Glen Rose Nursing and Rehab: Care Plan Failures - TX
The finding, tagged under federal care planning requirements, covered five residents whose care plans contained no mention of discharge planning at all. Not outdated plans. Not incomplete ones. No mention whatsoever.
The director of nursing knew discharge planning was supposed to be in the care plan. She said it was asked about at every care plan meeting. She did not know it was missing for Resident 1, Resident 2, Resident 3, Resident 4, or Resident 5. When asked who was responsible for putting it there, she named either the MDS Coordinator or the social worker, then settled on the social worker, because the social worker worked discharge planning.
The MDS Coordinator had a different understanding. She said she did not know that a resident's discharge planning preference had to go into the care plan unless there was an active discharge plan in place. She said the social worker was the one to handle that, and the social worker would update the care plan accordingly.
The administrator said the same thing: the social worker would put in the update. She also said she did not know that a resident's preference on discharge planning was a requirement in the care plan when no discharge was currently being planned.
Three people in leadership positions. Three versions of the same answer, each pointing down the hall to someone else.
When inspectors asked to speak with the social worker directly, the administrator said she was on PTO and unavailable. The administrator said she would have the social worker update the care plans when she returned. She said she was sure the social worker did not know the documentation was required, or it would have been done.
She also said she did not know of any effects on residents if the information was simply not in the care plan, given that none of them had an active discharge plan in place.
That framing, that the absence only matters when discharge is already happening, gets the purpose of the documentation backwards. Discharge planning preferences are recorded precisely so that staff know what a resident wants before the question becomes urgent, before a hospitalization, before a family dispute, before a resident is moved somewhere they didn't choose. The care plan is where those preferences live so that any staff member, on any shift, can see them without having to ask again.
None of that information existed in the records for five residents at this facility.
Federal inspectors rated the violation at the level of minimal harm or potential for actual harm, and noted it affected some residents. It was cited under F0656, which covers the requirement that facilities develop and implement comprehensive care plans that include measurable goals and discharge planning based on each resident's needs and preferences.
The violation was identified during a complaint inspection on November 21, 2025.
What the inspection record captures is not a documentation technicality. It is a picture of a facility where three supervisors, including the director of nursing and the administrator, had no shared understanding of a basic care planning requirement, and where the one person who might have had answers was unreachable. The administrator's response, that she would wait for the social worker to return and have her fix it, suggests the underlying confusion about ownership of the task remained unresolved even after inspectors left.
Five residents at Glen Rose Nursing and Rehab had preferences about where they might go and what their future might look like. Whether anyone had ever asked them, or written it down, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Glen Rose Nursing and Rehab Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
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 3, 2026 · Our methodology
Glen Rose Nursing and Rehab Center in Glen Rose, TX was cited for violations during a health inspection on November 21, 2025.
The finding, tagged under federal care planning requirements, covered five residents whose care plans contained no mention of discharge planning at all.
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.