Duncanville Healthcare And Rehabilitation Center
Duncanville Healthcare and Rehabilitation Center in Duncanville, TX — inspection on September 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.