Advanced Health & Rehab Center of Garland

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from types of abuse: mental abuse/verbal abuse/physical abuse/sexual abuse/deprivation of goods and services by facility staff for 1 resident (Resident #5) out of 10 residents reviewed for abuse and neglect. The facility failed to ensure Resident #5 was free from abuse when CNA-C spanked him twice on his bottom while he was lying on the floor on 3/13/2025. This failure could place residents at risk of being physically or emotionally abused. Record Review of Resident #5's face sheet revealed he was an [AGE] year-old male and was admitted on [DATE] and readmitted [DATE]. His diagnoses included: [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one of five residents (Resident #1) reviewed for assistive devices and supervision. The facility failed to ensure Resident #1 was provided increased supervision, due to psychiatric issues, Mild intellectual disability, and Diabetes. In addition, she resided on the memory care unit prior to going to the appointment 01/05/2026. Resident #1 was not returned to the memory care unit upon returning from the elopement incident. An Immediate Jeopardy (IJ) situation was identified on 01/08/2026. While the IJ was removed on 01/09/2026, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being, for one (Resident #1) of 3 residents reviewed for care plans, in that: Resident #1's care plan did not address her behaviors of wandering, intellectual disability, or her most recent elopement incident. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. Record review of Resident face sheet dated 01/07/2026, reflected she was a 57 years-old, female that was admitted on [DATE]. Resident DX: [...]

Inspectors wroteBased on interview, record review, and observations, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 7 residents (Resident #1) reviewed for pain management. The facility failed to provide Resident #1, who was on hospice services for end-stage cancer to the breast, liver, bone, and bile ducts, with effective pain management from 12/26/25 through 01/04/26. The facility did not reevaluate, advocate, or provide the full amount of pain medication available as allowed by physician's orders for appropriate pain management. This failure resulted in Resident #1 exhibiting non-verbal signs of excruciating pain to include screaming during care, crying, thrashing/writing in bed, and moaning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 10 residents (Resident #1) reviewed for baseline care plans. The facility failed to develop a baseline care plan within 48 hours of Resident #1's admission to the facility on [DATE] that addressed the resident's pain management needs while on hospice services for an end-stage diagnoses of malignant cancer of the breast, liver, bone, and bile ducts. As a result, she experienced on-going, excruciating pain from 12/26/25-01/04/26. This failure could place residents at risk of not having their individual care needs met in a timely manner, diminished quality of life, and unnecessary pain and suffering.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 4 residents (Resident #2) reviewed for pharmaceutical services. MA T failed to supervise Resident #2 after she left the resident's medications in his room during morning medication administration on 01/04/26. This failure could place the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) observed for infection control. 1. The facility failed to ensure CNA C sufficiently performed hand hygiene during incontinent care of Resident #1 on 11/05/2025. 2. The facility failed to ensure CNA B sufficiently performed hand hygrine during incontinent care of Resident #2 on 11/05/2025. 3. The facility failed to ensure LVN F performed hand hygiene prior to entering room and making resident contact to Resident #3 on 11/06/2025. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for each resident for 1 of 6 residents (Resident #2) reviewed for Comprehensive Care Plans. The facility failed to ensure Resident #2 had comprehensive care plan identified to reflect his transfer requirement of a hydraulic lift and transfer device. Additionally, the facility failed to ensure CNA A used two people during a hydraulic lift and transfer device when she obtained the weight of Resident #2 on 10/02/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of five residents (Resident #1) reviewed for Wound Care treatment and services. The facility failed to ensure Resident #1's wounds were dressed and covered while at the facility. These failures could place the residents at risk for the development or worsening of pressure wounds, cross contamination and infections. Findings Included:Record review of Resident #1's Face Sheet dated 11/06/2025 at 11:35 AM revealed he was a [AGE] year-old male admitted from an acute care hospital on [DATE]. Relevant diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent any risk of hazards and/or accidents for 1 of 5 residents (Resident #2) reviewed for accidents and supervision. The facility failed to ensure CNA A used two staff members during a hydraulic lift transfer when she obtained the weight of Resident #2 on 10/02/2025. The failure could place residents at risk for accidents and injuries, limiting their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with the comprehensive care plan and professional standards of practice, for 1 of 4 residents (Resident #3) reviewed for respiratory care. The facility failed to ensure Resident #3's oxygen tubing was positioned off the floor and was unencumbered from the bedside table. This failure placed residents at risk of not receiving safe and sufficient respiratory care. Findings Included: Record review of Resident #3's Face Sheet dated 11/07/2025 at 9:04 AM revealed he was a [AGE] year-old male admitted from an acute care hospital on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident call system was accessible to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member of to a centralized staff area for four of ten residents (Residents #1, #2, #3, and #4) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #1, #2, #3, and #4's rooms were in a position that was accessible to the residents on 09/25/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident free from physical restraints not required to treat the residents' medical symptoms as was possible for one of five residents (Resident #1) reviewed for physical restraints. The facility failed to ensure Residents #1 had physician orders or a physician assessment for the bolster mattress on her bed. This failure could place residents at risk of not having an environment that was free of restraints which could result in injury.

