TEXAS DEPARTMENT OF STATE HEALTH SERVICES

KIRK COLE
INTERIM COMMISSIONER

P.O. Box 149347

Austin, Texas 78714-9347
1-888-963-7111
TTY: 1-800-735-2989
www.dshs.state.tx.us

December 10, 2015

Certified Mail Number: 7011 0470 0003 0321 1332
and First Class Mail Service
CT Corporation System, Registered Agent
UHS of Timberlawn, Inc
DBA Timberlawn Mental Health System
1999 Bryan Street Ste 900
Dallas, TX 75201
Certified Mail Number: 7011 0470 0003 0321 1349
and First Class Mail Service
Craig L. Nuckles, CEO
Timberlawn Mental Health System
4600 Samuell Boulevard
Dallas, TX 75228
Re: Notice of Violation (Notice), Timberlawn Mental Health System, Psychiatric Hospital,
License #000752, Case #1068154440, 1068155638, 1068155637 and 1068156819, Docket
#A24571-505-2015, A24603-029-2015, A24676-029-2016 and A24677-029-2016
respectively
The Department of State Health Services (Department) has reviewed documents and evidence related
to an on-site complaint investigation, unannounced full survey, second on-site complaint investigation,
and unannounced follow-up full survey of Timberlawn Mental Health System (Respondent) located at
4600 Samuell Boulevard, Dallas, TX 75228 (Facility) conducted on or about February 25, 2015, April
22, 2015, May 13, 2015 and July 1, 2015, respectively.
As a result of that review, the Department proposes to impose an administrative penalty in the amount
of $1,050,000.00 and revocation of the Facilitys License #000752 pursuant to its authority under
Chapters 571-578 of the Texas Health and Safety Code (HSC) and Title 25 of the Texas Administrative
Code (TAC) Chapters 134, 404 and 411 (Rules).
The proposed action is based upon the following allegations (names of persons identified by initials or
numbers will be provided upon request if permitted by law) for the on-site complaint investigation,
unannounced full survey, second on-site complaint investigation, and unannounced follow-up full
survey conducted on or about February 25, 2015, April 22, 2015, May 13, 2015 and July 1, 2015,
respectively:

Notice of Violation
Timberlawn Mental Health System
Page 2

February 25, 2015 on-site complaint investigation:

1. The Facility failed to protect patients, to wit:
The Facility failed to protect and provide patients with a safe environment by failing to modify,
secure or remove hazardous objects for two (2) patients. The Facility failed to remove materials
resulting in Patient #1s death. Furthermore, the Facility failed to monitor and record the
observation round for Patient #12. The Facilitys failure violated 25 TAC 411.477(a)(1)(B)
and 411.477(a)(2), which states:
411.477 Protection of a Patient
(a) Modifying the environment and monitoring the patient. A hospital shall protect a patient by
taking the following measures:
(1) modifying the hospital environment based on the patient's needs including:
(B) securing or removing objects that are hazardous to the patient.
(2) monitoring the patient at the level of monitoring most recently specified in the patient's
medical record
An administrative penalty in the amount of $40,000 ($25,000 for Patient #1 plus $15,000 for Patient
#12) is proposed for this rule violation.
2. The Facility failed to monitor quality assessment and performance improvement activities, to
wit :
The Facility failed to monitor and ensure current and previously identified patient safety risks
were addressed from May 2014 through February 18, 2015. Furthermore, safety measures were
not implemented for Patients #1 and 12. Furthermore, observations conducted in the Facilitys
lobby, trauma and geriatric unit on February 18, 2015 revealed the continued presence of
hazardous items accessible to patients, in violation of 25 TAC 411.493(d)(1)(A) and
411.493(d)(3) (6), which states:
411.493 Quality Assessment and Performance Improvement Program
(d) Quality assessment and performance improvement program activities.
(1) As part of its quality assessment and performance improvement activities a hospital shall
collect and aggregate data to:
(A) monitor the effectiveness and safety of services and the quality of care.
(3) The hospital shall analyze the aggregated data, at least quarterly, to assess the need for
performance improvement.

