Rockwall Nursing Care Center

In the surveyor’s words

From the most serious findings on record at Rockwall Nursing Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF656Nov 18, 2023

  Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being of (Resident #5, Resident #6, Resident #11, Resident #20, Resident #40, Resident #46, and Resident #59) 7 of 14 comprehensive care plans and elopement risk assessments reviewed. 1. The facility failed to implement the interventions listed on Resident #6's comprehensive care plan. Consequently, Resident #6 eloped from the facility, compromising his safety. 2. […]

• Immediate jeopardy, isolatedF689Oct 21, 2025

  Based on interviews, and record reviews, the facility failed to provide adequate supervision and assistance to prevent accident hazards for one of ten residents (Resident #3) reviewed for accidents and hazards. CNA A failed to follow Resident #3's care plan and mechanical lift instructions of using two people to perform the transfer on 09/27/25, which resulted in the resident falling and fracturing 5 ribs. The non-compliance was identified as PNC on 10/21/25 and the IJ template was provided to the facility on [DATE] at 4:30 PM. The noncompliance began on 09/27/25 and ended 09/29/25. The facility corrected the non-compliance before the investigation began. This failure placed the resident at risk of serious harm, injury and death. […]

• Immediate jeopardy, isolatedF689Nov 1, 2024

  Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents. The facility failed to ensure Resident #1 who was a fall risk, had precautions in place to prevent Resident #1 from falling in the dining room on 10/30/2024. Resident #1 was left alone in the dining room by staff and fell out of his wheelchair. He sustained a bilateral subdural hematoma and was hospitalized . Resident #1 had a fall on 10/28/24 from his bed in which he sustained a hematoma. The noncompliance was identified as PNC IJ. The noncompliance began on 10/30/24 and ended on 10/31/24. […]

• Immediate jeopardy, isolatedF689Nov 18, 2023

  Based on interview and record review the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement of (Resident #6) 1 of 7 residents reviewed for accidents, hazards, and supervision. 1. The facility failed to adequately assess, supervise, and implement care interventions for Resident #6 to prevent an elopement from the facility on 11/05/2023 for approximately 10-20 minutes. 2. The facility failed to implement the interventions listed on Resident #6's comprehensive care plan. Consequently, Resident #6 eloped from the facility, compromising his safety. An IJ was identified on 11/16/2023 at 5:30 PM. The IJ template was provided to the Administrator and DON on 11/16/2023 at 5:46 PM. […]

• Immediate jeopardy, isolatedF580Mar 9, 2023

  Based on interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for one (Resident #1) of five residents reviewed for physician notification. 1) The ADON failed to consult the wound care physician on 01/03/2023 about altered skin integrity to Resident #1's left calf and discoloration of toe on Resident #1's left foot per PCP-M.D. […]