Duncanville Healthcare And Rehabilitation Center

Penalties

• May 20, 2025 — Fine ($17,345)
• Feb 7, 2024 — Fine ($1,668)
• Jan 12, 2024 — Fine ($7,105)

Inspection findings

1. May 20, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected May 22, 2026 · CMS health inspection

2. Apr 30, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected May 3, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected May 3, 2026 · CMS health inspection

3. Apr 8, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Apr 10, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Apr 10, 2026 · CMS health inspection

4. Mar 25, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 26, 2026 · CMS health inspection

5. Dec 5, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Dec 6, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 6, 2025 · CMS health inspection

6. Nov 8, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0691 Quality of Life and Care Deficiencies

     Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

     Corrected Nov 11, 2025 · CMS health inspection

7. Sep 18, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Sep 21, 2025 · CMS health inspection

8. Aug 14, 2025 Health · 8 findings
   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected Aug 17, 2025 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Aug 17, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Aug 17, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Aug 17, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0773 Administration Deficiencies

     Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

     Corrected Aug 17, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Aug 17, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 17, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Aug 17, 2025 · CMS fire safety

9. May 20, 2025 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0678 Quality of Life and Care Deficiencies

     Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

     Corrected May 19, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0839 Administration Deficiencies

     Employ staff that are licensed, certified, or registered in accordance with state laws.

     Corrected May 21, 2025 · CMS health inspection

10. May 6, 2025 Health · 2 findings
    • Not serious Scope/severity E Complaint

      F0584 Resident Rights Deficiencies

      Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

      Corrected May 7, 2025 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected May 7, 2025 · CMS health inspection

11. May 1, 2025 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from the wrongful use of the resident's belongings or money.

      Corrected May 2, 2025 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

      Corrected May 2, 2025 · CMS health inspection

12. Jan 23, 2025 Health · 2 findings
    • Not serious Scope/severity E Complaint

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Feb 17, 2025 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Feb 17, 2025 · CMS health inspection

13. Nov 20, 2024 Health · 1 finding
    • Not serious Scope/severity E Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Nov 21, 2024 · CMS health inspection

14. Oct 16, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Nov 13, 2024 · CMS health inspection

15. Jul 10, 2024 Health · 8 findings
    • Not serious Scope/severity D Complaint

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Sep 6, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Sep 6, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0761 Pharmacy Service Deficiencies

      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.

      Corrected Sep 6, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0804 Nutrition and Dietary Deficiencies

      Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

      Corrected Sep 6, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0806 Nutrition and Dietary Deficiencies

      Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

      Corrected Sep 6, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Sep 6, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0842 Resident Assessment and Care Planning Deficiencies

      Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

      Corrected Sep 6, 2024 · CMS health inspection

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Aug 12, 2024 · CMS fire safety

16. Feb 25, 2024 Health · 8 findings
    • Not serious Scope/severity E Complaint

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Feb 26, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Feb 26, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0677 Quality of Life and Care Deficiencies

      Provide care and assistance to perform activities of daily living for any resident who is unable.

      Corrected Feb 26, 2024 · CMS health inspection

    • Serious Scope/severity G Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Feb 26, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0755 Pharmacy Service Deficiencies

      Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

      Corrected Feb 26, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0800 Nutrition and Dietary Deficiencies

      Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

      Corrected Feb 26, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Feb 26, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0835 Administration Deficiencies

      Administer the facility in a manner that enables it to use its resources effectively and efficiently.

      Corrected Feb 26, 2024 · CMS health inspection

17. Feb 7, 2024 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0655 Resident Assessment and Care Planning Deficiencies

      Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

      Corrected Feb 8, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0761 Pharmacy Service Deficiencies

      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.

      Corrected Feb 8, 2024 · CMS health inspection

18. Jan 12, 2024 Health · 3 findings
    • Serious Scope/severity J Complaint

      F0580 Resident Rights Deficiencies

      Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

      Corrected Jan 13, 2024 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

      Corrected Jan 13, 2024 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0684 Quality of Life and Care Deficiencies

      Provide appropriate treatment and care according to orders, resident’s preferences and goals.

      Corrected Jan 13, 2024 · CMS health inspection

19. Sep 27, 2023 Health · 5 findings
    • Not serious Scope/severity E Complaint

      F0558 Resident Rights Deficiencies

      Reasonably accommodate the needs and preferences of each resident.

      Corrected Sep 28, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0584 Resident Rights Deficiencies

      Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

      Corrected Sep 28, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0801 Nutrition and Dietary Deficiencies

      Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

      Corrected Sep 28, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0802 Nutrition and Dietary Deficiencies

      Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

      Corrected Sep 28, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Sep 28, 2023 · CMS health inspection

20. Sep 11, 2023 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0584 Resident Rights Deficiencies

      Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

      Corrected Sep 12, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0761 Pharmacy Service Deficiencies

      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.

      Corrected Sep 12, 2023 · CMS health inspection

21. Aug 31, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0550 Resident Rights Deficiencies

      Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

      Corrected Sep 1, 2023 · CMS health inspection

22. Aug 4, 2023 Health · 1 finding
    • Serious Scope/severity J Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jul 31, 2023 · CMS health inspection

23. May 24, 2023 Health · 6 findings
    • Not serious Scope/severity D

      F0698 Quality of Life and Care Deficiencies

      Provide safe, appropriate dialysis care/services for a resident who requires such services.

      Corrected Jun 21, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Jun 21, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Jun 21, 2023 · CMS health inspection

    • Not serious Scope/severity D

      K0222 Egress Deficiencies

      Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

      Corrected Jun 21, 2023 · CMS fire safety

    • Not serious Scope/severity E

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Jun 21, 2023 · CMS fire safety

    • Not serious Scope/severity F

      K0372 Smoke Deficiencies

      Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

      Corrected Jun 21, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• CALLIES, MARILYN — w-2 managing employee, NOT APPLICABLE, since 08/31/2022
• CALLIES, MARILYN — corporate officer, NOT APPLICABLE, since 02/11/2013
• CERISE, FREDERICK — corporate officer, NOT APPLICABLE, since 03/24/2014
• CERISE, FREDERICK — operational/managerial control, NOT APPLICABLE, since 02/21/2015
• KIRLEY, FRANCIS — operational/managerial control, NOT APPLICABLE, since 02/21/2015
• LEE, BRIAN — operational/managerial control, NOT APPLICABLE, since 02/21/2015
• PIERCE, DANIEL — corporate officer, NOT APPLICABLE, since 03/16/2021
• RINER, MEERA — operational/managerial control, NOT APPLICABLE, since 02/21/2015
• TAYLOR, KIARA — w-2 managing employee, NOT APPLICABLE, since 09/20/2021
• DALLAS COUNTY HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 02/21/2015
• DALLAS COUNTY HOSPITAL DISTRICT — operational/managerial control, NOT APPLICABLE, since 02/21/2015
• NEXION HEALTH AT DUNCANVILLE INC — operational/managerial control, NOT APPLICABLE, since 02/21/2015
• NEXION HEALTH LEASING, INC. — operational/managerial control, NOT APPLICABLE, since 08/08/2001
• NEXION HEALTH LEASING, INC. — 5% or greater indirect ownership interest, since 08/08/2001
• NEXION HEALTH, INC. — operational/managerial control, NOT APPLICABLE, since 08/08/2001
• NEXION HEALTH, INC. — 5% or greater indirect ownership interest, since 08/08/2001