
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in privacy deficiency for assessing and flushing IV outside resident's room |
| CNA F | Certified Nursing Assistant | Named in call light accessibility and infection control deficiencies |
| LVN H | Licensed Vocational Nurse | Named in call light accessibility and infection control deficiencies |
| DON | Director of Nursing | Provided multiple interviews regarding deficiencies and facility expectations |
| ADON | Assistant Director of Nursing | Provided multiple interviews regarding deficiencies and facility expectations |
| LVN A | Licensed Vocational Nurse | Named in respiratory care deficiencies and medication storage observation |
| RN I | Registered Nurse | Named in respiratory care deficiency regarding nasal cannula storage |
| MDS Nurse | Named in assessment and care plan deficiencies | |
| Social Worker | Named in care plan deficiency for smoking | |
| CNA D | Certified Nursing Assistant | Named in infection control deficiency for improper glove use |
| CNA E | Certified Nursing Assistant | Named in infection control deficiency |
| CNA G | Certified Nursing Assistant | Named in infection control deficiency |
Inspection Report
Routine
Deficiencies: 11
Mar 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, environment, and medication management at Garland Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, failure to maintain resident privacy during treatments, inadequate cleaning of resident rooms and kitchen, inaccurate resident assessments, incomplete care plans, unsafe environment regarding fall prevention, improper respiratory care practices, improper medication storage, and lapses in infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure call lights were within reach and accessible for residents #58, #56, #54, #61, and #120. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure RN B assessed and flushed Resident #50's midline catheter inside the resident's room to maintain privacy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident rooms were thoroughly cleaned and sanitized, including vents, sinks, soap dispensers, mini fridges, and walls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #43's Quarterly MDS assessment accurately reflected use of an external catheter (Purewick). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive person-centered care plans for Resident #50's smoking and Resident #11's breathing treatments. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Residents #17 and #26 had physician orders for scoop mattresses and Resident #34 had a fall mat placed alongside her bed for fall prevention. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure proper respiratory care for Residents #10, #11, #32, #49, and #120 including proper storage of nasal cannulas, breathing masks, and humidifier bottles. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Probiotics requiring refrigeration were stored properly in the refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure the facility kitchen was cleaned properly including ice machine, floors, walls, cooking equipment, tea dispenser, and proper labeling and sealing of food items. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure CNA D did not use gloves taken from the pocket of her scrub top while providing incontinence care to Resident #42. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure CNA F changed gloves and performed hand hygiene while providing incontinence care to Resident #15. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for Reasonable Accommodation of Needs: 18
Residents reviewed for Privacy: 9
Resident rooms reviewed for environment: 12
Residents reviewed for Accuracy of Assessments: 8
Residents reviewed for Care Plans: 8
Residents reviewed for accident prevention: 6
Residents reviewed for Respiratory Care: 10
Medication reviewed for storage: 1
Residents reviewed for infection control: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in privacy violation for flushing Resident #50's IV outside resident's room |
| CNA F | Certified Nursing Assistant | Named in call light accessibility and infection control deficiencies |
| LVN H | Licensed Vocational Nurse | Interviewed about importance of call light accessibility and infection control |
| DON | Director of Nursing | Provided multiple interviews regarding call light accessibility, privacy, care plans, respiratory care, infection control |
| ADON | Assistant Director of Nursing | Provided interviews regarding call light accessibility, privacy, respiratory care, infection control |
| Housekeeper C | Interviewed about cleaning responsibilities and deficiencies | |
| Housekeeper K | Interviewed about cleaning responsibilities and deficiencies | |
| Housekeeping Supervisor | Interviewed about cleaning oversight and deficiencies | |
| Social Worker | Interviewed about smoking care plan oversight for Resident #50 | |
| MDS Nurse | Interviewed about inaccurate assessments and care plan deficiencies | |
| LVN A | Licensed Vocational Nurse | Interviewed about respiratory care and medication storage deficiencies |
| RN I | Registered Nurse | Observed Resident #120's nasal cannula storage |
| RN F | Registered Nurse | Observed Resident #34's missing fall mat |
| CNA D | Certified Nursing Assistant | Observed using gloves from scrub pocket during care |
| CNA E | Certified Nursing Assistant | Observed assisting CNA D during care |
| CNA G | Certified Nursing Assistant | Observed assisting CNA F during care |
| Dietary Manager | Interviewed about kitchen cleaning deficiencies | |
| Administrator | Provided multiple interviews regarding overall facility deficiencies and corrective actions |
Inspection Report
Routine
Deficiencies: 1
Feb 27, 2025
Visit Reason
The inspection was conducted to assess compliance with residents' rights to privacy and dignity during care, specifically focusing on the transfer of Resident #1.
