Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carrara during CMS and state inspections, most recent first.
Failure to Secure Indwelling Urinary Catheters: Three residents with indwelling urinary catheters had collection bags hanging from the bed frame and the catheters were not secured to the residents' legs. The residents included one female who was totally dependent with stroke, diabetes, and pressure ulcers; one male with TBI, diabetes, seizures, and severe cognitive impairment; and one male with an enlarged prostate who required minimal assistance. Staff stated the nurse was responsible for securing the catheter to the upper leg, and the ADON stated CNAs and nurses were responsible for proper catheter securement.
Surveyors found that an LVN failed to treat two residents with respect and uphold their communication rights. One cognitively intact resident in pain received a pill and water from an LVN who did not introduce herself or explain the medication. Another resident with severe cognitive impairment, dementia, and Parkinson's disease was observed with his call light out of reach; when questioned, the LVN entered without speaking or introducing herself, tossed the call light toward him, adjusted his blanket, and left, with the resident not reaching for the call light. The LVN later acknowledged she had been trained to introduce herself, explain medications, and interact with residents as part of their rights, and the DON confirmed nurses were expected to do so under the facility's resident rights policy.
A resident with arthritis and a pelvic fracture, who was cognitively intact and on PRN oxycodone and scheduled methocarbamol, was observed lying in bed groaning, grimacing, and reporting severe pain rated as 12/10. An LVN entered with water and a pill, did not introduce herself, did not ask the resident to rate her pain, administered oxycodone, and left the room without performing a pain assessment. In interview, the LVN admitted she did not assess the pain level despite knowing she was supposed to do so to evaluate medication effectiveness. The DON stated nurses are expected to assess pain levels, and facility policy requires asking residents to rate their pain using an appropriate scale.
A resident with severe cognitive and physical impairments requested a CNA to remove a lunch tray from his bedside table so he could access his iPad. The CNA delayed the action, citing dirty hands and a misunderstanding about where the tray should be placed, resulting in the resident being unable to access his personal items. This failure to accommodate the resident's request was confirmed through interviews and a recording, and was determined to be a violation of the resident's right to dignity and self-determination.
A resident with end-stage renal disease and multiple comorbidities did not have her blood pressure documented prior to being transported for dialysis, as required by physician orders and care plan. Review of records showed the last blood pressure entry was from the previous evening, and interviews with nursing staff confirmed the omission. The facility's own training materials stress the importance of accurate documentation, but the required entry was missing on all relevant records.
A resident with COPD and other chronic conditions was found to have a nebulizer mask stored improperly with personal items instead of in a labeled plastic bag as required by facility policy. Staff interviews confirmed awareness of the correct procedure, but the mask was not bagged or dated after use, resulting in a deficiency related to infection control and professional standards.
Surveyors found that staff did not properly separate dented cans of marinara sauce in the kitchen's dry storage area, contrary to food safety standards. Interviews revealed that cooks were responsible for inspecting and storing dry goods, and that dented cans should be reported and kept in a separate area, but this was not done. The facility lacked a specific policy on dented cans, and the DM acknowledged the potential hazard posed by such items.
A resident with a history of dementia and other conditions slid out of a mechanical lift sling during a transfer, despite the sling being properly hooked. The incident occurred due to possible mispositioning of the resident on the sling. The resident did not report pain, and subsequent hospital records indicated no new injuries. Staff had received prior training on mechanical lift use, but the incident revealed a lapse in ensuring proper positioning during transfers.
The facility failed to uphold residents' rights to dignity and respect, as evidenced by inadequate assistance with toileting and delayed call light responses for two residents. One resident, cognitively intact, was told to use an adult brief instead of receiving help to use the toilet, while another, moderately cognitively impaired, experienced long waits for call light responses. Staff interviews revealed expectations for timely responses and regular checks were not consistently met, particularly during night shifts.
