Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in
locked compartments for 4 of 6 (SS Cart 1, SS Cart 2, SS Cart 3 and GV Cart) medication/treatment carts
reviewed for label and storage of drugs and biologicals.
The facility failed to ensure medication carts SS Cart 1 and SS Cart 2 were not left unlocked, unsecured,
and unattended.
The facility failed to ensure treatment carts, SS Cart 3 and GV Cart were not left unlocked, unsecured, and
unattended.
This failure could place residents at risk of having access to unauthorized medications, wound care and
medical supplies leading to possible harm or drug diversions.
Findings included:
During an observation on 11/16/2024 at 12:15 PM and 12:30 PM SS Cart 1 and SS Cart 2 were parked
against the wall with drawers facing the hallway , both carts were unlocked and were not in line of site of a
staff. A resident was observed propelling himself in his wheelchair down the hall within arms length of SS
Cart 1 and SS Cart 2. On the opposite hall SS Cart 3 was parked against the wall with the drawers facing
the hallway unlocked and not in line of site of staff. SS Cart 1 and SS Cart 2 contained the following
medications: Lasik, Levetiracetam, Losartan, Sertraline, Risperidone, Lisinopril, Tamsulosin, Baclofen,
Trazadone, Mirtazapine, Fluoxetine, Fluphenazine, Divalproex, Metoprolol, Sucralfate, Gabapentin,
Olanzapine, Bicalutamide, Eliquis, Rosuvastatin, Ranolazine, Buspar, Desmopressin, Albuterol, Mucinex,
and Nasal Spray . SS Cart 3 contained the following items contained wound care creams (zinc oxide
ointments, skin protectant ointment, and Vitamin A&D ointment) inhalers and eyedrops.
During an interview on 11/16/2024 at 12:30 PM RN A stated she was not responsible for SS Cart 1 and SS
Cart 2 and was not sure why the nurse did not secure the carts or where the nurse was at that time. RN A
then secured the medications carts. RN A stated she was responsible for SS Cart 3 and she had gotten
distracted by talking with a visitor and forgot to lock the cart. RN A stated residents could have been
affected by the medication carts being left open by getting medications that were not theirs.
During an interview on 11/16/2024 at 12:40 PM MA B stated she was responsible for SS Cart 1 and SS
Cart 2, she stated she did not know why she had left the carts open. MA B stated medication and
(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 4
Event ID:
675572
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
675572
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glen Rose Nursing and Rehab Center
1019 Holden St
Glen Rose, TX 76043
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
treatment carts should have been locked when she was not with them. MA B stated the affect on residents
could have been possible overdose. MA B stated she was responsible to ensure carts were locked. MA B
stated what led to the failure was it was Saturday and she had gotten in a hurry because she wanted to go
home.
During an observation on 11/16/2024 at 12:45 PM GV Cart was parked at the edge of the nurse's station
with the drawers facing the residents in the secure unit. The GV Cart was unlocked, and the top drawer was
slightly open, four residents were standing/sitting with arm's reach of the GV Cart. RN C was on the other
side of the room with her back to Cart GV.
During an interview on 11/16/2024 at 12:50 PM RN C stated the cart should have been locked.
During an interview 11/21/2024 at 2:55 PM the DON stated her expectation was that medication and
treatment carts should have been locked when unattended. The DON stated the nurse assigned to cart is
responsible to ensure the cart was locked and the DON monitors. The DON stated the effect on residents
could have been injury. The DON did not have a response to what led to failure of the medication carts
being left unlocked.
During an interview on 11/21/2024 at 3:15 PM the ADMN stated her expectation was that medication carts
should have been locked when the cart was unattended. The ADMN stated the nurse who carried the keys
to the cart was responsible to ensure the cart was secure, and the DON was responsible to monitor. The
ADMN stated the effect on residents could have been residents advertently getting medication they were
no supposed to. The ADMN stated what led to failure was oversight by the staff.
Record Review of the facility's policy titled, Security of Medication Cart dated April 2007 revealed, The
medication cart shall be secured during medication passes. 1. The nurse must secure the medication cart
during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the
doorway of the resident's room during the medication pass. The cart doors and drawers should be facing
the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be
parked in the hallway against the wall with the doors and drawers facing the wall. The cart must be locked
before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when
out of the nurse's view. 5. When the medication cart is not being used, it must be locked and parked at the
nurse's station or inside the medication room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675572
If continuation sheet
Page 2 of 4
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
675572
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glen Rose Nursing and Rehab Center
1019 Holden St
Glen Rose, TX 76043
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interview, and record review the facility failed to maintain medical records on each resident, in
accordance with accepted professional standards and practices, that were complete and accurate for 2
(Resident #3 and Resident # 7) of 7 residents reviewed for resident records.
