Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Collinwood Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, an indwelling catheter, and a stage IV sacral pressure injury was on EBP for wound and catheter care, but staff did not consistently follow the facility’s EBP and hand hygiene policies. CNAs entered the room and provided care without gowns, and an RN changed gloves without cleaning hands before continuing wound care. Multiple CNAs and an RN could not explain the EBP policy, high-contact care activities, or MDROs, and the DON could not identify an MDRO surveillance plan or data collection tool.
Staff failed to follow Enhanced Barrier Precautions (EBP) for two residents on EBP who had active wound care orders and posted signage requiring gown and glove use for high-contact care activities. During observed peri care, transfers, linen changes, and wound care, CNAs, the ADON, and a PRN-TN wore gloves and performed hand hygiene but did not don gowns, and no gowns were available in or outside the rooms despite EBP instructions. In interviews, staff indicated they did not believe gowns were necessary without a known contagious infection, or reported that gowns were not present and that they usually wore them, while one resident confirmed that staff typically used gowns for wound and peri care.
Unclean Resident Rooms and Bathrooms on 500-Hall: Surveyors observed multiple resident rooms with dirty air vents, stained bathroom floors and walls, brown residue on toilets and bolts, soap scum buildup on sink faucets, cracked faucet parts, stained sinks, and a mini fridge with dried food particles. Housekeeping staff stated they were responsible for cleaning these areas and that some buildup was hard to remove, while the Housekeeping Director and Administrator acknowledged the rooms and bathrooms should have been cleaned thoroughly.
Failure to Provide and Document Scheduled Showers: A resident who required extensive ADL assistance and had skin tears, incontinence, and a history of shower refusal did not have documentation showing receipt of scheduled showers for the month reviewed. Staff stated shower sheets were required for every scheduled shower or refusal, but only one refusal was documented, and there were no progress notes or family contact notes related to repeated refusals. The resident later stated she wanted a shower, and staff confirmed the resident was supposed to receive showers several times per week.
A resident with dementia, cognitive communication deficit, and unsteadiness on feet had a fall risk care plan that identified him as high risk for falls. After a witnessed fall near the nurse station caused head and facial injuries, the facility did not add a new fall-prevention intervention to the care plan, even though the fall risk evaluation listed nonskid or rubber-soled footwear as a clinical suggestion.
Failure to perform proper hand hygiene and glove changes during incontinence care. A CNA provided incontinence care to a resident with severe cognitive impairment, bladder incontinence, and diagnoses including TBI, HTN, and DM2, but did not change gloves or sanitize hands after removing a soiled brief, touched a clean brief and the bed controller with soiled gloves, and left the room without washing or sanitizing hands. The CNA, RN, and DON all acknowledged the hand hygiene lapse and the risk of cross-contamination.
A resident with dementia, major depressive disorder, PTSD, and anxiety repeatedly expressed suicidal ideation and engaged in self-harm behaviors, but staff failed to update the care plan or provide immediate psychiatric or behavioral assessments after these incidents. The resident's anxiety was further exacerbated by a problematic roommate assignment, yet no interventions were implemented to address her concerns. Staff interviews revealed confusion about responsibilities for care planning and intervention, and the facility did not follow its own policy for managing suicidal ideation.
Two residents experienced verbal and physical abuse from another resident with a history of mental health issues, including threats and a physical assault that resulted in hospitalization. Despite staff awareness of escalating conflicts and behavioral problems, there was a lack of timely investigation, documentation, and protective interventions following reports of threats and aggression.
Two residents with significant behavioral and mental health needs did not have their care plans updated to address incidents of aggression and suicidal ideation, despite documented episodes of verbal abuse, threats, and self-harm. Staff interviews revealed confusion about responsibility for care plan updates, and the facility's policy requirements for comprehensive, measurable care planning were not followed.
A resident with severe cognitive impairment and multiple diagnoses reported to staff that her roommate threatened to stab her. Staff spoke with the accused roommate, who denied the allegation, and removed a back scratcher from the room, but did not conduct a thorough investigation or complete safety assessments. The resident moved herself out of the room for safety, and the Administrator later acknowledged that the required investigation and reporting procedures were not followed.
Treatment Cart #1 was found unlocked and unattended near the nurses' station, containing prescription creams, bandages, and medical supplies, with residents present in the area and no staff in sight. Facility policy requires carts to be locked when not in use, but the responsible nurse could not be identified.