Notice of Violation
Timberlawn Mental Health System
Page 3

(4) When a need for performance improvement is identified, the hospital shall develop and
implement an action plan to address the identified need.
(5) The hospital shall evaluate the success of the action plan to determine if the positive outcomes
are achieved and sustained.
(6) If the hospital determines that the positive outcomes have not been achieved or sustained, the
hospital shall modify the action plan and re-evaluate its implementation until the outcomes are
achieved and sustained.
An administrative penalty in the amount of $25,000 is proposed for this rule violation.
April 22, 2015 unannounced full survey:
3. The Facility failed to ensure the implementation of an active program for the prevention,
control and investigation of infections and communicable diseases, to wit:
The Facility failed to:

Ensure a clean and sanitary environment was maintained for the Geriatric, Trauma,
Lewis I and Burkett II units.
Ensure direct care staff for the Geriatric Unit practiced good infection control procedures
during patient care for Patients #2, #3 and #5.
Ensure that specimens collected from patients were processed timely for lab analysis for
the Bloss and Burkett I units.

This conduct is in violation of 25 TAC 134.41(d)(1), which states:

134.41 Facility Functions and Services
(d) Infection control. The facility shall provide a sanitary environment to avoid sources and
transmission of infections and communicable diseases. There shall be an active program for the
prevention, control, and investigation of infections and communicable diseases.
(1) Organization and policies. A person shall be designated as infection control coordinator. The
facility shall ensure that policies governing prevention, control and surveillance of infections
and communicable diseases are developed, implemented and enforced.
An administrative penalty in the amount of $135,000 ($15,000 x 4 units plus $15,000 x 3 patients
plus $15,000 x 2 units) is proposed for this rule violation.
4. The Facility failed to ensure a Registered Nurse (RN) reassessed patients, based on patient
needs, to wit:
The Facility failed to ensure a RN reassessed Patients #14, #39 and #40 after they were involved
in a physical altercation. Furthermore, the Facility failed to ensure an RN completed an initial
and on-going assessment of Patient #41 that sustained a fractured left wrist, in violation of 25
TAC 411.473(f), which states:

Notice of Violation
Timberlawn Mental Health System
Page 4

411.473 Nursing Services

(f) Reassessment. An RN shall reassess a patient, based on the patient's needs, but at least every
12 hours after the initial comprehensive nursing assessment, required by subsection (e) of this
section, is conducted.
An administrative penalty in the amount of $100,000 ($25,000 x 4 patients) is proposed for this rule
violation.
5. The Facility failed to secure or remove objects that are hazardous to the patient, to wit:
The Facility failed to ensure objects potentially used for self-harm were secure or removed from
the dining area where nine (9) adolescent patients were eating, in violation of 25 TAC
411.477(a)(1)(B), which states:
411.477 Protection of a Patient
(a) Modifying the environment and monitoring the patient. A hospital shall protect a patient by
taking the following measures:
(1) modifying the hospital environment based on the patient's needs including:
(B) securing or removing objects that are hazardous to the patient.
An administrative penalty in the amount of $135,000 ($15,000 x 9 patients) is proposed for this rule
violation.
6. The Facility failed to ensure quality assessment and performance improvement activities were
completed, to wit:
The Facility failed to track adverse patient events for Patients #14, #39, #40 and #47 involved in
altercations. Furthermore, the Facility failed to identify that twenty (20) patient urine samples
were not timely processed by a lab technician, in violation of 25 TAC 411.493(d)(1)(A) and
134.41(e), which states:
411.493 Quality Assessment and Performance Improvement Program
(d) Quality assessment and performance improvement program activities.
(1) As part of its quality assessment and performance improvement activities a hospital shall
collect and aggregate data to:
(A) monitor the effectiveness and safety of services and the quality of care.
134.41 Facility Functions and Services
(e) Laboratory services. The facility shall provide directly, or have available adequate laboratory
services to meet the needs of its patients.

