Duncanville Healthcare And Rehabilitation Center
Inspection Findings
F-Tag F0691
F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
outside or sweater and pants near Resident #1 right side of the mid-section.During an interview on 11/08/25 at 11:06 a.m., CNA A revealed that only nurses can burp (to expel air through the drainable end or filter opening. Done to manage any odor or splashing), [empty or change colostomy bags. CNA A stated that Resident #1 is the only resident that had a hard time getting his colostomy bag changed. She stated
she could tell the nurse, and it could take an entire shift for the nurse to change Resident #1 colostomy bag.
CNA A stated if the bag is not changed it could cause resident distress, there was the potential for it to leak
on to the skin and cause breakdown and the dignity of the resident, and if not emptied or changed the colostomy bag can have a blowout.During an interview on 11/08/25 at 11:42 a.m., CNA B revealed that aides could not change colostomy bags they were to inform their nurse on duty if resident requested or required their colostomy bag changed. CNA B stated that there had been occasions where a resident requested for their bag to be changed and had to ask the nurse to change the bag multiple times during a shift an entire shift and had witnessed the nurse take all shift before they would change the bag out. CNA B stated when the nurses did not change the bag that the bag would lift and leak onto the resident, which was
a dignity issue and could have led to possible skin irritation or breakdown.During an interview on 11/08/25 at 12:25 p.m., LVN C revealed that nurses were the only staff members who could burp/empty/change colostomy bags. LVN C stated that she had one resident on her hall who had a colostomy bag. LNV C stated that Resident #1 had requested it to be changed today on/or before 11 a.m. The LVN stated she had not changed the bag but had burped the bag and would change it after Resident #1 ate lunch. LVN C stated that she asked Resident #1 if he wanted to wait until after lunch for his colostomy bag to be changed and Resident #1 agreed. LVN C stated that residents have the right to have their bag changed upon request.
LVN C stated Resident #1 bag was not full so no risk to Resident #1 if bag was not changed.During an
interview on 11/08/25 at 1:14 p.m., the DON stated she expects nurses to burp/empty/change colostomy bags as soon as they are able once a resident request. The DON stated the harm of not changing the colostomy bag would be dignity issues at the least and to prevent bag from leaking on the skin which could be causative to the resident's skin and there is potential for infection.During an interview on 11/08/25 at 1:24 p.m., the ADM stated that the resident has the right to have his or her colotomy bag emptied changed at any time it was their right. The ADM stated that the harm of not emptying the colostomy bag when requested would cause resident dignity issues and prevent leaking on the skin. The ADM stated that his expectation of his staff was for staff to change upon request as soon as possible.During a record Review of facility document titled, Rights of the Elderly dated 7/21/18 reflected An elderly individual has all the rights, benefits, responsibilities and privileges granted by the constitution and laws of this stat and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights.(1) Has the right to make the individual's own choices regarding the individual's personal affairs, care, benefits and servicesRequested a policy on colostomy care from the DON on 11/08/25 it was not provided prior to exit.
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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.