Findings
The facility failed to ensure privacy during the transfer of Resident #1 from bed to wheelchair, as the transfer was conducted in the hallway instead of inside the resident's room. Interviews with staff and administration confirmed that transfers should be done inside the room to maintain dignity and privacy.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide privacy during transfer of Resident #1, transferring the resident in the hallway instead of inside the room. | Level of Harm - Minimal harm or potential for actual harm |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in privacy deficiency related to transferring Resident #1 in the hallway. | |
| CNA B | Named in privacy deficiency related to transferring Resident #1 in the hallway. | |
| ADON | Assistant Director of Nursing | Interviewed regarding privacy expectations and in-service coordination. |
| DON | Director of Nursing | Interviewed regarding privacy expectations and planned in-service about privacy during transfer. |
| Administrator | Interviewed regarding staff expectations for privacy and dignity during resident care. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Nov 26, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report and investigate alleged abuse between residents, failure to prevent resident elopement, and failure to ensure food safety standards in beverage handling.
Findings
The facility failed to timely report and investigate an alleged resident-to-resident altercation, resulting in minimal harm risk. The facility also failed to prevent elopement of a cognitively impaired resident from the secured unit due to inadequate supervision and door security. Additionally, the facility failed to ensure beverage containers were cleaned, labeled, and changed out daily, risking foodborne illness.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to timely report and investigate an altercation between Resident #2 and Resident #3 on 11/23/2024, failed to prevent Resident #1's elopement on 10/04/2024, and failed to maintain food safety standards in beverage handling. The investigation found substantiated failures in all areas.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse and report investigation results to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to thoroughly investigate alleged violations and report results within 5 working days. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure adequate supervision and secure environment to prevent resident elopement. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure beverage dispensers were cleaned, properly labeled with date and time, and changed out daily. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 1
Date of incident: Oct 4, 2024
Date of incident: Nov 23, 2024
BIMS score: 15
BIMS score: 12
BIMS score: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN E | Reported resident altercation and notified provider, ADON, DON, and Administrator | |
| ADON | Assistant Director of Nursing | Heard incident, intervened, separated residents, and reported to Abuse Coordinator and Administrator |
| DON | Director of Nursing | Received notification of incident, expected Administrator to report to HHSC and investigate |
| Administrator | Failed to report and investigate alleged abuse incident timely | |
| CNA C | Certified Nursing Assistant | Observed Resident #1 outside during elopement and redirected her back inside |
| LVN A | Licensed Vocational Nurse | Documented Resident #1 elopement event and notified responsible parties |
| Maintenance | Ensured all doors were operating as required after elopement | |
| DA | Kitchen staff member responsible for filling beverage containers | |
| DM | Kitchen manager responsible for beverage container sanitation | |
| ADON/ICP | Assistant Director of Nursing/Infection Control Practitioner | Oversaw kitchen sanitation and beverage container cleaning |
Inspection Report
Complaint Investigation
Deficiencies: 5
Aug 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to immediately notify the physician and family of a resident's fall and injury, and failure to provide appropriate care and documentation following the incident.