Inspectors wroteFindings included: Record review of Resident #5's Face Sheet, dated 09/30/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included schizoaffective disorder (psychotic symptoms) and vascular dementia (memory loss). Record review of Resident #5's Quarterly MDS assessment, dated 9/194/25, reflected he had a BIMS score of 13 (intact cognitive response). Active diagnoses included schizophrenia and altered mental status. Record review of Resident #5's Comprehensive Care Plan, dated 8/19/25, reflected the resident required psychotropic medication. Record review of Resident #5's physician's orders, dated 9/30/25, reflected the resident was prescribed the following medication: Ativan Oral tablet 1 MG, give 1 mg by mouth every 8 hours as needed for agitation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure when there is a transfer or discharge of resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge appropriate information is communicated to the receiving health care institution; and the facility failed to provide and document sufficient preparation and orientation in a form and manner the resident could understand for one (Resident #1) of five residents reviewed for hospital transfers. 1. The facility sent Resident #1, who they indicated was having a behavioral emergency (pulling on his g-tube, ostomy and catheter) and was in danger of dislodging them, in a private non-medical transport vehicle and left him without facility staff or a family member to supervise him while in the ER waiting area.2. [...]

Inspectors wroteBased on interview and record review the facility failed to establish and implement an admissions policy for one (Resident #1) of three residents reviewed for admissions. The facility did not provide Resident #1 and his RP with a written admission agreement, consent to treat, resident rights notification, Medicare/Medicaid information or disclosure of services and charges at the time of admission. This failure placed residents at risk of receiving care and services without informed consent, being uninformed of rights and financial obligations and not knowing how to exercise Medicare/Medicaid protections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 5 of 34 (Residents #31, #49, #64, #17, and #107) residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #31, #49, #64, #17, and #107's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 10 of 15 resident rooms in the memory care unit (Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10) reviewed for environment. 1. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, and #10, in the memory care unit, were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice machine in the facility kitchen was thoroughly cleaned. 2. The facility failed to ensure kitchen cooking equipment was cleaned. 3. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 4. The facility failed to ensure foods in the refrigerator was sealed from air-borne contaminants. 5. The facility failed to ensure the storage bins in the dry food area was clean and covered from air-borne contaminants. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of twelve (Resident #97 and Resident #102) residents reviewed for infection control. 1. The facility failed to ensure RN C removed her gloves and performed hand hygiene before using the laptop on the medication cart outside of Resident #97's room on 04/08/2025. 2. The facility failed to ensure Medication Aide F removed her gloves and performed hand hygiene before using the laptop on the medication cart outside of Resident #102's room on 04/09/2025. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #17) of six residents reviewed for Care Plans. The facility failed to ensure Resident #17's treatment for Dermatitis was care planned. This failure could place the resident at risk of not receiving the necessary care and services needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in accordance with currently accepted professional principles for 1 (hall 200 medication cart) of 4 medication carts reviewed for medication storage. The facility failed to dispose of one bottle of Magnesium Oxide (vitamin supplement), which expired January of 2025, from the Hall 200 medication cart on 04/09/2025. This failure could place residents at risk of receiving medications which might not provide the full therapeutic benefits of the medication or possibly cause side effects.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 residents (Resident #1) reviewed for Notification of Changes. The facility failed to notify Resident#1's durable power of attorney for healthcare when Resident#1 missed a scheduled dialysis appointment on 03/07/25. This failure could place residents at risk of not receiving treatment when there was a change in their condition, which could lead to worsening of conditions and serious injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and the residents' choice for 3 (Resident #1, Resident #2, and Resident #3) of 8 residents reviewed for respiratory care. 1. On [DATE] RN H failed to obtain a physician's order to administer oxygen to Resident #1 when readmitted to the facility after an acute care hospital stay with the primary diagnoses of Acute on Chronic Respiratory Failure with Hypoxia (a worsening of chronic respiratory failure that can lead to hypoxia [low blood oxygen]); COPD; and CHF. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility who acts as the fiduciary of the residents' fund, failed to hold, safeguard, manage and account for the personal funds of the resident deposited with the facility, to include the right to know, in advance, what charges a facility may impose against a resident's personal funds for one (Resident #3) of three residents reviewed for trust fund management. The facility failed to ensure Resident #3's trust fund account was spent down to avoid being over the amount allowed to have Medicaid Insurance benefits. These failures could place residents whose funds were managed by the facility at risk of losing their Medicaid insurance benefits and placed the residents' funds at risk of being misappropriated and residents/RP's not being aware of the residents' financial situation. Findings Included: [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (Residents #7 and #9) of eight residents reviewed for medications and pharmacy services. 1. The facility failed to take Resident #7's blood pressure and administer her medication in accordance with the physician orders. Resident #7 was not administered Metoprolol Tartrate (beta blocker to treat high blood pressure) on 08/20/24, 08/21/24 and 08/28/24 due to her blood pressure being out of parameters. However, there was no documented evidence to indicate her blood pressure was taken in her clinical record to validate the medication was not warranted. 2. [...]