The facility failed to ensure skin assessments were documented in medical record for Resident #3 and
Resident # 7.
This failure could place residents at risk of having errors in care and treatment.
The Findings included:
Resident #3
Record review of Resident #3's face sheet dated 11/21/2024 revealed a [AGE] year-old-male admitted on
[DATE], with the following diagnosis Alzheimer's disease, heart disease, high blood pressure, and repeated
falls.
Record review of Resident #3's admission MDS assessment dated [DATE] revealed; Section C- Cognitive
Patterns: Resident #2 had a BIMS score of 0 (meaning severe cognitive impairment).
Record review of Resident #3's care plan dated 10/25/2024 revealed Resident #2 required weekly skin
inspections.
Record review of Resident #3's electronic medical chart revealed no evidence of weekly skin inspections
completed between his admission on [DATE] and November 18, 2024.
During an observation on interview on 11/21/2024 at 1:48 PM, Resident #3 had a rash to the back and both
arms, and rash on the outer side of his legs and calves. RN A stated Resident #3 skin had been assessed,
and benadryl had been added to his regime for itching on 11/10/24 and hospice had orders ointment for
resident's skin. RN A stated she had assessed Resident #3's skin but had forgotten to complete the skin
assessment because the treatment nurse had been completing the assessements and had been out on
personal leave for several weeks.
Resident #7
Record review of Resident #7's face sheet dated 11/21/2024 revealed [AGE] year-old-female admitted on
[DATE] with the following diagnosis senile degeneration of brain, dementia, repeated falls, and Type 2
diabetes mellitus.
Record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed; Section C- Cognitive
Patterns: Resident #1 had a BIMS score of 6(meaning severe cognitive impairment).
Record review of Resident #7's care plan dated 10/19/2024 revealed Resident #1 required weekly skin
inspections.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675572
If continuation sheet
Page 3 of 4
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
675572
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Glen Rose Nursing and Rehab Center
1019 Holden St
Glen Rose, TX 76043
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Record review of Resident #7's electronic medical chart revealed no evidence of weekly skin inspections
completed between 10/03/2024 and 11/06/2024.
During an observation and interview on 11/21/2024 at 1:09 PM, Resident #7 had right elbow small circular
scabbed wound and left shoulder blade abrasion. DON stated Resident #7 had a fall which led to the
scabbed wound and shoulder blade abrasion. DON stated Resident #7 had been assessed and was
treated for the abrasion.
During an interview on 11/21/2024 at 12:45 PM, RN A stated every resident should have a skin
assessment weekly. RN A stated skin assessments populate when needed to be completed and the nurse
that was working that day was responsible to complete the skin assessment. RN A stated the skin
assessment were not documented as expected in electronic medical record. RN A stated residents skin
was assessed daily when providing incontinent care and during resident showers.
During an interview on 11/21/2024 at 2:55 PM, the DON stated every resident was supposed to have had
weekly skin assessments documented in their electronic chart. The DON stated skin assessments were
triggered weekly for nursing staff to complete. The DON stated the treatment nurse was responsible to
ensure they were completed, but she had been out for a family emergency and the nurses were supposed
to have documented the assessments. The DON state residents skin was being assessed daily during
incontinet care, showers and treatments. The DON stated she felt skin assessments were being done, they
were just not documented in the medical chart. The DON was responsible to monitor to ensure they were
being done. The DON stated what led to failure of skin assessments being undocumented was the
treatment nurse was not in the building.
During an interview on 11/21/2024 at 3:15 PM, the ADMN stated it was her expectation that skin
assessments be completed and documented weekly for every resident. The ADMN stated the effect on
residents having undocumented skin assessments could be potentially missing a skin condition that could
have worsened or turned into an infection. The ADMN stated the DON was responsible to monitor to ensure
skin assessments were being completed. The ADMN stated what led to failure of not skin assessments not
being documented was the treatment nurse had been out, and some slipped thru the cracks.
Record review of facility policy titled, Skin Assessment: New Admits or Resident Returning from Hospital
Stay. Dated March 7, 2007, revealed It is the policy of this facility to establish a method whereby nursing
can assess a resident's skin integrity to allow of appropriate interventions be initiated in a timely manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675572
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the November 21, 2024 survey of Glen Rose Nursing and Rehab Center?
This was a inspection survey of Glen Rose Nursing and Rehab Center on November 21, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Glen Rose Nursing and Rehab Center on November 21, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional princip..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.