Findings
The facility failed to immediately notify Resident #1's physician and family after a fall on 08/02/24, failed to document the incident properly, and failed to provide appropriate care and monitoring. Resident #1 sustained fractures of the left tibia and fibula and was hospitalized. The facility implemented staff training and suspended involved staff. An Immediate Jeopardy was identified and later removed after corrective actions.
Complaint Details
The complaint involved failure to notify the physician and family of a resident's fall and injury, failure to document and monitor the resident properly, and failure to provide necessary care, resulting in fractures of the left tibia and fibula. The investigation confirmed neglect and failure to follow protocols by CNA A and LVN B. Immediate Jeopardy was identified and later removed after corrective actions.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 4
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to immediately notify the resident's physician and family of a fall and injury resulting in fractures. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure the resident was free from neglect, including failure to provide necessary care and services to prevent harm. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to develop and implement policies and procedures to prevent neglect. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to develop the complete care plan within 7 days of the comprehensive assessment and revise it according to the resident's needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Date of fall: Aug 2, 2024
Date of survey completion: Aug 12, 2024
Number of residents reviewed: 6
Medication dosage: 5
Medication dosage: 50
Medication dosage: 1
Medication dosage: 8.6
Time of fall: 23:06
Length of floor mat: 6
Height of floor mat: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Failed to notify physician, document fall, complete incident report, and monitor Resident #1 after fall. |
| CNA A | Certified Nursing Assistant | Failed to prevent Resident #1 from falling during incontinent care and failed to report fall. |
| DON | Director of Nursing | Spoke to LVN B about failure to report fall and coordinated staff training. |
| ADON C | Assistant Director of Nursing | Assessed Resident #1 after fall and transferred to hospital. |
| MDS Coordinator E | MDS Coordinator | Provided information on Resident #1's care plan and assessment discrepancies. |
| Administrator | Facility Administrator | Managed investigation and staff suspensions related to Resident #1's fall. |
| Medical Director | Physician | Resident #1's attending physician, not notified timely of fall. |
| LVN D | Licensed Vocational Nurse | Reported Resident #1's leg swelling and condition changes. |
| LVN O | Licensed Vocational Nurse | Reported Resident #1's leg swelling and color changes. |
| Hospital RN | Registered Nurse | Provided care to Resident #1 at hospital. |
| Police Detective | Law Enforcement | Investigated circumstances of Resident #1's injury. |
Inspection Report
Routine
Deficiencies: 5
Feb 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, staffing, infection control, and safety in the nursing home.
Findings
The facility was found deficient in multiple areas including improper wound care technique, inadequate supervision during resident transfers, failure to maintain required RN coverage, delayed medication re-ordering, and lapses in infection prevention practices such as failure to sanitize blood pressure cuffs and improper perineal care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure proper wound care technique for pressure ulcers, including cleaning from inside to outside. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate supervision and assistance during resident transfer using Hoyer lift, resulting in unsafe swinging of resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain required RN coverage for at least 8 consecutive hours a day, 7 days a week on 9 days between August 2023 and January 2024. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely re-order medications for residents, risking missed doses. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to sanitize blood pressure cuffs between residents and improper wiping technique near wounds, risking cross-contamination and infection. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days without RN coverage: 9
BIMS score: 0
BIMS score: 13
BIMS score: 15
BIMS score: 10
BIMS score: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Named in wound care deficiency for improper cleaning technique and wiping near wound | |
| CNA A | Named in unsafe Hoyer lift transfer and lack of training | |
| CNA B | Named in unsafe Hoyer lift transfer and lack of training | |
| MA B | Named in medication re-ordering deficiency for failure to timely re-order medications | |
| MA A | Named in infection control deficiency for failure to sanitize blood pressure cuffs | |
| ADON | Assistant Director of Nursing | Provided interviews regarding wound care, medication re-ordering, infection control, and staff training |
| DON | Director of Nursing | Provided interviews regarding wound care, RN coverage, infection control, and staff training |
| Administrator | Provided interviews regarding facility expectations on wound care, RN coverage, medication management, and infection control |
Inspection Report
Routine
Deficiencies: 5
Feb 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, staffing, infection control, and safety in the nursing home.
