Duncanville Healthcare And Rehabilitation Center
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
She stated after a few days the family decided to place Resident #1 on hospice on 09/07/25. In a telephone
interview on 09/18/25 at 3:19 PM with previous DON revealed she and the dietitian met with the family of Resident #1 regarding him not eating. She stated she could not remember the exact date of the meeting but that it was around the beginning of the month. She stated the family stated Resident #1 was not eating because of recent dental work and he wanted to give up because of his sickness. She stated Resident #1 never stated he had suicidal ideations. She stated when the family stated he was giving up and not eating was not an indication to her that he would attempt suicide. She stated he had not attempted suicide prior to being admitted to the facility. She stated her assessments prior to admission nor during admission revealed any thoughts of suicide. An interview on 09/18/25 at 6:23 PM, the ADM stated Resident #1 tying the call light cord around his neck was not reported to the State Survey Agency because there was no indication in
the Provider Letter that the incident should have been reported. He stated Resident #1 was found by one of
the Medication Aides. He stated Resident #1 had not shown any evidence of suicidal ideations in any assessment completed during admission or when there was a change in condition when he was placed on hospice. He stated the only time Resident #1 made a statement that he wanted to harm himself was after
he was found with the cord around his neck on 09/10/25. He stated the resident had no documented history of suicide attempts or wanted to harm himself. He stated when the statement was made by the resident that
he wanted to kill himself, he was placed one to one until he was taken to the hospital for psychological evaluation, his family and hospice were notified. He stated Resident #1 passed away from his heart condition prior to the evaluation being completed. He stated the hospice staff were still in the building they had just finished talking to Resident #1. He stated he would have been responsible for reporting incidents to HHSC and conducting facility investigations. He stated there was no incident report completed and there was no investigation done. He stated not completing an incident report and investigation could have placed residents at harm if signs are not recognized and acted upon timely.In a telephone interview on 09/19/25at 8:40 AM, with the Administrator of Hospice, she stated Resident #1was placed with hospice on 09/07/25.
She stated Mr. [NAME] was declining due to his heart condition and he was not wanting to eat, and the NP had suggested tube feeding but the family had refused and that was when hospice had been suggested.
She stated the nurse, and social worker had gone to the facility to complete the assessment on 09/10/25.
She stated they were leaving the building when they were notified of the incident.Attempted to contact Medication Aide who found Resident #1 on 9/181925 at 5:43 PM and again on 9/19/25 a message was left both times with no return phone call. Record review of TULIP did not reflect a facility reported incident that corresponded to the allegations in the incident described above.Record review of the facility policy's titled, Abuse Prohibition Policy, dated 5/01/01 and last reviewed 6/2/25, reflected, 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations.
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Duncanville Healthcare and Rehabilitation Center in Duncanville, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Duncanville, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Duncanville Healthcare and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.