A facility failed to report and investigate an incident where a resident with a history of mental health issues expressed suicidal ideation by attempting to harm herself with a call light cord. Despite the resident's serious condition, the event was not reported to the State Agency as required, nor was an investigation initiated promptly, breaching the facility's policy.
A resident with a history of mental health issues expressed suicidal ideation by wrapping a call light cord around her neck. The facility failed to conduct a thorough investigation or report the incident to the State Survey Agency. Despite monitoring the resident until her transfer to a behavioral unit, the lack of documentation and formal investigation was a significant oversight.
The facility's kitchen failed to meet professional standards for food service safety, with deficiencies in food storage, labeling, and dating. Observations revealed expired and unlabeled food items, dented cans, and a broken egg among others. The Dietary Manager and Administrator were informed of these issues, which were not in compliance with the facility's food storage policy.
The facility failed to ensure call lights were accessible to four residents, risking their ability to obtain assistance. A resident with moderate cognitive impairment couldn't find her call light, which was on the floor. Another resident with severe cognitive impairment and hemiplegia also couldn't locate her call light. A male resident with anoxic brain damage struggled to reach his misplaced call light, and a female resident with muscle wasting found her call light out of reach. Staff interviews confirmed the importance of accessible call lights for resident safety.
The facility failed to maintain cleanliness in six resident rooms, with observations of dirt and grime on air conditioning units, dust on filters, and calcium buildup on faucets. Interviews with the Director of Environmental Services and the Administrator revealed lapses in housekeeping and maintenance procedures, potentially risking residents' respiratory health.
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their MDS assessments. A resident with hand contractures was inaccurately documented as having no impairments, despite requiring assistance with daily activities. Another resident with severe cognitive impairment and hand contractures was also inaccurately assessed, with her MDS not reflecting her need for splints. A third resident with hemiplegia was documented as having no impairments, despite being unable to use his right arm. Staff interviews confirmed these discrepancies, highlighting a failure in the facility's assessment process.
A resident with Parkinson's disease did not have this condition included in their care plan, despite it being an active diagnosis. The facility's staff, including the DON, ADON, and MDS Nurse, confirmed the oversight, acknowledging that the care plan should have addressed the resident's Parkinson's disease to ensure all necessary care was provided.
A facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by a CNA's inadequate hand hygiene and glove-changing practices during incontinence care for two residents. The CNA did not perform hand hygiene before putting on gloves or between glove changes, and handled soiled items without proper sanitation. Interviews with staff confirmed the importance of these practices to prevent cross-contamination and infection, yet the observed actions did not align with the facility's infection control procedures.
Failure to Follow EBP and Infection Surveillance Requirements
Penalty
Summary
The facility failed to provide and implement an effective infection prevention and control program by not following its own enhanced barrier precautions (EBP) policy and by not maintaining facility surveillance for multidrug-resistant organisms (MDROs). The deficiency involved one resident who had severe cognitive impairment, required maximum assistance with activities of daily living, used a Hoyer lift for transfers, had an indwelling catheter for neurogenic bladder, was incontinent of bowel, and had an unhealed stage IV pressure injury to the sacrum. The resident’s care plan and physician orders identified EBP for wound care and urinary catheter care, with staff expected to don gown and gloves inside the room before providing care. During observation, CNA staff entered the resident’s room, washed their hands, and put on gloves but did not put on gowns before repositioning the resident, despite the resident being on EBP and gowns and gloves being available in the room. Later, during wound care, RN staff and CNA staff initially used gown and gloves, but the RN changed gloves and then put on another clean glove without cleaning her hands after removing a glove, which was not consistent with the facility’s hand hygiene policy. The wound care was provided to the resident’s stage IV sacral pressure injury, which was documented as measuring 6.01 cm by 2.73 cm by 0 cm at the time of observation. Interviews with multiple CNAs and one RN showed that several staff members could not describe the facility’s current EBP policy or procedures, could not identify examples of high-contact resident care activities, did not understand the meaning of MDROs in relation to EBP, and could not recall when EBP in-service training had last been provided. Some staff did not know who the facility Infection Preventionist was or what that role involved. The DON stated that the most current EBP in-service had been provided in February 2026, but could not identify whether an MDRO was being tracked in the facility and could not identify the surveillance plan or data collection tool used for evidence-based infection surveillance. The DON also stated that the facility had not established or implemented an infection control surveillance plan based on a facility assessment.