Findings
The facility was found deficient in multiple areas including improper wound care technique, inadequate supervision during resident transfers, failure to maintain required RN coverage, untimely medication re-ordering, and lapses in infection prevention practices such as failure to sanitize blood pressure cuffs and improper wiping technique near wounds.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure proper wound care technique for pressure ulcers, specifically cleaning from inside to outside. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate supervision and assistance during resident transfer using Hoyer lift, resulting in unsafe swinging of resident in sling. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain required RN coverage for at least 8 consecutive hours a day, 7 days a week on 9 days between August 2023 and January 2024. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely re-order medications for residents, risking missed doses. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to sanitize blood pressure cuffs between residents and improper wiping technique near wounds risking cross-contamination and infection. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Days without RN coverage: 9
BIMS score: 0
BIMS score: 13
BIMS score: 15
BIMS score: 10
BIMS score: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Named in wound care deficiency and infection control findings | |
| CNA A | Named in unsafe Hoyer lift transfer deficiency | |
| CNA B | Named in unsafe Hoyer lift transfer deficiency | |
| MA B | Named in medication re-ordering deficiency | |
| MA A | Named in infection control deficiency related to blood pressure cuff sanitization | |
| ADON | Assistant Director of Nursing | Interviewed regarding wound care, medication re-ordering, infection control |
| DON | Director of Nursing | Interviewed regarding wound care, RN coverage, infection control |
| Administrator | Interviewed regarding staffing and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 27, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in residents, specifically Resident #2 who had a pressure ulcer.
Findings
The facility failed to reposition Resident #2 every 2 hours as ordered, despite the resident having a Stage 4 pressure ulcer on the sacrum. Interviews with staff confirmed the failure to reposition the resident, placing him at risk for worsening of the wound.
Complaint Details
The complaint investigation found that Resident #2 was not repositioned every 2 hours as required, despite having a tracheostomy and a Stage 4 pressure ulcer. Staff interviews confirmed the nurses and CNAs were responsible but failed to comply due to workload. The Director of Nursing acknowledged the risk of skin breakdown and wound worsening.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #2, including failure to reposition every 2 hours. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for pressure ulcers: 7
Pressure ulcer stage: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Stated responsibility to reposition Resident #2 every 2 hours and acknowledged being busy on the floor |
| CNA C | Certified Nursing Assistant | Stated nurse was responsible to reposition Resident #2 |
| DON | Director of Nursing | Confirmed repositioning responsibility and risk of wound worsening; facility did not submit policy at exit |
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 25, 2023
Visit Reason
The inspection was conducted due to a complaint and investigation of an elopement incident involving Resident #1 who left the secured unit without supervision, posing immediate jeopardy to resident health and safety.
Findings
The facility failed to ensure adequate supervision to prevent elopement of Resident #1, failed to perform required quarterly elopement risk assessments, and failed to provide staff training and competency in elopement prevention and supervision. An Immediate Jeopardy was identified but later removed after corrective actions were implemented.