The facility failed to provide timely incontinence care for three residents, leading to potential risks such as skin breakdown and urinary tract infections. A resident reported long wait times for assistance, while two others, dependent on staff for ADL care, received infrequent care despite being on a 2-hour toileting program. Staff interviews confirmed the expectation of regular checks, highlighting a discrepancy between documented care and facility protocols.
The facility did not ensure a safe environment for a resident at risk for elopement. Staff members failed to adequately supervise or address the resident's attempts to leave the facility. RN A did not report the resident's agitation and desire to leave, and LVN B did not provide sufficient supervision, resulting in the resident leaving unnoticed and being found by police three miles away. The initial elopement assessment inaccurately scored the resident as no risk for elopement, and the care plan did not address the moderate risk until after the incident. Staff interviews revealed inconsistent awareness and preparedness regarding elopement risks, and facility policies and protocols for elopement response were not consistently followed.
The facility failed to maintain accurate clinical records for a resident by not keeping copies of shower sheets and not documenting the resident's refusals to shower for two months. Staff interviews confirmed that the shower sheets were discarded monthly and no documentation of refusals or family notifications was made.
Failure to Secure Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure three residents with indwelling urinary catheters had their catheters anchored or secured to protect the urethral opening and maintain proper urine flow. Resident #1 was a female with diagnoses including stroke affecting speech and swallowing, diabetes, and pressure ulcers; she was totally dependent on staff for all ADLs and had a care plan noting bowel and bladder incontinence with use of briefs and a urinary catheter. Her physician orders directed that the Foley catheter anchor be changed as needed, but during observations the catheter collection bag was hanging on the bed frame and the catheter was not anchored to her leg. Resident #2 was admitted with traumatic brain injury, diabetes, and seizures, had a BIMS score of 3, and was totally dependent for ADLs; his care plan reflected an indwelling urinary catheter. During observations, his catheter collection bag was hanging from the bed frame and the catheter was not secured to his leg. Resident #3 was admitted with diagnoses including low oxygen levels due to poor breathing, high blood pressure, and pneumonia; he had a BIMS score of 14 and required minimal assistance with ADLs. His care plan reflected a urinary catheter related to an enlarged prostate, and observations showed his catheter collection bag hanging from the bed frame with the catheter not secured to his leg. Staff interviews stated the nurse was responsible for ensuring the catheter was secured to the resident's upper leg, and the ADON stated CNAs and nurses were responsible for ensuring urinary catheters were properly secured to residents' legs.
Failure to Treat Residents With Respect and Honor Communication Rights
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity and that their rights to communication and information were honored. For one cognitively intact female resident with arthritis and a pelvic fracture, an LVN entered the room while the resident was lying in bed, groaning, grimacing, and stating she was in pain. The LVN brought a cup of water and a cup with a pill, handed them to the resident, and did not speak to her, introduce herself, or explain what medication she was administering. The resident stated she was used to the nurse not introducing herself. The LVN later acknowledged she had been trained to introduce herself and explain medications but did not do so on this occasion, and stated that doing so was important for assessment. The DON stated that nurses were supposed to introduce themselves and explain medications, and that failure to do so could keep residents from having the right to be informed. For a male resident with severely impaired cognitive skills, non-Alzheimer's dementia, and Parkinson's disease, surveyors observed him lying in bed awake and alert with his call light at the end of the bed, out of reach. When questioned about the call light, the LVN entered the room without speaking or introducing herself, picked up the call light, and tossed it toward the resident while he looked at her, then straightened his blanket and walked away; the resident did not reach for the call light. In a subsequent interview, the LVN stated the resident moved around a lot and the call light would be moved, and admitted she did not speak to him because she was "just in her head," despite having been trained to introduce herself and interact with residents and acknowledging it was important because it was the residents' right. The facility's Resident Rights policy stated that all residents would be treated equally and that all direct care staff would be educated on residents' rights and the facility's responsibility to properly care for its residents.