Failure to Use Required PPE for Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for two residents on EBP. Both residents had active wound care orders and posted EBP signage on their doors instructing staff to don gown and gloves for high-contact resident care activities such as dressing, changing linens, toileting/brief changes, and wound care. For Resident #1, a male with vascular dementia, scabies history, dermatitis, and a non-pressure wound on the right upper back requiring Xeroform and calcium dressing three times weekly, staff did not follow these requirements during observed care. On the survey date, the surveyor observed an EBP sign on Resident #1’s door and entered the room while CNA A was providing peri care without a gown. The ADON and a PRN-TN then entered and provided wound care to Resident #1’s back while CNA A assisted with positioning and transferring the resident to bed and reported changing the resident’s linens, all without wearing gowns. Only gloves and hand hygiene were used. No gowns were available in or outside Resident #1’s room despite the posted EBP instructions requiring gown and gloves for peri care, transfers, changing linens, and wound care. In interviews, CNA A stated he did not wear a gown because he believed the resident did not have a contagious infection or virus and did not think a gown was needed, although he acknowledged infection control training. For Resident #2, a female with primary progressive multiple sclerosis, an acute upper respiratory infection, and a sacral pressure wound requiring daily dressing changes, the care plan and orders specified EBP related to urinary catheter and wound care, with interventions stating staff must don gown and gloves for high-contact activities including dressing, bathing, transfers, hygiene, changing linens, toileting/brief changes, device care, and wound care. An EBP sign with these instructions was posted on her door. During observation, the surveyor noted there were no gowns in or outside the room. CNA B provided peri care without a gown, and later the ADON and PRN-TN performed sacral wound care wearing only gloves and performing hand hygiene, but without gowns. CNA B acknowledged changing the resident without a gown, stating the gown was not in the room and that she usually wore one. The PRN-TN stated she associated gown use primarily with residents having COVID-19 or respiratory conditions, despite having infection control training, and recognized that staff could transmit germs on their clothes. Resident #2 reported that staff usually wore gowns for wound and peri care and believed CNA B was rushed and forgot.
Unclean Resident Rooms and Bathrooms on 500-Hall
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for 10 of 15 resident rooms on the 500-hall. During observations of resident rooms #1 through #10, surveyors found air condition vents with dark dirt stains between and on the vents, bathroom floors with white and grayish stains, brown stains on walls near an assist rail, brownish stains on toilet bolts and toilet bases, soap scum buildup on sink faucets, cracks in a faucet, stains inside a bathroom sink, and a mini fridge with red stains and dried food particles inside. In one room, a tissue used to test a white substance on the bathroom floor lifted the substance up, and several bathrooms had visible stains around the toilet and in the corners of the floor. Housekeeping P stated she was responsible for cleaning the rooms on the 500-hall and identified the observed areas as housekeeping responsibilities. She stated the faucets had dirt buildup that could not be removed and that the dried soap scum was hard to clean. The Housekeeping Director stated the cleaning staff were supposed to clean all areas of the resident rooms and bathrooms and agreed the identified areas should have been cleaned by staff, but said they had not been successful cleaning the faucets. The Administrator stated his expectation was for housekeeping to clean resident rooms thoroughly every day and acknowledged the air condition vents were not thoroughly cleaned.
Failure to Provide and Document Scheduled Showers
Penalty
Summary
The facility failed to ensure that a dependent resident received the necessary assistance with ADLs, specifically scheduled showers, to maintain good nutrition, grooming, and personal and oral hygiene. Resident #7 was a female admitted with a diagnosis that included rash and other non-specific skin eruption. Her MDS assessment reflected that she was unable to complete the BIMS interview and required extensive assistance with ADL care. Her care plan noted that she refused showers and had skin tears in multiple areas, with interventions to encourage showers and keep her skin clean and dry. Record review for July 2025 showed only one shower sheet for Resident #7, dated 07/24/25, and it documented that she refused a shower. There were no progress notes indicating that she refused showers during the month, and there were no notes showing attempts to contact her responsible party regarding refusal. Her care plan also identified that she was incontinent of urine and bowel, with an approach for hygiene as needed after every incontinent episode to maintain dignity. During interviews, Resident #7 stated she wanted a shower and later received one when asked in Spanish. The ADON stated the resident was scheduled for showers on Tuesday, Thursday, and Saturday during the 2 PM to 10 PM shift, and that a shower sheet should have been completed each time, whether the resident showered or refused. CNA A stated she often provided bed baths but did not complete the shower sheets, and LVN D stated staff were required to document refusals and notify him so he could attempt to persuade the resident and notify family. The DON stated his expectation was that residents receive scheduled showers, refusals be documented in progress notes, and the responsible party be contacted if the resident still refused.