Complaint Details
The complaint investigation was triggered by Resident #1 eloping from the secured unit on 10/22/2023 at 5:53 p.m. The resident was located by police on 10/24/2023 and taken to the hospital for evaluation. The facility's missing resident protocol was initiated, and an Immediate Jeopardy was identified and later removed after corrective actions.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision to prevent Resident #1's elopement from the secured unit. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to perform quarterly elopement risk assessments as required by policy. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide staff training and demonstrate competency in elopement prevention and supervision. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Date of elopement: Oct 22, 2023
Date Immediate Jeopardy identified: Oct 24, 2023
Date Immediate Jeopardy removed: Oct 25, 2023
Quarterly elopement evaluation missing: 1
Staff on Secure Unit during observation: 3
Head counts per day: 3
Door lock delay: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided multiple interviews regarding the elopement incident, facility procedures, and corrective actions | |
| DON | Director of Nursing | Interviewed regarding elopement evaluations, staff training, and oversight |
| LVN A | Licensed Vocational Nurse | Interviewed about training and observations related to Resident #1 |
| CNA B | Certified Nursing Assistant | Interviewed about training and observations related to Resident #1 |
| CNA C | Certified Nursing Assistant | Interviewed about training and observations related to Resident #1 |
| CNA D | Certified Nursing Assistant | On duty during elopement, provided details about the event and training |
| LVN E | Licensed Vocational Nurse | Interviewed about observations during elopement and staff training |
| LVN F | Licensed Vocational Nurse | Night shift nurse during elopement, described actions taken and training |
| Hospitality Aide G | Interviewed about observations and training related to Resident #1 | |
| Clinical Resource Nurse | Interviewed about Secure Unit evaluations and elopement risk assessments | |
| ADON | Assistant Director of Nursing | Interviewed about Secure Unit evaluations and staff responsibilities |
| Resident #1's physician | Physician | Provided clinical perspective on Resident #1's verbalizations and elopement risk |
| Maintenance Director | Worked on door latch adjustments and participated in corrective actions |
Inspection Report
Deficiencies: 1
Oct 11, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care plan requirements, specifically to assess whether residents had comprehensive, person-centered care plans that included measurable objectives and timeframes.
Findings
The facility failed to develop and implement a complete, person-centered care plan for Resident #1 that included measurable objectives and timeframes, specifically lacking a care plan addressing Hospice services. This deficiency could place residents at risk of not receiving individualized care and services to meet their needs.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, specifically missing a Hospice care plan for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect and failure to provide appropriate care to Resident #1 following a fall on 08/10/2023.
Findings
The facility failed to ensure Resident #1 was free from neglect, specifically failing to notify nursing staff timely after a fall, resulting in delayed assessment and treatment of injuries including a fractured wrist. Staff were re-educated on fall protocols and the facility implemented measures to prevent further neglect and falls.
Complaint Details
The complaint investigation focused on neglect related to Resident #1's fall on 08/10/2023, where CNAs moved the resident without nurse assessment and failed to report the fall timely. The investigation found staff counseling and suspension occurred, and training was provided to prevent recurrence.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to protect Resident #1 from neglect by not ensuring timely nurse assessment after a fall and improper handling by CNAs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement resident-directed care and treatment consistent with facility policy and professional standards for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for neglect: 7
Falls on 08/10/2023: 2
BIMS score: 15
PRN pain medication dosage: 10.325
Transport ETA: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Resident #1's day nurse on 08/24/2023, provided information on medication and training |
| CNA B | Certified Nursing Assistant | Provided information on fall incidents and fall precautions |
| CNA C | Certified Nursing Assistant | Provided information on fall prevention training and neglect definition |
| CNA D | Certified Nursing Assistant | Involved in moving Resident #1 after fall without nurse assessment, re-educated and suspended |
| CNA E | Certified Nursing Assistant and Transportation Driver | Involved in moving Resident #1 after fall without nurse assessment, provided detailed account of incident |
| ADON | Assistant Director of Nursing | Provided information on fall investigation and staff training |
| DON | Director of Nursing | Provided information on fall incidents, staff monitoring, and training |
| ADM | Administrator | Provided information on fall prevention efforts and staff accountability |
| PCP | Primary Care Physician | Provided medical opinion on Resident #1's falls, injuries, and care |
Inspection Report
Deficiencies: 4
Aug 3, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to coordination of assessments with the pre-admission screening and resident review (PASARR) program, medication storage and labeling, and ensuring specialized services and drug security in the facility.
