Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to immediately inform the resident, consult with the resident's
physician, and notify, consistent with his or her authority, the resident's representative when there was a
significant change in the resident's physical, mental, or psychosocial status in either life threatening
conditions or clinical complications for 1 of 3 residents (Resident #1) reviewed for change in condition. The
facility failed to ensure Resident #1's RP was notified when Resident #1 was found sitting up in bed with his
midline IV (flexible catheter inserted into a vein in the arm) removed from his left arm on 12/03/25, which
resulted in his arm having to be elevated and wrapped to lessen any swelling and bleeding. This failure
could place residents at risk of their RP not being aware of conditions that may require them to make
medical decisions. Findings include:Record review of Resident #1's, undated, face sheet reflected a [AGE]
year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included
Atherosclerotic cardiovascular disease (caused by plaque buildup in arterial walls), Chronic Kidney Failure
(gradual loss of kidney function over time), Dementia (loss of thinking, remembering, and reasoning skills),
and Malignant Neoplasm of Brain (cancer that grows aggressively, and can spread). Record review of
Resident #1's admission MDS, dated [DATE], indicated he had a BIMS score of 5, which indicated severe
cognitive impairment. Record review of Resident #1's Care Plan, dated 11/20/2025, indicated At risk for
impaired cognitive function/dementia or impaired thought processes. Record review of Resident #1's SBAR
Communication Form, dated 12/3/2025 at 11:00 AM, and completed by RN B, reflected Resident #1 had a
change in skin color that started on 12/3/25. Under section Name of Family/Health Care Agent Notified was
FM [Name]. Record review of Resident #1's Skin Check, dated 12/3/25 at 19:57 (7:57 PM) and completed
by LVN B, reflected Resident #1 had a new skin tear on his left outer forearm that was acquired in-house.
The Skin Check further revealed Resident #1's skin was not warm and dry, his skin color was not within
normal limits, and his skin turgor (skin's elasticity, its ability to snap back after being stretched) had
decreased. Record review of Resident #1's Progress Notes, dated 12/03/2025 at 11:22 AM and written by
RN B, revealed Midline observed out of pt's arm during this shift. Catheter tip was intact. Plan of care
ongoing. Record review of Resident #1's Progress Notes, dated 12/03/2025 at 11:29 AM and written by RN
B, revealed eINTERACT SBAR Summary for Providers: The Change in Condition/s [sic] reported on this
CIC Evaluation are/were: Change in skin color or condition. Primary Care Provider responded with the
following feedback: A. Recommendations: Wound care order. Record review of Resident #1's Progress
Notes, dated 12/03/2025 at 13:20 (1:20 PM) and written by RN B, revealed Monitor PIV / PICC / Midline /
Central Line For S/S Of Infection/Infiltration Every Shift **Notify Provider If Present every shift. Record
review of Resident #1's Progress Notes, dated 12/04/2025 at 11:34 AM and written by RN B, revealed Pt
transfered [sic] to [Hospital] ER per family - [RP]'s [Name] request. Pt is stable at time of transfer. [FM],
[Name] at bedside. In
(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 3
Event ID:
675579
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
675579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beacon Harbor Healthcare and Rehabilitation
6700 Heritage Parkway
Rockwall, TX 75087
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
an interview on 12/09/25 at 5:47 PM with the RP, she stated the facility removed Resident #1's midline IV
from his left arm on 12/3/2025 without informing her. The RP stated she visited Resident #1 on 12/2/2025
and he was fine with no issues. The RP stated FM visited Resident #1 on 12/3/2025 and he was told the
facility removed the midline IV. The RP stated FM said he observed Resident #1 sitting up in his chair with
his arm wrapped. The RP stated on 12/4/2025, a male staff member called her and asked if they could
insert another midline IV in his right arm. In an interview on 12/10/25 at 3:05 PM with LVN A, she stated if
there was any type of change in condition, they contacted the NP or the doctor to get orders. She stated
they also notified the DON and the RP. LVN A stated the RP must always be contacted for any change in
condition. LVN A stated she should had contacted the RP. She stated she was trained on changes in
conditions and proper notifications by the ADONs and the DON. In an interview on 12/11/25 at 11:00 AM
with ADON C, she stated when a resident had a change in condition, they assessed the resident and
contacted the doctor or the NP and shared their findings and then notified the RP. ADON C stated they
processed any orders (medications, lab work, etc.). ADON C stated once they received the results, they
informed the doctor and NP and implemented any new orders given. ADON C stated they updated the RP
as soon as possible to get approval and if the RP was not in agreement, they notified the doctor. In an
