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Garland Nursing: Immediate Jeopardy Transfer Violation - TX
Federal inspectors determined the incident posed immediate danger to resident health and safety....
Latest reports, citations, and penalties from CMS data
Federal inspectors determined the incident posed immediate danger to resident health and safety....
Licensed nurse LN 8 administered the resident's medications around 9:30 a.m....
The nursing assistant, identified in inspection records only as CNA 1, brought the resident into the dining room around 3 p.m....
CNA 1 had brought the resident to the dining room entrance for activities but didn't escort them to a table....
The violation affected eight of eight residents observed during the meal service at the 70-bed facility....
On September 2, 2025, around 2:00 P.M., CNA 521 responded to the resident's call light....
The resident suffered from gangrene, infection following the procedure, and wound healing complications....
The failure violated federal screening requirements designed to ensure nursing home residents with serious mental illness receive appropriate care....
Federal inspectors found the 70-bed facility systematically cut corners during investigations of self-reported incidents between April and July 2025....
The family of Resident 105 reported the alleged abuse to Former Director of Nursing 610 on May 19....
The odors weren't coming from residents' rooms or soiled utility areas....
Federal inspectors observed the medication violations during a 10-minute period that morning....
A follow-up observation the next day confirmed the same problem....
Day shift staff weren't told about the malfunction and had no idea they needed to increase supervision of residents with dementia....
The discovery triggered an immediate response on October 30, including deep cleaning of the affected resident's room and emergency pest control treatment....
Despite two staff members documenting the resident's declining mental status within 50 minutes of each other, no one notified the physician....
The resident, identified as R4 in inspection documents, maintained full mental capacity with a perfect cognitive assessment score of 15 out of 15....
Federal inspectors found that Resident #1 had no Pressure Ulcer Record from August 1 through September 22, 2025....
The confrontation occurred after the resident urinated on the floor, according to a November inspection report....
The October 8 confrontation began when Resident B was sitting in the back west hallway with a female resident nearby....