F 0726
Level of Harm - Minimal harm
or potential for actual harm
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Purpose of
Visit: Investigations
Residents Affected - Some
Entrance Date: [DATE]
Facility Census: 75
Complaint Intakes:
1010357 TX00543373
The following acronyms were used in the document:
CNA - Certified Nurse Aide
DON - Director of Nursing
HR- Human Resources
NAR-Nurse Aide Registry
Based on interviews and record review, the facility failed to ensure sufficient nursing staff with appropriate
competencies and skills set to provide nursing and related services for 3 (CNA A, CNA B, CNA C) of 10
employees reviewed for staff qualifications.
The facility failed to ensure CNA A, CNA B, and CNA C had a current nurse aide certification while
employed at the facility and actively providing care for residents.
This failure could result in residents being provided care by staff who have not provided documentation of
training and competency in providing care.
Findings include:
Record review of CNA A's NAR. Certificate registry date [DATE], revealed CNA As certification expired on
[DATE].
Record review of CNA A's Timecard Report for [DATE]-[DATE], revealed CNA A worked a total of 5
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
455823
Printed: 05/15/2026
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
455823
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Treemont Healthcare and Rehabilitation Center
5550 Harvest Hill Rd
Dallas, TX 75230
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 0726
shifts scheduled 10:00pm-6:00am.
Level of Harm - Minimal harm
or potential for actual harm
Record review of CNA B's NAR. Certificate registry date [DATE], revealed CNA Bs certification expired on
[DATE].
Residents Affected - Some
Record review of CNA B's Timecard Report for [DATE]-[DATE], revealed CNA B worked a total of 3 shifts
scheduled 2:00pm-10:00pm.
Record review of CNA C's NAR. Certificate registry date [DATE], revealed CNA Cs certification expired on
[DATE].
Record review of CNA C's Timecard Report for [DATE]-[DATE], revealed CNA C worked a total of 7 shifts
scheduled 10:00pm 6:00am.
Attempted interview on [DATE] at 3:20pm with CNA B via phone, the attempt was unsuccessful.
Attempted interview on [DATE] at 3:22pm with CNA C via phone, the attempt was unsuccessful.
In an interview with CNA A on [DATE] at 3:25pm revealed she was responsible for notifying HR and the
Administrator when licensed expired. CNA stated she did not inform staff that her license had expired.
In an interview on [DATE] at 4:00pm, the DON stated HR was expected to complete background and
registry checks routinely. The DON stated background checks and registry checks should be completed
prior to hire and annually once hired. The DON stated staff were responsible for notifying HR that their
licenses/certifications are expired. The DON stated the risk of staff working with an expired license or
certification can result in incompetent staff, residents at risk for abuse and neglect, and a lack of quality of
care.
In an interview with the Administrator on [DATE] at 4:40pm, the Administrator stated HR was responsible for
completing background checks and registry checks prior to hire and annually once hired. The Administrator
stated an HR coordinator was just hired 30 days ago. The Administrator stated it was the responsibility of
the staff to notify HR that their license or certification has expired or close to being expired. The
Administrator stated completing checks annually was how the facility monitors criminal history, expired
licenses, and certifications. The Administrator stated if an aide's certification was expired or close to
expiring, it was their responsibility to renew their certification. The Administrator stated if an aide's
certification is expired, an aide cannot perform duties until their certification is renewed. The Administrator
stated CNA A, CNA B, and CNA C's certifications expiration dates were [DATE] and [DATE]. The
Administrator stated the risk of staff working with an expired license or certification can cause a lack of
skills and affect the quality of care the resident would receive. The Administrator stated staff working with
an expired license or certification can result in termination.
A policy for nurse aide registry verification was requested from the Administrator on [DATE] but was not
received at the time of exit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455823
If continuation sheet
Page 2 of 2