Failure to Update Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #10 that included measurable objectives and time frames to meet his medical, nursing, and psychosocial needs identified in the comprehensive assessment. Resident #10 was a male admitted to the facility with diagnoses including dementia, cognitive communication deficit, and unsteadiness on feet. His quarterly MDS reflected moderately impaired cognition with a BIMS score of 08 and limited assistance needed from one staff member for activities of daily living. His comprehensive care plan identified him as at risk for falls related to generalized weakness and documented prior falls on 03/31/25 and 06/22/25, with the plan revised on 06/25/2025. After Resident #10 fell and sustained an abrasion to the right eyebrow, a laceration on the face, and an abrasion to the left elbow, the facility did not add a new intervention to the fall risk care plan. The incident report documented that he had a witnessed fall near the nurse station while ambulating to his room, lost balance, and fell forward, hitting his head. The fall risk evaluation completed the same day showed a score of 16, indicating high risk for potential falls, and included a clinical suggestion for rubber-soled shoes or nonskid slippers for ambulation, but this intervention was not reflected in the care plan. Facility staff, including the ADON, DON, and Administrator, stated the care plan should have been updated after the fall.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when CNA B did not follow hand hygiene and glove-use practices during incontinence care for one resident. Resident #37 was a female admitted to the facility with diagnoses including dysarthria, a personal history of traumatic brain injury, hypertension, and type 2 diabetes. Her quarterly MDS reflected severely impaired cognition with a BIMS score of 03, and her care plan identified bladder incontinence related to immobility with a goal to remain free from skin breakdown due to incontinence and brief use. During observation, CNA B was providing incontinence care while the resident was lying on her left side. After removing the soiled brief and barrier pad, CNA B dropped the items into a bag on the floor and did not change gloves or use hand sanitizer before placing a clean brief and barrier pad under the resident. CNA B then touched the resident's bed controller and assisted the resident to turn and lie flat while still wearing the same gloves. After securing the brief and covering the resident, CNA B removed her gloves but did not use hand sanitizer or wash her hands before leaving the room. CNA B later stated she should have removed the gloves and washed her hands or used sanitizer after removing the soiled brief, should not have touched the clean brief and bed controller with soiled gloves, and should have cleaned her hands before exiting the room. RN A and the DON both stated proper hand hygiene and glove changes were important to prevent cross-contamination and spreading infection.
Failure to Provide Timely Behavioral Health Interventions for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with multiple mental health conditions, including dementia, major depressive disorder, post-traumatic stress disorder (PTSD), and anxiety disorder. The resident had a documented history of suicidal ideation and self-harm attempts, including a prior incident at another facility where she attempted to cut her neck. Despite these known risks, the facility did not address suicidal ideations in the resident's care plan, nor were interventions implemented following multiple episodes where the resident expressed suicidal thoughts or attempted self-harm. On several occasions, staff documented the resident expressing a desire to die, crying, and making statements about wanting to harm herself. These episodes included the resident attempting to exit the building, grabbing potentially dangerous objects such as scissors and a lamp, and threatening self-harm. In each instance, while staff responded to the immediate situation by removing objects and contacting the physician or family, there was no evidence that a psychiatric, psychological, or behavioral assessment was conducted immediately following these incidents. The care plan was not updated to reflect the resident's suicidal ideations, and no new interventions were put in place to address her ongoing mental health needs. Additionally, the facility failed to consider the impact of roommate assignments on the resident's mental health. The resident expressed increased anxiety after being assigned a new roommate with whom she did not get along, yet no interventions or changes were made in response to her concerns. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for updating care plans and implementing interventions for residents with behavioral health needs. The facility's own policy required immediate reporting and intervention for suicidal ideation, but these procedures were not followed in practice.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in two residents experiencing verbal and physical abuse from another resident. One resident, who had a history of mental health diagnoses including Bipolar Disorder, Major Depressive Disorder, and paranoia, threatened to stab her roommate. This threat was reported to staff, but no immediate investigation or protective measures were initiated at that time. The care plan for the resident making threats noted paranoia, but there was no documentation of interventions or follow-up after the threat was reported. A few days later, the same resident entered another resident's room and physically assaulted her with a pole-like object, causing injuries that required hospitalization. The assaulted resident suffered an eye injury, bruises, and abrasions. Staff responded to the incident by intervening and calling emergency services, but prior to the assault, there were documented behavioral issues and escalating conflicts between the involved residents that were not adequately addressed. The care plan for the assaulted resident did not address the incident or provide interventions for her safety. Interviews with staff and the administrator revealed that the facility was aware of ongoing behavioral issues and conflicts among the residents, including previous threats and arguments. However, there was a lack of timely investigation, documentation, and implementation of protective measures following reports of threats and escalating behaviors. The administrator acknowledged that no safe surveys or investigations were conducted after the initial threat, and that staff had become conditioned to the aggressive resident's behavior, failing to take appropriate action to prevent further harm.