Failure to Assess Pain Level Prior to Administering PRN Analgesic
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pain management was provided consistent with professional standards of practice and the resident’s person-centered care plan. A cognitively intact female resident with arthritis and a pelvic fracture was admitted with orders for oxycodone 15 mg every six hours as needed for pain and scheduled methocarbamol 1000 mg four times daily. Her comprehensive care plan included monitoring and documenting pain and adverse reactions to analgesic therapy. On the day of the survey observation, the resident was lying in bed, groaning and grimacing, and verbally reported her pain as a 12 on a 1–10 scale, stating it hurt badly when she moved. At that time, an LVN entered the room with water and a pill cup, did not introduce herself, did not ask the resident to rate her pain, and then left the room after administering the medication. The LVN later confirmed she had given oxycodone for pain and admitted she did not assess the resident’s pain level, stating she “just did not” and was unaware the resident’s pain was at a level 12. She acknowledged she was supposed to ask the pain level to determine if the medication was effective. The DON stated that nurses were expected to assess residents’ pain levels to see if pain medicine was working. The facility’s pain management policy required asking the resident to rate pain intensity using a numerical, verbal, or visual scale preferred by the resident, which was not followed in this instance.
Failure to Accommodate Resident's Request for Tray Removal
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to accommodate a resident's request to remove a lunch tray from his bedside table, which impeded his ability to access his iPad. The resident, an elderly male with severe cognitive impairment (BIMS score of 5) and significant functional limitations in both upper and lower extremities, required setup or clean-up assistance with eating. During the incident, the CNA was attending to the resident's colostomy bag and, when asked to remove the tray, delayed the action, stating her hands were dirty and she intended to remove it after finishing her task. The resident reported that the aide refused to remove the tray even after completing the colostomy care, and this interaction was inadvertently recorded and reported by a family member. Interviews with facility staff confirmed the sequence of events. The CNA acknowledged delaying the removal of the tray and expressed a misunderstanding, believing the resident wanted the tray removed from the room rather than just off the table. A licensed vocational nurse (LVN) present in the room at the time was focused on disconnecting the resident's IV and did not notice the request or the conversation between the resident and the CNA. The administrator confirmed that the incident was identified as a customer service issue and unprofessional conduct, based on the review of the recording and staff interviews. The facility's policy on resident rights, as reviewed in the report, guarantees residents the right to a dignified existence and to be treated with respect, kindness, and dignity. The failure to promptly accommodate the resident's reasonable request for tray removal constituted a violation of these rights, as the resident was unable to access his personal items and exercise self-determination in his environment.
Failure to Document Pre-Dialysis Blood Pressure for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with multiple complex medical conditions, including end-stage renal disease, heart failure, and hypotension during hemodialysis. According to physician orders, the resident was to have vital signs, including blood pressure, checked every shift and prior to being transported to dialysis. On the date in question, there was no documentation of the resident's blood pressure being taken before she was sent to dialysis, as required by both physician orders and the resident's care plan. Record reviews showed that the last documented blood pressure was from the previous evening, and there was no entry for the day of dialysis on the electronic record, medication administration record, treatment administration record, or the dialysis communication form. Interviews with nursing staff revealed that the nurse responsible for preparing the resident for dialysis stated he had checked her vitals and that they were within normal range, but he could not recall the specific reading and admitted he must not have documented it. The Director of Clinical Services and the ADON confirmed that there was no documentation of the blood pressure reading for that day and acknowledged the importance of this documentation for resident care. The deficiency was identified through interviews and record reviews, which confirmed that the required documentation was missing. The facility's own in-service training materials emphasized the importance of following physician orders and accurate documentation to ensure continuity of care and compliance with regulations. Despite this, the failure to document the resident's blood pressure prior to dialysis was not in accordance with accepted professional standards and practices.