Findings
The facility failed to coordinate assessments with the PASARR program and did not complete timely requests for specialized behavior services for one resident. Additionally, the facility failed to properly store controlled medications in locked compartments and secure medications for destruction, posing risks of misuse and harm. Interviews and record reviews confirmed these deficiencies with minimal harm or potential for actual harm to residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to coordinate assessments with the pre-admission screening and resident review program and failed to incorporate PASARR recommendations into care plans for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete a request for nursing facility specialized behavior services within 20 days as agreed upon during an IDT meeting for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store all drugs and biologicals in locked compartments and permit only authorized personnel access to keys for two residents' medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to secure Resident #2's and Resident #3's Oxycodone tablets for destruction in a double locked storage area prior to destruction. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 2
Medication tablets: 5
Medication tablets: 42
Observation period: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Mentioned in relation to medication storage deficiency and video observation |
| DON | Director of Nursing | Mentioned in relation to medication storage deficiency and interviews about PASARR services |
| ADM | Administrator | Mentioned in relation to review of security footage and implementation of new medication control policies |
| Maintenance Manager | Mentioned regarding access codes and video review related to medication storage | |
| PASRR Rep | Interviewed regarding PASARR services and timelines for Resident #1 | |
| SW | Social Worker | Interviewed regarding attempts to secure specialized behavior services for Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 5
Jun 18, 2023
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to maintain a safe, clean, and comfortable environment, failure to provide adequate assistance devices to prevent accidents, and failure to provide appropriate care according to residents' comprehensive care plans.
Findings
The facility failed to maintain doors and hallways in good condition, posing trip hazards; failed to apply and monitor a knee immobilizer for a resident with a fractured patella; and failed to provide timely repositioning and incontinence care for two residents, increasing risk for injury and skin breakdown.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to environmental hazards, failure to follow physician orders for immobilizer use, and inadequate care for incontinent residents leading to risk of injury and skin breakdown.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to maintain doors to rooms and bathroom walls in good condition, with gouges, black streaks, food splatter, and holes allowing ingress of insects and rodents. | Level of Harm - Minimal harm or potential for actual harm |
| Hallways 300 and 600 had damaged drywall and vinyl baseboards peeling away, posing trip hazards. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to place Resident #1's immobilizer on left knee as ordered and failure to implement care plan interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely repositioning and incontinence care for Resident #3, resulting in skin redness and risk for pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely repositioning and incontinence care for Resident #5, resulting in skin redness and risk for pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Rooms reviewed for environment: 24
Rooms with deficiencies: 3
Hallways reviewed for environment: 4
Hallways with deficiencies: 2
Residents reviewed for quality of care: 5
Residents affected by immobilizer deficiency: 1
Residents affected by incontinence care deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Unaware of Resident #1's fractured patella and immobilizer order; unable to apply immobilizer; worked 6am-2pm shift; not serviced on neglect |
| LVN B | Licensed Vocational Nurse | Admitted Resident #1; received hospital report by phone; never received physician orders; no call to hospital for immobilizer order |
| DON | Director of Nursing | Stated nurses must follow doctor orders; responsible for transferring hospital discharge orders; acknowledged breakdown in communication regarding immobilizer; confirmed expectations for repositioning and incontinence care |
| Maintenance Director | Aware of environmental deficiencies; working on repairs; notified via staff texts about maintenance issues | |
| ADM | Administrator | Aware of remodeling and maintenance needs; hiring assistant for maintenance director; acknowledged facility appearance issues |
| CNA E | Certified Nursing Assistant | Provided care to Resident #3; unable to provide timely incontinence care due to staffing; trained on incontinent care |
| CNA D | Certified Nursing Assistant | Provided care to Resident #5; lacked training on incontinent care; learned by observation and self-teaching |
Inspection Report
Annual Inspection
Deficiencies: 0
May 23, 2023
Visit Reason
The inspection was conducted as an annual survey of Garland Nursing and Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
May 2, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement written policies and procedures to prevent abuse, neglect, and theft, specifically related to an incident where Resident #1 hit Resident #2 on 04/07/2023.