Notice of Violation
Timberlawn Mental Health System
Page 5

An administrative penalty in the amount of $360,000 ($15,000 x 4 patient altercations plus $15,000
x 20 patient urine samples) is proposed for this rule violation.
May 13, 2015 second on-site complaint investigation:
7. The Facility failed to ensure that patients were provided the proper treatment environment,
to wit:
The Facility failed to provide patients with the proper treatment environment: the inadequate
monitoring of Patients #1 and #2 allowed the two patients to have a sexual encounter.
Furthermore, the Facility exceeded its bed capacity by three (3) patients on or about May 7 8,
2015. Finally on or about May 12, 2015, the Facility could not account for the whereabouts of
patients in rooms #142, #144, #148, #154, #158 and #160 at all times. , The Facilitys failure to
adequately and safely monitor all of these patients violated 25 TAC 404.154(3), which states:
404.154 Rights of All Persons Receiving Mental Health Services
Persons receiving mental health services from department facilities, community centers, and
psychiatric hospitals have the following rights.
(3) The right to a humane treatment environment that ensures protection from harm, provides
privacy to as great a degree as possible with regard to personal needs, and promotes respect and
dignity for each individual.
An administrative penalty in the amount of $185,000 ($50,000 for Patient #1 and #2 plus $15,000 x
remaining 9 patients) is proposed for this rule violation.
July 1, 2015 unannounced follow-up full survey:
8. The Facility failed to protect patients, to wit:
The Facility failed to protect and provide patients with a safe environment by failing to modify,
secure or remove hazardous objects for Patients #7, #10, #13, #27, #28 and #29. The Facility
failed to remove materials resulting in Patient #7s injury, in violation of 25 TAC
411.477(a)(1)(B), which states:
411.477 Protection of a Patient
(a) Modifying the environment and monitoring the patient. A hospital shall protect a patient by
taking the following measures:
(1) modifying the hospital environment based on the patient's needs including:
(B) securing or removing objects that are hazardous to the patient.
An administrative penalty in the amount of $25,000 is proposed for this rule violation.

Notice of Violation
Timberlawn Mental Health System
Page 6

9. The Facility failed to monitor patients, to wit:

The Facility failed to monitor and document the location and behavior in the patient observation
rounds records for Patients #7, #10, #13, #27, #28 and #29. Furthermore, the Facility failed to
monitor Patient #7, who swallowed a piece of metal, resulting in injury, in violation of 25 TAC
411.477(a)(1)(B) and 411.477(a)(2), which states:
411.477 Protection of a Patient
(a) Modifying the environment and monitoring the patient. A hospital shall protect a patient by
taking the following measures:
(1) modifying the hospital environment based on the patient's needs including:
(B) securing or removing objects that are hazardous to the patient.
(2) monitoring the patient at the level of monitoring most recently specified in the patients
medical record.
An administrative penalty is the amount of $25,000 is proposed for this rule violation.
10. The Facility failed to monitor quality assessment and performance improvement activities, to
wit:
The Facility failed to monitor the safety of services and the quality of care for Patient #26, who
was observed with an injury, in violation of 25 TAC 411.493(d)(1)(A) and 411.493(d)(3)
(6), which states:
411.493 Quality Assessment and Performance Improvement Program
(d) Quality assessment and performance improvement program activities.
(1) As part of its quality assessment and performance improvement activities a hospital shall
collect and aggregate data to:
(A) monitor the effectiveness and safety of services and the quality of care.
(3) The hospital shall analyze the aggregated data, at least quarterly, to assess the need for
performance improvement.
(4) When a need for performance improvement is identified, the hospital shall develop and
implement an action plan to address the identified need.
(5) The hospital shall evaluate the success of the action plan to determine if the positive outcomes
are achieved and sustained.
(6) If the hospital determines that the positive outcomes have not been achieved or sustained, the
hospital shall modify the action plan and re-evaluate its implementation until the outcomes are
achieved and sustained.

