Rambling Oaks Courtyard: Medication Safety Failure - TX
That's what inspectors found when they visited the facility on September 2, 2025.
The resident, identified in the inspection report as Resident 1, had been using the nasal spray on his own. There was no confirmed physician's order authorizing self-administration. There was no documented assessment establishing that he was capable of managing his own medication. And the spray was sitting in the open, on top of a side table, in a facility that houses residents who are confused and could wander into the room.
The director of nursing said the nasal spray should have been inside the nurses' cart, administered by nursing staff. She acknowledged the resident might have been confused and used the medication on his own through a different route than intended. She also acknowledged the broader risk: other residents, some of them allergic to the medication's contents, could access it and have a reaction. After the inspection, she said she would check whether a physician's order was already in place and would conduct staff training on not leaving medications in residents' rooms.
The administrator said the expectation was clear: staff were supposed to scan each room for medications left at bedside. She said family members sometimes bring medications from home, but those medications still cannot remain in the room without the facility's knowledge and control. She committed to working with the director of nursing to make sure no resident was self-administering medications without a proper assessment on file.
What neither of them disputed was that it had been happening.
The facility's own written policies, one dating to 2003 and revised in 2017, state that all medications are administered by licensed medical or nursing personnel and that a specific physician's order must be obtained before any medication is given. A second policy, revised in 2016, states that medications are to be administered only upon written order, and that drug orders must be recorded on the physician's order sheet in the resident's chart.
The nasal spray on the side table met none of those conditions.
The risks the director of nursing described were not theoretical. Overuse of nasal spray medications can cause nose irritation and, depending on the drug, more serious effects from repeated dosing. A confused resident picking up someone else's medication and inhaling it would have no way of knowing the correct dose, the drug name, or whether they were allergic to it. Staff had not caught it. Nobody had scanned the room.
The inspection was triggered by a complaint, not a routine survey. Inspectors rated the harm level as minimal or potential, and noted that some residents were affected. The facility has 112 beds and sits at 112 Barnett Boulevard in Highland Village, a suburb north of Dallas.
What the inspection captured was a narrow failure with a wider implication: a medication that should have been locked in a nursing cart was instead sitting out in a resident's room, and the people responsible for scanning those rooms had not done it. The director of nursing said she would fix it with an in-service. The administrator said she would coordinate with the director of nursing.
The resident kept using the spray on his own until someone noticed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rambling Oaks Courtyard Extensive Care Community from 2025-09-02 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
RAMBLING OAKS COURTYARD EXTENSIVE CARE COMMUNITY in HIGHLAND VILLAGE, TX was cited for violations during a health inspection on September 2, 2025.
That's what inspectors found when they visited the facility on September 2, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.