Failure to Update Care Plans for Aggression and Suicidal Ideation
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by regulation and facility policy. For one resident with diagnoses including Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, and Cognitive Communication Deficit, the care plan did not address incidents of verbal abuse or threats toward another resident. Documentation showed that this resident was involved in a physical altercation, where she was observed hitting another resident with an object, resulting in injuries. Despite these behaviors and prior reports of paranoia, the care plan lacked interventions or measurable objectives to address the resident's aggressive and threatening behaviors. Another resident, with a history of Dementia, Major Depressive Disorder, PTSD, and Anxiety Disorder, exhibited multiple episodes of suicidal ideation and self-harm attempts. Progress notes documented several incidents where the resident expressed a desire to die, attempted to harm herself with objects such as scissors and a stapler, and required intervention from staff, police, and emergency medical services. However, the care plan for this resident did not include any interventions or objectives related to suicidal ideation or self-harm, despite these repeated and documented behaviors. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans following significant changes in resident condition or behavior. The MDS Nurse, ADON, and Administrator each described different understandings of who was responsible for ensuring care plans were updated to reflect acute issues such as suicidal ideation or resident-to-resident aggression. The facility's own policy required timely and comprehensive care planning, including measurable objectives and timeframes, but these requirements were not met for the residents involved.
Failure to Investigate and Report Alleged Threat of Harm
Penalty
Summary
The facility failed to conduct a thorough investigation and report findings to the State Survey Agency within 5 working days after a resident alleged that her roommate threatened to stab her. The incident involved a female resident with severe cognitive impairment, as indicated by a BIMS score of 03, and multiple diagnoses including Schizoaffective Disorder, Major Depressive Disorder, cerebral infarction, hemiplegia, and hemiparesis. Documentation showed that when the allegation was reported, staff spoke with the accused roommate, who denied the threat, and removed a back scratcher from the room, but no further investigation or safety assessments were completed. Interviews revealed that the resident who made the allegation moved herself out of the shared room to feel safe and reported her fear to staff. The Administrator acknowledged that no safe surveys were conducted and admitted that a more thorough investigation should have been completed, even though the allegation was not immediately substantiated. The facility's policy requires all allegations of abuse to be investigated and reported, but this process was not followed in this case.
Unattended and Unlocked Treatment Cart
Penalty
Summary
Surveyors observed that Treatment Cart #1 was left unlocked and unattended near the nurses' station, positioned between two wings of the facility. The cart contained bandages, prescription creams, scissors, gauze, iodine, honey patches, and saline. There were residents present in the immediate area, and no staff were at the nurses' station at the time. The cart remained unlocked and unattended for at least five minutes, during which time all drawers were accessible. The facility's policy requires that medication carts be kept closed and locked when out of sight of the medication nurse, and that no medications be kept on top of the cart. Interviews with the Administrator and Assistant Director of Nursing (ADON) confirmed that the treatment cart should have been locked at all times and that all nurses are responsible for ensuring this. The ADON was unable to determine which nurse left the cart unlocked and stated that all nurses had been in-serviced on the importance of keeping treatment carts locked. The facility's policy and in-service documentation both emphasized the requirement to keep medication carts locked and secured when not in use to prevent unauthorized access.
