Inspection Report Summary
The most recent inspection on July 24, 2025, identified deficiencies related to call light accessibility, cleanliness and homelike environment, respiratory care, food safety, and infection prevention and control. Earlier inspections showed similar issues, particularly with call light systems, respiratory care, infection control practices, and environmental cleanliness. Complaint investigations were not listed in the available reports. No fines, immediate jeopardy findings, or enforcement actions were mentioned in any report. The pattern of deficiencies has remained consistent over time without clear improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
109% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 5
Date: Jul 24, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident rights, environment, respiratory care, food safety, and infection control.
Findings
The facility was found deficient in several areas including failure to reasonably accommodate resident needs by ensuring call lights were within reach, failure to maintain a clean and homelike environment in resident rooms and dining areas, failure to provide safe and appropriate respiratory care, failure to maintain food safety standards in the kitchen, and failure to implement proper infection prevention and control practices.
Deficiencies (5)
Failure to ensure call light systems were accessible to residents, placing them at risk of not obtaining assistance.
Failure to maintain a safe, clean, comfortable, and homelike environment including unclean resident rooms and dining area surfaces.
Failure to provide safe and appropriate respiratory care including improper storage of suction tips and oxygen tubing.
Failure to store, prepare, distribute, and serve food in accordance with professional standards including uncovered tea dispenser, unlabeled and expired food, and unclean ice machine and scoop holder.
Failure to maintain an infection prevention and control program including improper glove use and hand hygiene by staff during incontinence care.
Report Facts
Residents reviewed for reasonable accommodation: 24
Resident rooms reviewed for environment: 15
Residents reviewed for respiratory care: 6
Date of inspection: Jul 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Stated call lights should be within reach for Resident #76. | |
| LVN A | Stated call lights should be within reach for all residents and commented on infection control failures. | |
| CNA D | Stated call lights should be within reach for Resident #79. | |
| ADON | Assistant Director of Nursing | Stated expectation for call lights to be within reach and commented on respiratory tubing storage. |
| DON | Director of Nursing | Stated call lights and respiratory equipment should be properly placed and covered; in-serviced staff on these issues. |
| Administrator | Emphasized importance of call lights within reach and proper cleaning; briefed on kitchen and housekeeping deficiencies. | |
| Housekeeping D | Responsible for cleaning 500 hall rooms; acknowledged cleaning deficiencies. | |
| Housekeeping Supervisor | Oversaw housekeeping staff; acknowledged cleaning deficiencies and maintenance issues. | |
| LVN B | Commented on respiratory care deficiencies and proper storage of oxygen tubing. | |
| Dietary Manager | Acknowledged kitchen food safety deficiencies. | |
| CNA E | Observed failing to follow infection control practices during incontinence care. |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including reasonable accommodation of resident needs, respiratory care, and infection prevention and control.
Findings
The facility was found deficient in ensuring call lights were accessible to residents, proper respiratory care was provided including proper storage of respiratory equipment and physician orders for oxygen administration, and maintaining infection prevention and control practices, particularly hand hygiene and glove use during incontinent care.
Deficiencies (3)
Failed to ensure call light system was accessible to Resident #78.
Failed to provide safe and appropriate respiratory care for Residents #321 and #322, including improper storage of nebulizer masks and nasal cannulas and lack of physician order for oxygen administration for Resident #322.
Failed to maintain an infection prevention and control program, including failure of CNA D to change gloves and perform hand hygiene during incontinent care for Residents #49 and #89.