Findings
The facility failed to timely report and investigate an alleged abuse incident between two residents that occurred on 04/07/2023, with the report to the state survey agency delayed until 04/11/2023. Staff acted according to policy during the event, and the abuse allegation was ultimately found to be unfounded. The facility's abuse policies and prevention programs were reviewed and found to be in place but not properly followed regarding timely reporting.
Complaint Details
The complaint investigation focused on an incident where Resident #1 hit Resident #2 on 04/07/2023. The facility delayed reporting the incident to the state survey agency until 04/11/2023. Interviews with staff including CNAs, the ADON, DON, and Administrator revealed confusion and delays in reporting. The incident was ultimately determined inconclusive but was reportable as resident-to-resident abuse. The facility installed cameras after the incident and revised reporting procedures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to implement written policies and procedures to prohibit and prevent abuse for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report alleged abuse incident to the state survey agency within required timeframes. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 6
Residents affected: 2
Incident date: Apr 7, 2023
Report delay days: 4
Scratch length: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Witness to resident altercation and involved in reporting | |
| CNA B | Witness to resident altercation and involved in reporting | |
| ADON | Assistant Director of Nursing | Charge nurse during incident, involved in assessment and reporting |
| DON | Director of Nursing | Interviewed regarding incident and reporting requirements |
| Administrator | Facility Administrator | Responsible for reporting abuse allegations and facility oversight |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 28, 2023
Visit Reason
The inspection was conducted as an annual survey of Garland Nursing and Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 14, 2023
Visit Reason
The inspection was conducted as an annual survey of Garland Nursing and Rehabilitation to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 5
Dec 7, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, environment, food safety, and facility maintenance at Garland Nursing and Rehabilitation.
Findings
The facility failed to maintain a safe, clean, and comfortable environment for residents, including issues with sanitation in Resident #57's room, unaddressed wheelchair repairs for multiple residents, inadequate grooming assistance for Resident #62, food storage and labeling violations in the kitchen, and poor maintenance and cleanliness on Hall 300. These deficiencies posed risks to resident quality of life, safety, and health.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to keep Resident #57's room clean and sanitized, with urine-soaked linens and strong odor. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly repair wheelchairs for Residents #60, #46, #56, and #39, with cracked armrests and exposed padding. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide necessary grooming services, specifically failure to remove Resident #62's facial hair timely. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store, prepare, distribute, and serve foods in accordance with professional standards, including unlabeled, expired, or improperly sealed food items and unclean equipment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a safe, clean, and comfortable physical environment on Hall 300, including grimy floors, broken tiles, missing caulking, damaged walls, and missing veneer on furniture. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents observed for environment: 7
Residents reviewed for quality of life: 5
Food items with missing or expired dates: 30
Maintenance log entries: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Reported cleaning schedule and challenges with Resident #57's room sanitation. | |
| CNA B | Described challenges assisting Resident #57 with toileting and hygiene. | |
| Medical Director | Discussed Resident #57's behaviors and evaluations. | |
| LVN D | Reported on Resident #57's care challenges and communication with administration. | |
| Housekeeper Supervisor | Discussed cleaning responsibilities and awareness of odor complaints. | |
| Administrator | Acknowledged odor issues, wheelchair repair responsibilities, and maintenance efforts. | |
| Director of Rehab | Unaware of wheelchair repair issues; explained responsibility changes. | |
| CMA G | Discussed grooming expectations and Resident #62's facial hair care. | |
| LVN H | Explained grooming policies including facial hair removal. | |
| Dietary Manager | Discussed food storage, labeling practices, and cleaning schedules. | |
| Housekeeper A | Reported cleaning responsibilities and repair reporting for Hall 300. | |
| Housekeeper Supervisor | Discussed staffing and cleaning assignments. |
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