F0921

E

Unmonitored Public Access Through Posted Entry Code at Main Door

Plano, Texas Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide a safe, secure, and monitored entry environment at Door #1, where a four-digit access code was posted next to the keypad on the outside of the building. During observation, a surveyor used the posted code to unlock Door #1 and enter the facility without any staff presence at the front desk or in the adjacent halls and without any alarm or notification sounding to alert staff of the entry. The surveyor waited approximately 7–10 minutes before locating a staff member in an office behind the front desk, demonstrating that individuals could enter the building unobserved. The facility’s Resident Rights policy, provided in lieu of a physical environment policy, stated that staff would abide by resident rights in accordance with CMS guidance but did not address the specific physical environment or access control procedures.

Multiple staff interviews confirmed that the code to Door #1 had been posted on the inside and outside of the door for several months so that staff and visitors could enter without difficulty, and that there was no system in place to reliably monitor who entered through this door when the front desk was not staffed. A staff member reported being very concerned about resident safety, especially after 4 p.m. when no one was stationed at Door #1, and relayed complaints from relatives, including one family member who was worried about the safety of her loved one because the entry code was visible to the public and usable after hours, including near midnight. The social worker reported a resident complaint over the summer about unknown people in the hall at night talking, and stated that there were no staff at the front desk in the evenings and at night, with nurses expected to monitor Door #1 from the nurses’ stations.

The Director of Maintenance stated that all doors, including Door #1, had alarms that would sound if someone attempted entry without the code, but acknowledged that once the posted code was entered, there was no alarm or bell to notify staff that someone had come in, and he was unsure how the facility monitored such entries. Nursing staff, including LVNs, stated that no one specifically monitored Door #1 after hours, that they only knew someone had entered if the person came to the nurses’ station, and that they personally felt unsafe because anyone could enter using the posted code. The ADON confirmed that staff were present by Door #1 only during daytime hours and that after that time it was everyone’s responsibility to monitor the door, while acknowledging it was a safety concern that no one monitored Door #1 after hours. The Administrator stated the code had been posted for several months due to staff and family forgetting it, reported no known incidents of harm related to the posted code, and expressed the view that having the code posted and the door unmonitored did not present a true safety concern to residents.