Failure to Properly Store Nebulizer Mask for Resident Receiving Respiratory Care
Penalty
Summary
A deficiency occurred when a resident who required respiratory care for conditions including COPD, asthma, and chronic kidney disease was not provided care consistent with professional standards and the facility's own policies. During observation, the resident's nebulizer mask and tubing were found stored in the top drawer of the nightstand with personal items, not in a plastic bag labeled with the resident's name and date as required. The resident confirmed having used the nebulizer earlier that day. Staff interviews revealed that both nursing and CNA staff were aware that nebulizer masks should be bagged when not in use to prevent contamination, and that this was standard practice in the facility. Further interviews with the ADON and Regional Nurse Consultant confirmed that respiratory care items, including nebulizer masks and tubing, were to be changed weekly, dated, and stored in bags when not in use. The facility's policy also specified that nebulizer masks should be stored in a plastic bag with the resident's name and date. The failure to properly store the nebulizer mask was directly observed and acknowledged by staff, but had not been corrected at the time of the survey, resulting in a deficiency related to infection control and adherence to care standards.
Failure to Properly Store and Segregate Dented Cans in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the dry storage area, two large cans of marinara sauce were found to be dented and not placed in a separate storage area as required. Staff interviews revealed that it was the cook's responsibility to inspect and store dry goods upon delivery, and that dented cans should be separated and reported to the Dietary Manager (DM), who would then notify the vendor. However, the dented cans were not properly separated at the time of the survey. The DM confirmed that staff were responsible for labeling, storing, and inspecting food items, and that he would inspect items after delivery. He also stated that dented cans were to be kept in a separate area and acknowledged the risk of botulism associated with dented cans. The facility did not have a specific policy regarding dented cans, and the FDA Food Code was referenced, indicating that dented cans may present a serious potential hazard.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide adequate supervision for a resident during a mechanical lift transfer, resulting in the resident sliding out of the sling. The incident occurred when two CNAs were transferring the resident from a wheelchair to a bed. Despite the sling being properly hooked to the Hoyer lift, the resident slipped out legs first, with his head cushioned by a pillow. The CNAs immediately checked on the resident's wellbeing and notified the nurse, who conducted a head-to-toe assessment and initiated neuro checks. The resident did not report any pain at the time of the incident. The resident involved was an elderly male with a history of dementia, hypertension, diabetes mellitus, aphasia, and stroke. He required substantial assistance for transfers and was dependent on a mechanical lift for such activities. The resident's care plan indicated the need for a mechanical lift, and the incident was reported to Health and Human Services the following day. X-rays revealed a compression fracture of the T11 vertebral body, but hospital records later indicated that the fractures were chronic and not related to the incident. Interviews with staff revealed that the CNAs involved had received mechanical lift training prior to the incident. However, during the transfer, the resident's positioning on the sling may have contributed to the slide. The facility's mechanical lift protocol emphasized the importance of centering the patient in the sling before raising the lift. Despite the training, the incident highlighted a lapse in ensuring the resident was properly positioned during the transfer, which could have led to potential injuries.
Failure to Uphold Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by the treatment of two residents. One resident, a cognitively intact female with a history of arthritis and overactive bladder, was not provided assistance to use the toilet despite her requests. Instead, she was instructed by staff to use an adult brief, which she found undignified. The resident reported that the night shift staff were overwhelmed with responsibilities, leading to delays in responding to her call light, resulting in her experiencing incontinence due to the lack of timely assistance. Another resident, a moderately cognitively impaired male with multiple health issues including acute kidney failure and cardiac arrhythmia, also experienced delays in call light responses. This resident required substantial assistance with personal care and was at risk for falls and pressure ulcers. Despite these needs, the resident indicated through non-verbal communication that call lights were not answered promptly, particularly during the night shift. Interviews with facility staff, including CNAs and the DON, revealed that there was an expectation for call lights to be answered within 5 to 10 minutes and for residents to be checked every two hours. However, the residents' experiences and the Resident Council minutes indicated that these expectations were not consistently met, particularly during weekends and night shifts. The facility's policies on resident rights, abuse prevention, and call light response were not adhered to, contributing to the deficiencies observed.