Failure to Report and Investigate Suicidal Ideation Incident
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent neglect, specifically in the case of a resident who expressed suicidal ideation. The resident, a female with a history of chronic respiratory failure, anxiety disorder, PTSD, major depressive disorder, and Asperger syndrome, informed staff that she had attempted to harm herself by pulling a call light cord around her neck. Despite this serious incident, the facility did not report the event to the State Agency as required by their policy. The resident was receiving treatment for depression, including medication and therapy services, but a BIMS assessment was not conducted to evaluate her cognitive status. Interviews with facility staff revealed that the incident was not reported to the State Agency within the required timeframe, nor was an investigation initiated promptly. The Social Worker and VP of Clinical Services acknowledged the failure to report and investigate the incident, which was a breach of the facility's policy. The resident was placed on one-on-one monitoring and eventually transferred to a behavioral unit, but the lack of immediate reporting and investigation could have placed residents at risk of continued neglect.
Failure to Investigate and Report Suicidal Ideation
Penalty
Summary
The facility failed to thoroughly investigate and report an incident involving a resident who expressed suicidal ideation. The resident, a female with a history of chronic respiratory failure, anxiety disorder, PTSD, major depressive disorder, and Asperger syndrome, informed staff that she had wrapped her call light cord around her neck in an attempt to harm herself. Despite this serious allegation, the facility did not conduct a comprehensive investigation or report the incident to the State Survey Agency within the required timeframe. The resident's care plan included monitoring for signs of depression and suicidal ideation, yet a BIMS assessment was not conducted, and the facility's response to the resident's statements was inadequate. The social worker and VP of Clinical Services acknowledged that the incident was not documented in an incident report, and there was confusion about whether such documentation was necessary. The resident was monitored by facility staff and psych services until she was transferred to a behavioral unit, but the lack of a formal investigation and reporting process was a significant oversight. The facility's policy on investigating alleged abuse, neglect, and exploitation emphasizes the importance of thorough documentation and investigation, which was not adhered to in this case. The failure to investigate and report the incident could potentially place residents at risk by not ensuring that allegations of abuse or neglect are properly addressed and communicated to the appropriate authorities.
Deficiencies in Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed through various deficiencies in food storage, labeling, dating, and kitchen sanitation. Specifically, the facility did not ensure that food items in the refrigerator and freezer were labeled and dated according to guidelines. Expired foods were not discarded, and dented cans were not removed as required. Additionally, a broken egg was found among other eggs in the refrigerator, and several food items, including sliced meat and raw pork chops, were found unlabeled and undated. These deficiencies were identified during observations and interviews with the Dietary Manager, Dietician, and Administrator. The Dietary Manager acknowledged that all kitchen staff were responsible for storing food and removing expired items, but these tasks were not completed as expected. The Administrator was also informed of the findings and expressed an expectation for the kitchen to meet all required standards. The facility's policy on food storage, which mandates that all foods be covered, labeled, and dated, was not followed, leading to potential risks of food contamination.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to four residents, which could prevent them from obtaining assistance when needed. Resident #2, a female with moderate cognitive impairment and at risk for falls, was observed unable to find her call light, which was on the floor between her bed and side table. Similarly, Resident #21, with severe cognitive impairment and hemiplegia, could not locate her call light, which was on the floor behind her bed. She expressed that the call light should be clipped to her pillow to prevent it from falling. Resident #51, a male with anoxic brain damage and gait/balance problems, reported that his call light was often misplaced by staff when making his bed, making it difficult for him to reach due to his unstable hands. He was observed struggling to pull the call light from behind the bed. Resident #54, a female with moderate cognitive impairment and muscle wasting, was found with her call light wrapped around a drawer handle, out of her reach. She stated that she used the call light for assistance but could not reach it in its current position. Interviews with staff, including CNAs, LVN, ADON, DON, and the Administrator, revealed a consensus that the call light should always be within reach of residents. Staff acknowledged the importance of the call light for residents' safety and the potential risks if it is not accessible. The facility's policy on answering call lights emphasized ensuring the call light is within easy reach when residents are in bed or confined to a chair.
