The Melrose nursing home on West 29th Street is under severe restrictions and new management faces a limited window in which to make improvements after state workers found glaring problems they said were putting residents' lives in danger.
"Every twelve months a surveyor goes out," DADS Spokesperson Melissa Gale said. "And during those surveys, they're looking for compliance with all of the state and federal regulations. There are hundreds of them."
But we also wanted to know from nursing homes themselves why even a good operation can't seem to manage a score higher than 75.
"In order to get a number like that, a really high number, you would not accept any patients with wounds," an administrator who asked not to be named said. "If [a resident has] a sore it gets counted against you. Even if we didn't cause it, it still counts."
That administrator's nursing home typically has excellent scores. Her point was essentially that caring for people in failing health will always carry a certain risk and perfection just isn't possible.
On the other end of the spectrum is the Melrose nursing home. Across all the East Texas counties, it's the only one we found that scored a zero during this six month investigation. Gale said such a score was exceedingly rare.
"Well I don't think I can say anything. I wish I could," the administrator there said in February. "I'm not the owner and I think that's who you need to talk to."
When pressed for answers, she admitted there were problems.
"I was just brought in to clean things up," she said. "I'll put it like that."
One report said a resident was placed in a restricted unit with "no physician order or medical justification." She told the surveyor she was "being kept in the unit against her will."
She wasn't the only one. The report said 16 people were at risk for being "restrained against their will for staff convenience."
Around the same time one of the employees reported to the registered nurse on duty that one resident had raped another one. According to the report workers knew the rape victim "lacked the ability to say yes or no" and yet the acting nurse supervisor who was told "did nothing about it."
The police informed the Melrose administrators that the man who did it was a registered sex offender.
Several months later another surveyor from DADS had to intervene when he said staff neglect came dangerously close to killing one of the patients.
The surveyor found her "in the fetal position and virtually unresponsive." According to the report she'd been found "vomiting green bile" with no follow up from staff. Later they found her trying to "eat out of a trash can" but there was no record that anyone intervened.
It turned out she had lost ten percent of her weight in six days and no one noticed, according to the surveyor.
Those cases were just a selection of the worst problems from reports filled with cases of human fecal matter in places it's not supposed to be and all sorts of things covered in black and brown slime.
"These were serious deficiencies with this facility and they were deficiencies that could affect the quality of care and in some cases could even put residents in jeopardy," Gale said.
Gale said the people at Melrose were repeatedly told to come up with plans to correct the violations happening there. Letters to the facility and obtained by CBS 19 show just how many chances Melrose received, starting in July of last year, then October, November, and December.
"There are a lot of chances to come back into compliance with the regulations," Gale said. "But DADS does not hesitate to take action and hold these facilities accountable for their actions."
By January the agency was fed up. DADS revoked Melrose's ability to take new residents.
The nursing home can no longer receive Medicare and Medicaid money--which is often the biggest source of income. Gale said Melrose could reapply for access to those funds, and that DADS had been notified the facility intended to do so.
Melrose also racked up $125,500 in fines, although workers there claimed a financial hardship and had that bill cut down to $11,500.
Finally a company called Western Care lost its license to run the nursing home. But that doesn't mean Melrose is shutting down.
"Yeah they've already issued a new license for a new operator coming in to take over the facility," California resident Brad Smith said when reached by phone Thursday.
Smith is involved in a complicated web of companies that own and run Melrose. He told us he'd already gotten a company called Northcreek Healthcare to take over.
Northcreek Healthcare, LLC has no history of any involvement with Texas nursing homes, according to DADS.
Secretary of State records indicated that Northcreek had just been incorporated in April or 2014. Those records also led back to Walnut Creek, CA, where many of the other companies already involved list their address of record. Northcreek is also represented by the same Tyler attorney named in documents relating to the other companies.
It was not immediately clear how deep any actual link between them might run.
"Yeah they do have a plan there," Smith said. "Let me, I can have somebody who's more knowledgeable about this stuff get back with you."
No one from the company ever called.
"They have been granted a 90-day license and so we will be keeping a very close eye on that facility," Gale said.
"Closing a facility is the last resort because it does put people in such upheaval," she said. "These residents are very vulnerable and sometimes you're talking about relocating them to a facility that's out of their town where their family members can't come visit as frequently as they would like, and so it is the last resort. But we also have to make sure in the end that residents are protected."
Gale recommended visiting any nursing home you might want to use for the care of a loved one. She said the best way to get an accurate impression of how things are run is to show up unannounced and ask to talk to the staff and the people who live there.
To report suspected abuse at a Texas nursing home, call 1-800-458-9858.