Broadmoor Medical Lodge
Inspection Findings
F-Tag F0644
F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
company and the family requested to speak to the DME company. During a telephone interview on 11/18/25 at 12:54 p.m., the Habilitation Coordinator stated during the initial PSCP meeting on 06/10/24 a wheelchair was recommended and the family agreed to go through PASRR. The Habilition Coordinator stated she sent an email to the DON, ADON, Social Worker, DOR, and the MDS Coordinator on 10/03/24 informing them that they did not make a request for the customized wheelchair on 06/10/24. The Habilitation Coordinator stated she reached out again via email on 10/08/25 for an update. The Habilition Coordinator stated after following up several times she was notified by the DOR that the facility went through a part B source (DME company) not part A (PASRR). The Habilitation Coordinator stated the facility wheelchair was standard and the one through PASRR fitted specifically to the resident. The Habilition Coordinator stated the facility had 20 business days to initiate the wheelchair process from the IDT meeting on 06/10/24. The Habilition Coordinator stated the risk of not completing the process within the time frame put Resident #2 not having the full QOL she potentially could have. During an interview on 11/19/25 at 5:45 p.m., the DON stated she was not aware of the exact time when the NFSS should be completed after the IDT meetings. The DON stated that it was the MDS Coordinator responsibility to complete the NFSS within the appropriate time frame. The DON stated the Regional Clinical Reimbursement Specialist was responsible for monitoring and overseeing the PASRR process. The DON stated it was important to ensure the residents' needs were met in a timely manner. During a telephone
interview on 11/19/25 at 6:05 p.m., the Regional Clinical Reimbursement Specialist stated that the NFSS should be completed 21 days after the IDT meeting. The Regional Clinical Reimbursement Specialist stated that it was the DOR responsibility to complete the NFSS within the appropriate time frame and the MDS Coordinator entered the PSCP into the portal. The Regional Clinical Reimbursement Specialist stated the family had initiated getting a wheelchair through a separate DME company. The Regional Clinical Reimbursement Specialist stated the MDS Coordinator should have gone into the portal and updated the PCSP form that way the PASRR representative would have been notified. During an interview on 11/19/25 at 6:13 p.m., the Administrator stated he was unaware of the time frame that the NFSS should be completed after the IDT meeting. The Administrator stated it was the MDS Coordinator responsibility to complete the NFSS within the appropriate time frame. The Administrator stated the Regional Clinical Reimbursement Specialist was responsible for monitoring and overseeing. The Administrator stated it was important to ensure the information was submitted timely, so the residents receive what they need. Record
review of the facility's policy titled Preadmission Screening Resident Review Rules revised 09/03/2021 indicated. Post IDT Meeting Responsibilities.2. The facility will initiate the request for specialized services within 20 business days of the IDT/PCSP meeting.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Broadmoor Medical Lodge
5242 Medical Drive Rockwall, TX 75032
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0692
F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
main meal first between receiving a shake. The DON stated the nurse that was circulating the dining room should be monitoring to make sure they received them prior to the end of the meal service. The DON stated
she monitored by random rounds to ensure diet orders were followed. The DON stated there has not been any issues in the past. The DON stated it was important to receive the correct diet to help maintain their weight. During an interview on 11/19/25 at 6:13 p.m., the Administrator stated she expected the diet order to be followed. The Administrator stated they should have received their shakes/ice cream with their meals.
The Administrator stated she should have received two servings of proteins. The Administrator stated the cook was responsible for ensuring Resident #3 received double portions and the nurse was responsible for ensuring the residents received the shakes/ice cream. The Administrator stated the ADON/DON was responsible for monitoring and overseeing meal service. The Administrator stated it was important to receive the correct diet to prevent weight loss. Record review of the facility's policy titled Menus revised 10/2008 indicated. Menu shall a) meet the nutritional needs of residents; b) be prepared in advance; and c) be followed.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Broadmoor Medical Lodge
5242 Medical Drive Rockwall, TX 75032
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0849
F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
During an interview on 11/19/25 at 6:35 p.m., the Administrator said it was the nurse's responsibility to ensure hospice was notified of any changes in the residents. He said the nurse management team was the overseer of the process. He said hospice should be made aware of any changes in the residents to ensure their needs were met. He said failure to notify hospice was a lack of coordination of care. Record review of
the facility's policy Hospice Program revised July 2017, indicated the facility was responsible for the following. C. notify hospice about the following changes, (1) a significant change in resident physical, mental, social, or emotional status. D. Communicating with the hospice provider (and documenting such communication) to ensure that the residents needs are addressed and met 24-hours per day.
Event ID:
Facility ID:
If continuation sheet
BROADMOOR MEDICAL LODGE in ROCKWALL, 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 ROCKWALL, 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 BROADMOOR MEDICAL LODGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.