Report Facts
Residents reviewed for reasonable accommodation: 8
Residents reviewed for respiratory care: 10
Residents observed for infection control: 8
Residents affected by call light deficiency: 1
Residents affected by respiratory care deficiency: 2
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in infection control deficiency related to glove use and hand hygiene during incontinent care |
| CNA C | Certified Nursing Assistant | Mentioned in relation to call light accessibility for Resident #78 |
| LVN A | Licensed Vocational Nurse | Interviewed regarding call light accessibility and respiratory care deficiencies |
| DON | Director of Nursing | Interviewed regarding call light accessibility, respiratory care, and infection control deficiencies |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 20, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care, infection control, food safety, and environmental conditions in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, unclean and unsanitary resident rooms, improper use of a scoop mattress without physician orders, inadequate respiratory care including improper storage of oxygen equipment and missing physician orders, food storage and labeling violations in the kitchen, and failure to follow infection control protocols during incontinent care.
Deficiencies (6)
Failed to ensure call light system was accessible to residents, placing them at risk of not obtaining assistance.
Failed to provide a safe, clean, comfortable, and homelike environment; resident rooms were dirty with dust, grime, and calcium deposits.
Failed to obtain physician orders and assess resident for scoop mattress prior to installation, risking physical harm.
Failed to provide safe and appropriate respiratory care; nebulizer masks and nasal cannulas were improperly stored and missing physician orders for oxygen administration.
Failed to ensure food was stored, labeled, dated, and kitchen equipment cleaned according to professional standards, risking cross contamination.
Failed to maintain infection prevention and control program; CNA did not change gloves or perform hand hygiene during incontinent care, risking cross-contamination and infection.
Report Facts
Residents reviewed for reasonable accommodation: 8
Resident rooms observed for safe, clean environment: 14
Residents reviewed for respiratory care: 10
Residents reviewed for infection control: 8
Frozen meat tubes unlabeled: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in infection control deficiency for not changing gloves or performing hand hygiene during incontinent care |
| LVN A | Licensed Vocational Nurse | Interviewed regarding respiratory care and infection control practices |
| DON | Director of Nursing | Provided statements on call light accessibility, respiratory care, and infection control expectations |
| CNA C | Certified Nursing Assistant | Interviewed about call light accessibility rounds |
| LVN L | Licensed Vocational Nurse | Interviewed regarding scoop mattress and respiratory care |
| Housekeeping D | Housekeeping Staff | Interviewed about cleaning responsibilities for air filters and room sanitation |
| Maintenance Director | Maintenance Director | Interviewed about air filter cleaning and maintenance duties |
| Dietary Manager | Dietary Manager | Interviewed about kitchen food storage and labeling deficiencies |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 21, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards regarding medication administration, infection prevention and control, and clinical record maintenance at Rowlett Health and Rehabilitation Center.
Findings
The facility failed to maintain accurate and timely documentation of insulin administration for Resident #1, with staff documenting medication times late, which could be considered a medication error. Additionally, the facility failed to ensure proper hand hygiene between glove changes by a staff member during insulin administration, increasing the risk of infection spread.
Deficiencies (2)
Failure to maintain clinical records with accurate and timely documentation of insulin administration times for Resident #1.
Failure to perform hand hygiene between glove changes during blood sugar check and insulin administration by LVN C.
Report Facts
Dates of inaccurate insulin documentation: 12
Medication doses: 25
Medication doses: 6
Medication doses: 4
Blood sugar reading: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Named in medication administration documentation deficiencies and interviews regarding late documentation. | |
| LVN B | Named in medication administration documentation deficiencies and interviews regarding late documentation. | |
| LVN C | Named in infection control deficiency for failure to perform hand hygiene between glove changes. | |
| DON | Director of Nursing | Provided statements regarding proper medication documentation and hand hygiene policies. |
| Resident #1's attending physician | Interviewed regarding medication administration and documentation practices. |
Inspection Report
Deficiencies: 1
Date: Jun 27, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control standards, specifically related to maintaining a safe, clean, and comfortable environment to prevent the development and transmission of communicable diseases and infections.
Findings
The facility failed to maintain an effective Infection Prevention and Control Program by not removing soiled bed linens from Resident #1's bed, which could place residents at risk for the spread of infection. Interviews and observations confirmed the presence of soiled linens and lapses in routine cleaning practices.
