Advanced Health & Rehab Center Of Garland
Advanced Health & Rehab Center of Garland in Garland, TX — inspection on September 12, 2025.
Found 2 citations. 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
important docs are consent to treat and social security.
The BOM stated the next step was to ensure
evening Resident #1 admitted to the facility, but had been working earlier that day.
When she came to
called his RP to get his social security number and needed the RP to sign his Consent to Treat form.
The BOM stated, We still needed it because we still cared for him briefly while he was here, so it is a CYA [cover your ass]. [RP] finally answered me this morning and said no to giving his social until [RP] got what she needed on why he was discharged .
The BOM stated Resident #1's RP had come in a week prior to admission to tour the facility but claimed the RP did not come the night he admitted .
The BOM said a lot of the required forms at the time of admission could be done electronically, so the person did not have to be at the facility face to face to complete them.
The BOM stated by the end of the first week she liked to have all her required admission documentation in place.
She stated, I have nothing on him [Resident #1]. I know that is bad, but I did try to get it in my defense.
She [Resident #1's RP] could have signed them electronically the day he came in, but I feel like I didn't know he was coming, it was not set in stone.
The BOM stated she could not provide any evidence that the facility notified the resident and his RP of the required admission documentation and disclosures.
Review of the facility's Introduction statement in their admission Packet undated reflected, State and federal regulations require nursing homes to have written policies covering the rights of residents.The nursing home's staff must implement these policies and explain them to you.This booklet describes your rights and the responsibilities nursing homes have for ensuring those rights.
The admission Packet also included 10 forms that were listed as requiring receipt and acknowledgement by the resident or the RP/POA to include:1.
Consent to Treat2.
Assignment of Benefits3.
Schedule of Charges for Ancillary Services4.
Information about Medicare and Medicaid Eligibility5.
Medicaid Estate Recovery Program6.
Resident Rights Under Federal Law7.
Ombudsman Services and Contact Information8.
Family Council Information9.
Policy for Criminal History Check for Employees10.
Drug Testing Policy11.
Advanced Directive Education and Advanced Care Planning Information12.
Privacy Act.
455731 09/12/2025
Advanced Health & Rehab Center of Garland 1201 Colonel Drive Garland, TX 75043
iv.
Resident representative information including contact information; v.
Current medications
jeopardy to resident health or recent immunizations; vi.
Special instructions or precautions for ongoing care to include precautions safety such as isolation or contact; vii.
Special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; viii.
Comprehensive care plan goals, and ix.
Any other
for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form and manner that the resident can understand; h.
Document assessment findings and other relevant information regarding the transfer in the medical record.This was determined to be an Immediate Jeopardy (IJ) on [DATE].
The ADM was notified.
The ADM was provided with the IJ template on [DATE] at 12:02 PM.
The following Plan of Removal submitted by the facility was accepted on [DATE] at 3:45 PM and reflected: Immediate Actions Taken (Date: [DATE]):1.
None- the resident did not return after discharge.Systemic Changes Implemented:Transport Protocol:1. EMT refusal of transport will trigger an automatic notification to the physician and DON before arranging alternative transport.2. A return to acute check list for non-emergency transport was created to document resident behaviors and medical devices prior to any transfer. 3.
The checklist assists staff in decision making to determine if supervision is needed during non-emergency transport for residents who are not alert and oriented and have behaviors.
The determination of supervision is not just for appointments, but for any destinations, including the ER.4. A trained CNA, or Licensed nurse will be assigned to supervise transportation if supervision is deemed necessary from the checklist.
The DON or Designee will arrange supervision if needed.5.
The supervising staff member will stay with the resident at the ER and check them in with ER personnel.6. If there is a behavioral emergency during transport staff are instructed to pull over to a safe place, stay with the resident and call 911.Education & Training1.
Regional Nurse DON/designee will educate DON on emergency transport vs non-emergency transport with posttest.
Completion by [DATE]. DON/designee will educate all licensed nurses on emergency transport vs non-emergency transport with posttest.
Completion by [DATE]. DON/designee will educate license nurses on the Return to Acute Checklist before calling non-emergency transport.
Completion by [DATE]. DON/designee will educate CNAs on recognizing and reporting line-pulling, fidgeting, and self-harm risks immediately to the charge nurse.
Completion by [DATE].
Staff unavailable to attend in service on [DATE] will receive personalized education and posttest prior to assuming their duties.
Monitoring:1. DON/Designee will audit 100% of all hospital/ER transfers for 30 days to verify:a.
Completion of Return to Acute Checklist for non-emergency transport.2.
Findings will be reviewed in QA/QI Committee meetings monthly for 3 months, then quarterly thereafterDate Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE].Monitoring interviews for the Immediate Jeopardy were started on [DATE] at 2:45 PM with nine nursing staff and management across multiple shifts to include: DON, ADM, RN B, ADON I, ADON J, RN K, LVN L, LVN M and LVN N.
All staff were able to provide competency of education on the new Resident Transfer Checklis
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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.