Deficient Cleanliness in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in six rooms, as observed during a survey. Specific deficiencies included dirt particles and black grime on air conditioning units, dust on air filters, and calcium buildup on faucet handles. Additionally, handrails in some bathrooms had black specks of dirt and reddish dots. These observations were made in rooms #505, #507, #509, #511, #510, and #610, indicating a lack of proper cleaning and sanitization. Interviews with the Director of Environmental Services and the Administrator revealed that the facility's housekeeping and maintenance procedures were not adequately followed. The Director of Environmental Services acknowledged the issues and mentioned that maintenance was responsible for cleaning air filters, but the maintenance director was on leave. The Administrator expressed surprise at the findings and recognized the potential risk of respiratory problems for residents due to the unclean conditions. The facility's policy on maintaining a safe and comfortable environment was not effectively implemented, leading to these deficiencies.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their Minimum Data Set (MDS) assessments. Resident #35, a male with contractures in both hands, was inaccurately documented as having no upper extremity impairments in his Quarterly MDS Assessment. Observations and interviews confirmed the resident's condition, which required assistance with daily activities due to his inability to use his hands. Despite having a physician's order for hand splints, the MDS did not reflect his actual impairments. Similarly, Resident #40, a female with a severe cognitive impairment and contractures in her left hand, was also inaccurately assessed. Her MDS indicated no upper extremity impairments, contradicting her care plan and physician orders that required the use of an elbow extensor splint and a hand carrot splint. Observations confirmed her left hand was contracted, and interviews with staff highlighted her dependency on assistance for all activities of daily living due to her impairments. Resident #46, a male with hemiplegia affecting his right side, was documented in his MDS as having no upper extremity impairments, despite observations showing his right arm was limp and non-functional. Interviews with staff confirmed his dependency on assistance for mobility and personal hygiene. The MDS Coordinator acknowledged the discrepancies and the importance of accurate assessments to ensure appropriate care, highlighting a failure in the facility's assessment process.
Failure to Include Parkinson's Disease in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with Parkinson's disease. This deficiency was identified during a review of the resident's records, which revealed that the care plan did not address the resident's Parkinson's disease, despite it being an active diagnosis. The resident, who was cognitively intact with a BIMS score of 15, was admitted to the facility with Parkinson's disease, yet the care plan dated 06/18/24 lacked any mention of this condition. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the MDS Nurse confirmed the oversight. They acknowledged that the resident's Parkinson's disease should have been included in the care plan to ensure the resident received all necessary care. The facility's policy mandates that the interdisciplinary team develop a comprehensive care plan for each resident, which includes all relevant diagnoses and treatments. The omission of Parkinson's disease from the care plan could potentially result in unmet needs for the resident.
Inadequate Infection Control Practices During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA D during incontinence care for two residents. For Resident #21, CNA D did not perform hand hygiene before putting on gloves and failed to change gloves throughout the incontinence care process. This included not washing hands after cleaning the resident's bottom, which could lead to cross-contamination. The resident, a female with severe cognitive impairment and hemiplegia, required assistance for bed mobility and toilet use, making proper infection control practices crucial. Similarly, during incontinence care for Resident #46, CNA D initially washed his hands and put on gloves but did not sanitize his hands between glove changes. After cleaning the resident's bottom, CNA D changed gloves without performing hand hygiene, and later handled the resident's brief without gloves. Resident #46, a male with hemiplegia and bowel and bladder incontinence, was cognitively intact, highlighting the importance of adhering to infection control protocols to prevent potential infections. Interviews with staff, including CNA D, LVN B, the ADON, and the DON, revealed acknowledgment of the importance of hand hygiene and glove changes to prevent cross-contamination and infection. The facility's hand hygiene policy emphasized the necessity of washing hands before and after resident contact and after removing gloves. Despite this, the observed practices during incontinence care did not align with the facility's infection control procedures, posing a risk of infection transmission.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 932 citations issued within 25 miles in the last 12 months — including the 31 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Plano
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Remo | 1.3 mi | ★★★★★ | 23 | 0 |
| Remington Transitional Care Of Richardson | 2.6 mi | ★★★★★ | 1 | 0 |
| The Park In Plano | 2.7 mi | ★★★★★ | 11 | 0 |
| Lindan Park Care Center Lp | 3.7 mi | ★★★★★ | 0 | 0 |
| The Reserve At Richardson | 4.3 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.