Stallings Court Nursing And Rehabilitation
Stallings Court Nursing and Rehabilitation in Nacogdoches, TX — inspection on May 28, 2026.
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
cancer lesion that was on her forehead.
She said she did not have any open wounds or pressure ulcer
heel protectors after she was admitted .
She said the heel protectors were to relieve pressure on their
touch the bed.
During an interview on 5/28/2026 at 1:34 PM, the ADON said Resident #1 had a DTI to her heel and had the heel protectors in place with wound care daily.
She said the Treatment nurse performed wound care and the facility had a wound physician that visited weekly.
She said the heel protectors should be on while a resident was in bed, and all staff were responsible for ensuring they were in place.
She said they had a stock supply of foam heel protectors in the facility.
She said the purpose of the heel protectors was to prevent wounds.
She said they tried to float the heels with a pillow under the ankles, so the heel did not touch the bed.
She said she was not aware Resident #1 only had one heel protector.
During an interview on 5/28/2026 at 1:50 PM, the DON said she received a phone call from the Treatment nurse one day and was informed Resident #1 had a DTI to her heel and she questioned the Treatment Nurse when the last skin assessment was conducted and was told Resident #1 did not have any wounds observed between that week and that was when the heel protectors were put in place for Resident #1 when the wound was identified.
She said the heel protectors should be on a resident while they were in bed and should have both heel protectors on.
She said her feet should be positioned offloaded and not touching the mattress.
She said she was made aware yesterday (5/27/2026) that Resident #1 only had one heel protector on and her heels were not floating.
She said Resident #1's heels should be floated with a pillow so the heels should not touch the mattress.
She said the heel protectors were to prevent the skin from touching the mattress and relieve pressure.
She said on admission Resident #1 did not have any wounds on her feet and acquired the wound in house.
She said the facility had a wound physician who visited weekly and was seeing Resident #1.
During an interview on 5/28/2026 at 2:39 PM, the Administrator said she had been at the facility since March 2026.
She said she was made aware in a morning meeting by the Treatment nurse that Resident #1 had developed a wound to her heel that was not present on admission to the facility.
She said the Treatment nurse put heel protector orders in place for Resident #1 to ensure the wound did not get any worse.
She said the heel protectors were for both feet.
She said the staff would place a pillow under her legs to keep the heels from touching the mattress.
She said she was not aware the resident was not wearing heel protectors.
She said the purpose of the heel protectors was to help prevent pressure wounds.
She said she planned to reeducate the staff to communicate, and it was not acceptable to not have things in place.
She said all staff were responsible for ensuring residents had heel protectors if ordered and should be worn when in bed.
She said the risk would be that they could develop more wounds if they did not wear them.
Record review of the facility's policy titled Prevention of Pressure Ulcers, revised March 2005, indicated .The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. 5.
Risk factor-immobility c. when in bed, every attempt should be made to float heels' (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician.
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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.