Notice of Violation
Timberlawn Mental Health System
Page 7

An administrative penalty in the amount of $10,000 is proposed for this rule violation.
11. The Facility failed to ensure a Registered Nurse (RN) reassessed patients, based on patient
needs, to wit:
The Facility failed to ensure a RN reassessed Patient #8, who was sent to the emergency room
(ER) on June 27, 2015 for medical treatment, after Patient #8 returned from the ER, in violation
of 25 TAC 411.473(f), which states:
411.473 Nursing Services
(f) Reassessment. An RN shall reassess a patient, based on the patient's needs, but at least every
12 hours after the initial comprehensive nursing assessment, required by subsection (e) of this
section, is conducted.
An administrative penalty in the amount of $10,000 is proposed for this rule violation.
In accordance with Government Code Section 2001.054(c), you have the right to show compliance with
all requirements of law prior to final action by the Department. Within 20 calendar days following the
day you receive this notice, you may:
1) Admit the allegations and accept the Departments determination to impose an Administrative
Penalty in the amount of $1,050,000.00 and revocation of the Facilitys License #000752. Mail in
the license and remit the recommended penalty amount of $1,050,000.00 by cashiers check or
money order made payable to the Department of State Health Services, with a notation of: Deposit
in Budget #ZZ156, Fund #150, and return the enclosed Response to Notice form, with the first box
checked. Please be sure to sign and date the form; or
2) Submit a written request for an informal conference and a hearing (if necessary), regarding the
occurrence of the alleged violations, the amount of the penalties, or both; or,
3) Submit a written request for a contested case hearing to be held at the State Office of Administrative
Hearings regarding the occurrence of the alleged violations, the amount of the penalty, or both.
Please use the attached RESPONSE TO NOTICE form to notify the Department of which option you
have selected.
YOU MUST RESPOND TO THIS NOTICE WITHIN 20 CALENDAR DAYS AFTER THE
DATE YOU RECEIVE THIS NOTICE. IF YOU DO NOT RESPOND TO THIS NOTICE BY
THE DEADLINE: YOUR OPPORTUNITY TO REQUEST A CONFERENCE WILL BE
DEEMED WAIVED; AND THE DEPARTMENT WILL SET THIS CASE FOR HEARING
BEFORE THE STATE OFFICE OF ADMINISTRATIVE HEARINGS PURSUANT TO HSC
241.059(h).

Notice of Violation
Timberlawn Mental Health System
Page 8

If you have any questions regarding this proposal, please contact me at (512) 834-6665, ext. 3320.
Sincerely,

Dianne Estrada, MBA

Program Specialist
Enforcement Unit
Division for Regulatory Services
Enclosure

RESPONSE TO NOTICE OF VIOLATION (NOTICE)

Timberlawn Mental Health System, Private Psychiatric Hospital, (Respondent), have received a Notice
from the Department of State Health Services (Department), in which I was notified that the Department
is proposing an Administrative Penalty of $1,050,000 and revocation of the Facilitys License #000752,
Case #1068154440, #1068155638, #1068155637 and #1068156819, Docket #A24571-505-2015,
#A24603-029-2015, #A24676-029-2016 and #A24677-029-2016 respectively.

Please select an option by checking the applicable box. Sign in the space provided below, and return
this page not later than the 20th calendar day after you receive this notice.
OPTION 1

Respondent admits the allegations and accepts the proposed action in the
Departments Notice. Respondent waives the right to an administrative hearing or an
appeal. Respondent shall mail in License #000752 and remit an administrative penalty
in the amount of $1,050,000 by cashiers check or money order made payable to the
Department of State Health Services, with a notation of: Deposit in Budget #ZZ156,
Fund #150. Mail the penalty with this form to: Texas Department of State Health
Services, Cash Receipts Branch MC-2003, PO Box 149347, Austin, Texas 787149347.

OPTION 2

Respondent does not accept the proposed action in the Departments Notice and
requests an informal conference and, if necessary, a hearing.

OPTION 3

Respondent does not accept the proposed action in the Departments Notice and
requests a hearing before the State Office of Administrative Hearings.

If you are not including a payment with your response, please mail your response to:
Texas Department of State Health Services, Enforcement Unit MC 7927, Attn: Dianne Estrada,
P.O. Box 149347, Austin, TX 78714-9347 or fax it to: 512-834-6625.

SIGNATURE OF RESPONDENTS
AUTHORIZED REPRESENTATIVE

PRINTED NAME AND TITLE OF

SIGNATORY

DATE

000752
LICENSE NUMBER

IMPORTANT CHANGE OF ADDRESS:

To ensure proper notification, please indicate change of address below.

Street Address

City, State, Zip