Inadequate Incontinence Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADL) to three residents, specifically in the area of timely incontinence care. Residents #2, #5, and #6 did not receive incontinence care every two hours or as needed, as documented in their care plans. This lack of care was observed over several days, with significant gaps between documented care times, which could lead to risks such as skin breakdown, urinary tract infections, and loss of dignity. Resident #2, a cognitively intact female with a history of arthritis and overactive bladder, reported that the night shift staff were reluctant to assist her with toileting, suggesting she use a diaper instead. She expressed dissatisfaction with the care received, noting long wait times for assistance, which led her to use a diaper to avoid accidents. Resident #5, who has vascular dementia and is dependent on staff for ADL care, was observed to have received incontinence care infrequently, despite being on a 2-hour toileting program. Resident #6, with significant cognitive impairment and total dependence on staff, also experienced infrequent incontinence care, as documented in his care records. Interviews with staff, including CNAs and the DON, confirmed that residents should be checked every two hours and as needed, especially those who are fall risks or unable to use call lights. The DON acknowledged the risks associated with inadequate ADL care and emphasized the importance of documenting care in the computer system. The facility's protocols and guidelines stress the importance of maintaining residents' dignity and preventing neglect, yet the documented care for these residents did not align with these standards.
Elopement Risk Management and Supervision Deficiencies
Penalty
Summary
The facility failed to ensure a safe environment for Resident #79, who was at risk for elopement. On multiple occasions, staff members did not adequately supervise or address Resident #79's attempts to leave the facility. RN A failed to report Resident #79's agitation and desire to leave to the appropriate authorities, while LVN B did not provide sufficient supervision to prevent Resident #79 from eloping. This resulted in Resident #79 leaving the facility unnoticed and being found by the police three miles away. The facility's lack of proper supervision and failure to conduct timely elopement risk assessments placed Resident #79 in immediate jeopardy and exposed other residents to potential harm. The deficiency was further highlighted by discrepancies in the documentation and assessments related to Resident #79. The initial elopement assessment scored Resident #79 as no risk for elopement, despite evidence of wandering behavior. Additionally, the care plan did not adequately address Resident #79's moderate risk for elopement until after the elopement incident occurred. This lack of accurate assessment and care planning contributed to the failure to prevent Resident #79 from leaving the facility. Interviews with staff members revealed varying levels of awareness and preparedness regarding elopement risks. While some staff members acknowledged Resident #79's wandering behavior and frustration, others did not recognize the seriousness of his desire to leave. The facility's policies and protocols for elopement response were not consistently followed or implemented effectively, leading to Resident #79 eloping and being exposed to potential dangers outside the facility.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one resident. Specifically, the facility did not keep copies of shower sheets for February and March 2024 for a resident, nor did they provide nurses' notes on the resident's refusals to shower during that period. The resident, a [AGE] year-old woman with multiple diagnoses including chronic obstructive pulmonary disease and a urinary tract infection, had a BIMS score of 3 and was admitted and discharged within the specified timeframe. The shower log revealed no showers in February and only four in March, despite the resident's scheduled shower days being Tuesdays, Thursdays, and Saturdays. Interviews with staff confirmed that the shower sheets were discarded at the end of each month and that no documentation of the resident's shower refusals or notifications to family were made. The Director of Nursing (DON) and other staff members were unable to locate any additional shower sheets or nurses' notes for the resident for the months in question. The facility's policy, revised in July 2017, mandates that documentation in the medical record should be complete, accurate, and include details such as the date and time of procedures, the name and title of the individual providing care, and whether the resident refused the procedure. The failure to maintain these records as per the policy could lead to incomplete and inaccurate clinical records for the resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Plano
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Hillcrest Of North Dallas | 0.5 mi | ★★★★★ | 1 | 0 |
| Landmark Of Plano Rehabilitation And Nursing Cente | 1.1 mi | ★★★★★ | 19 | 0 |
| Life Care Center Of Plano | 1.4 mi | ★★★★★ | 2 | 0 |
| Continuing Care At Highland Springs | 1.5 mi | ★★★★★ | 6 | 2 |
| The Healthcare Resort Of Plano | 1.6 mi | ★★★★★ | 1 | 0 |
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