Stallings Court Nursing: Heel Wound Care Failure - TX
The director of nursing said she learned about it on May 27, 2026, the day before federal inspectors arrived for a complaint inspection.
The resident, identified in inspection records as Resident #1, had no wounds on her feet when she was admitted. The facility's own treatment nurse identified a deep tissue injury, known as a DTI, to her heel after admission, meaning the wound developed while she was in the facility's care. A DTI is damage to tissue beneath the skin caused by sustained pressure, often appearing as a bruised or discolored area before the skin breaks down further. Once orders for heel protectors were put in place, the intention was straightforward: both protectors on while she was in bed, with a pillow positioned from knee to ankle to keep her heels from touching the mattress entirely.
Nobody made sure that was happening.
The assistant director of nursing told inspectors on May 28 that she had not known Resident #1 was down to one heel protector. The director of nursing said the same. The administrator, who had been at the facility since March 2026, said she also had not known. All three described the same protocol when asked: both heel protectors on, heels floated off the mattress, pillow under the legs. All three said they were unaware it wasn't being done.
The director of nursing put it plainly. She said Resident #1's heels should have been floated so they were not touching the mattress. She said the heel protectors were meant to prevent skin from contacting the mattress and to relieve pressure. She said the facility had a wound physician who visited weekly and was already seeing Resident #1. She said on admission the resident had no wounds on her feet.
The administrator said she planned to reeducate staff about communication and said it was not acceptable for ordered equipment to not be in place. She said the risk was that the resident could develop more wounds.
The facility had foam heel protectors in stock. The assistant director of nursing confirmed that. There was no shortage of supplies. The protectors were available. The order was in place. The staff responsible for putting them on simply did not, or put on one and left the other off, and no one caught it during rounds or care checks until, by the DON's own account, the day before inspectors walked in.
The facility's pressure ulcer prevention policy, last revised in March 2005, states that when a resident is in bed, every attempt should be made to float the heels by placing a pillow from knee to ankle or with other devices as recommended. The policy existed. The order existed. The wound existed anyway.
What the inspection record does not answer is how long Resident #1 had only one heel protector on, or how many times staff entered her room during that period, checked her positioning, and left without noticing or without fixing it. The DON said she became aware the day before the inspection. She did not say how long before that the situation had been going on.
Resident #1 came into Stallings Court without wounds on her feet. She left that part of her history behind her when the DTI appeared. The facility's response, once the wound was identified, was to put protectors in place and float the heels. The execution of that response is what inspectors found wanting, a woman in bed with one heel in a protector and one heel not, pressure building against the mattress, while the treatment nurse, the ADON, the DON, and the administrator each described the correct procedure to inspectors with confidence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stallings Court Nursing and Rehabilitation from 2026-05-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
Stallings Court Nursing and Rehabilitation in Nacogdoches, TX was cited for violations during a health inspection on May 28, 2026.
The director of nursing said she learned about it on May 27, 2026, the day before federal inspectors arrived for a complaint inspection.
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.