interview on 12/11/25 at 11:45 AM with ADON D, she stated when there was a change in condition, if the
resident did not have a cognitive diagnosis, she discussed the lab results with the resident. ADON D stated
they notified the resident, the RP, the physician, the NP and the DON. ADON D stated after a change in
condition, the physician would give new orders, continue with existing orders, repeat lab work, or order an
x-ray. ADON D stated they updated the family and the DON. ADON D stated if a family member was
present at the facility, she reviewed the face sheet to confirm if they were able to release information,
because the resident may not want that person to be informed. ADON D stated if the person was on the
face sheet as an emergency contact, she would inform them too. ADON D stated she still notified the RP
and never relied on a family member to inform the RP. In an interview on 12/11/25 at 12:25 PM with RN B,
she stated when there was a change in condition, they notified the doctor, the RP and the DON. RN B
stated if there were new orders, they informed the RP prior to implementation and if the RP consented, they
proceeded. RN B stated if the RP was not in agreement, they updated the doctor. RN B stated they also
completed the Change of Condition Form in the EMR. RN B stated Resident #1 had a change in condition
on 12/3/2025 which consisted of his midline IV being observed out of his left arm with visible bleeding. RN
B stated she found the midline IV out of Resident #1's arm, and she informed the FM when he arrived to
visit Resident #1. RN B stated she did not inform the RP due to telling the FM. RN B stated they were
supposed to notify the RP to ensure the RP was made aware. RN B stated due to the FM not being the RP,
she should have notified the RP herself. RN B stated by not informing the RP, prevented the RP from being
aware of any change in condition. RN B stated she was trained on changes in conditions and proper
notifications by the ADONs and the DON. In an interview on 12/11/25 at 1:40 PM with NP E, she stated RN
B informed her Resident #1 pulled out his midline IV. NP E stated RN B notified her on 12/3/25 that there
was bleeding from Resident #1's arm. NP E stated she put in an order to cleanse the arm and an order for
a wound care assessment due to it being opened. NP E stated the next day on 12/4/25, the RP requested
Resident #1 be sent out to the hospital for further evaluation. In an interview on 12/11/25 at 2:05 PM with
the MD, she stated it was believed Resident #1 pulled out the midline IV as it was not removed by staff. The
MD stated RN B notified her the midline IV was out and there was a change in condition which included a
skin tear. The MD stated Resident #1 was a [AGE] year-old male, on a blood thinner and had a long-term
use of steroids. The MD stated in addition to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675579
If continuation sheet
Page 2 of 3
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
675579
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Beacon Harbor Healthcare and Rehabilitation
6700 Heritage Parkway
Rockwall, TX 75087
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Resident #1's serious co-morbidities all contributed to him having thin skin. The MD stated NP E put in a
new order to Cleanse left arm wounds with NS, pat dry, apply xeroform (mesh gauze dressing), cover with
ABD and secure with kerlix (woven gauze bandage) every day shift every Tuesday, Thursday, Saturday for
Wound care. In an interview on 12/11/2025 at 2:30 PM, the DON stated his expectation was for nursing to
notify the family and the MD of any change in condition. The DON stated RN B should have notified
Resident #1's RP as soon as possible when he first had a change in status on 12/3/25. In an interview on
12/11/2025 at 3:20 PM with the ADM, he stated he expected staff to follow policy which included notifying
the RP. The ADM said they coached the nurses on what the policy was, so they had an understanding. The
ADM stated staff could not be expected to do something they did not know. The ADM stated his expectation
was if there was a change of condition, the family and the RP should be notified as soon as possible. The
ADM stated it was important for the family and the RP to know what was going on with the resident. The
ADM stated nurses were educated on when to notify and to not deviate from the facility's policy. Record
review of the facility's policy, Change in Condition, with a revision date of April 2025, reflected .5.The
resident/resident representative will be notified of the change of condition and any changes in the resident's
medical or nursing care.
Event ID:
Facility ID:
675579
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
FAQ · About this visit
Common questions about this visit
What happened during the December 11, 2025 survey of BEACON HARBOR HEALTHCARE AND REHABILITATION?
This was a inspection survey of BEACON HARBOR HEALTHCARE AND REHABILITATION on December 11, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BEACON HARBOR HEALTHCARE AND REHABILITATION on December 11, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
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.