Deficiencies (1)
Failure to remove soiled bed linens from Resident #1's bed, risking spread of infection.
Report Facts
Residents observed for infection control: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aide | Interviewed regarding responsibility and routine for changing bed linens for Resident #1 | |
| LVN | Interviewed about Resident #1's condition and bed linen changes | |
| DON | Interviewed about Resident #1's status and facility linen changing responsibilities |
Inspection Report
Deficiencies: 3
Date: May 10, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication security, provision of special eating equipment and utensils, and maintenance of accurate medical records in the facility.
Findings
The facility was found deficient in securing medications properly, providing adaptive eating aids to a resident who needed them, and maintaining accurate medication orders for a resident. These deficiencies posed risks of medication errors, loss of resident independence in eating, and inaccurate medical records.
Deficiencies (3)
Medications were not secured properly as a medication aide left medications on top of the medication cart unattended.
Failure to provide special eating equipment and utensils for a resident who needed adaptive aids to eat independently.
Failure to maintain accurate medical records by having a medication order written for enteral administration when the resident did not have a g-tube.
Report Facts
Medication carts reviewed: 4
Residents reviewed for feeding assistance: 3
Residents reviewed for clinical records: 5
Resident #69 weight on 04/02/23: 86.2
Resident #69 weight on 05/03/23: 86.2
Resident #69 weight on 12/02/22: 82.6
Resident #69 weight gain percentage: 4.36
Tramadol dosage: 50
Tramadol frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA H | Medication Aide | Named in medication cart security deficiency for leaving medications unsecured |
| DON | Director of Nursing | Interviewed regarding medication cart security and feeding assistance deficiencies |
| Occupational Therapist T | Occupational Therapist | Interviewed regarding feeding assistance and adaptive equipment for Resident #69 |
| Speech Therapist M | Speech Therapist | Interviewed regarding feeding assistance and adaptive equipment for Resident #69 |
| LVN T | Licensed Vocational Nurse | Interviewed regarding medication administration for Resident #85 |
| MA G | Medication Aide | Interviewed regarding medication administration for Resident #85 |
| Dietary Manager | Dietary Manager | Interviewed regarding feeding assistance and meal ticket system |
| Regional Dietitian | Regional Dietitian | Interviewed regarding feeding assistance and meal ticket system |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
The inspection was conducted as an annual survey of Rowlett Health and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically focusing on the handling, storage, processing, and transport of linens to prevent the spread of infection.
Findings
The facility failed to ensure that soiled laundry and bedding were not stored in the 300-unit shower room, with linens and resident socks found in direct contact with the shower floor unbagged, posing a risk for infection spread. Staff were subsequently in-serviced on proper infection control and disposal of soiled linens.
Deficiencies (1)
Failed to handle, store, process, and transport linens to prevent the spread of infection; soiled laundry and bedding were stored in the 300-unit shower room in direct contact with the floor and not bagged.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON | Interviewed regarding observation of soiled linens in shower room and infection control issues. | |
| DON | Interviewed about staff in-service on infection control and disposal of soiled linens. |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding residents' right to a safe, clean, comfortable, and homelike environment, specifically focusing on the condition of Resident #1's room.
Findings
The facility failed to ensure that Resident #1's room walls were in good repair, as there was a large hole behind the headboard of the bed. The hole was deemed a cosmetic issue that did not create physical risk but diminished the homelike environment for the resident.
Deficiencies (1)
Failure to ensure Resident #1's walls in her room were in good repair, with a hole approximately 1 ft long and 6 inches wide behind the bed.
Report Facts
Hole dimensions: 12
Hole dimensions: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Responsible for facility repairs; stated the hole was caused by bed placement and was a cosmetic issue. | |
| Administrator | Not aware of the hole; stated expectation for repairs to be reported and completed. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 8, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Rowlett Health and Rehabilitation Center following a survey completed on 2023-02-08.
Findings
No health deficiencies were found during the survey.
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