Inspectors wroteBased on interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for two (Resident #4 and Resident #5) of four residents reviewed for pressure ulcers and non-pressure wounds. 1. The facility failed to document wound care was provided for Resident #4 in August 2024 on 29 occasions. 2. The facility failed to document wound care was provided for Resident #5 in August 2024 on 36 occasions. The facility failure could place residents at risk of not receiving wound care, wounds worsening and a lack of oversight of their clinical records by the nursing staff and nursing management.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary that included, (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for one (Residents #6) of two residents reviewed for discharge planning. The facility failed to complete a discharge summary for Resident #6 when she had a planned discharge home. This failure could place residents at risk of a recapitulation of the stay being unavailable to help ensure continuity of care once they went back home.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents and failed to be responsible for the quality and timeliness of the services for one (Resident #1) of eight residents reviewed for labs. The facility failed to complete Resident #1's lab order for C-diff (a bacterium that can cause diarrhea and inflammation of the colon, also known as colitis) as ordered by the physician. The failure could place residents at risk for delays in the provision of treatment for laboratory abnormalities and acute exacerbation of clinical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of eight residents reviewed for infections. The facility failed to ensure COVID positive Resident #2, was appropriately isolated for 10 days per their facility COVID policy. On 09/03/24, Resident #2 was on day 7 of 10 in her isolation when she was in the communal dining room eating lunch at a table with residents nearby who were not wearing a mask and at risk of contracting the virus. The facility failure placed residents at risk of contracting COVID-19, which could lead to a decline in their health.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean and homelike environment for five of ten residents (Resident #4, Resident #51, Resident #76, Resident #97, Resident #107) surveyed for environment. The facility failed to ensure the privacy curtains were in clean and in good condition/repair for Resident #4, Resident #51, Resident #76, Resident #97, and Resident #107. These failures could place residents at risk for not living in a safe, clean, and homelike environment.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that the resident had the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition for 1 of 8 resident (#54) whose care was reviewed in that: Resident #54 was not provided sufficient modes of communication. This deficient practice could affect residents with a communication/language barrier by contributing to low self-esteem and unmet needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for two (Resident #24 and Resident #29) of eight residents reviewed for ADLs. 1. The facility failed to ensure Resident #24 received incontinence care every two hours. 2. The facility failed to ensure Resident #29 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for skin breakdown, infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of 8 residents (Resident #89) observed for infection control. CNA A failed to perform hand hygiene during while providing incontinence care to Resident # 89. This failure could place the residents at risk for infection.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one (Resident # 69) of 7 residents reviewed for resident call system. The facility failed to ensure the call light in resident room [ROOM NUMBER] A used by Resident #69 was always working. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide an environment that was free from accident hazards over which the facility has control and failed to provide supervision and assistive devices to each resident to prevent avoidable accidents for 1 of 3 resident (Resident #50) reviewed for accidents free of hazards. The facility failed to ensure Resident #50 did not elope from the facility on 08/23/23. The noncompliance was identified as PNC. The PNC began on 08/23/23 and ended 08/24/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of accidents, hazards, and improper supervision. Findings Included: Record Review of Resident #50's face sheet dated 09/19/23 revealed a [AGE] year-old male admitted on [DATE]. diagnoses included.: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 5 of 13 Residents (Resident #10 #20, #30, #40, and #50), reviewed for accuracy of MDS assessments. 1. The Quarterly MDS assessment of Resident #10 indicated that the resident had no psychotic behaviors or disorders. 2. The Quarterly MDS assessment of Residents #10, #20, #40, and 50 did not address resident mood, diagnosis, and behaviors associated with diagnosis. 3. The Quarterly MDS assessment for Resident # 30 did not document the resident's anxiety, and oxygen use. 4. The Quarterly MDS assess for Resident # 50 did not document resident, anxiety, history of wandering and elopement, as well as psychotropic medications, psychiatric conditions, medication use and oxygen use. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Residents # 10, #20, and #50) of 9 residents reviewed for comprehensive care plans. The facility failed to develop and implement a comprehensive individualized care plan addressing resident's behaviors and interventions. These failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care and worsening of contractures. Resident #10 A Record review of Resident #10's face sheet, dated 09/21/23, revealed [AGE] year-old female admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure the proper labeling and dating of all foods stored in the refrigerator, freezer, and dry food storage areas. 2. The facility failed to ensure that staff was wearing the proper head and face coverings when serving food. These failures could place residents at risk for food-borne and transmission-based illnesses.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 8 residents (Resident #27) reviewed for Care Plans. The facility failed to ensure Resident #27's fall mat was placed alongside the resident's bed per his care plan. This failure could place residents at risk of for needs not being met.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure resident environment remained as free of accidents hazards as possible: and each resident recieved adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #27) reviewed for accidents and hazards. The facility failed to ensure Resident #27's fall mat was placed alongside the resident's bed. This failure could place residents at risk of for needs not being met.