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 Landmark Of Plano Rehabilitation And Nursing Cente during CMS and state inspections, most recent first.
A resident with intact cognition, multiple chronic conditions (CHF, Type II DM, hyperlipidemia, MDD, HTN), bowel incontinence, and dependence on staff for toileting and incontinent care reported that staff did not change his brief for five hours and called law enforcement, who responded for an elder abuse complaint. The resident stated he was changed before breakfast, later used his call light for help, and that staff brought his meal without changing him. The DON acknowledged speaking with the responding officer and informing the administrator, identified as the abuse coordinator responsible for reporting to HHSC, but the allegation was not reported to the State Agency as required by facility policy and state reporting timeframes. Other staff (a CNA and an LVN) described the resident’s care needs and routine changing practices and denied that he waited five hours, but their interviews confirmed the facility was aware of the allegation and still failed to submit the required report.
A resident with multiple chronic conditions and self-care deficits was evaluated and recommended for Occupational Therapy (OT), but did not receive any OT services as outlined in her treatment plan. The OT discharge summary was initiated but not completed, and the facility lacked documentation and a policy related to rehabilitation services.
Two residents who were dependent on staff for ADLs did not consistently receive scheduled showers or bed baths, as confirmed by missing documentation, resident interviews, and staff admissions. Despite care plans requiring regular hygiene assistance, staff failed to provide or document these services, and supervisory staff were unaware of the lapses.
The facility did not ensure that OOH-DNR forms for three residents were completed correctly, with missing required signatures from residents, representatives, witnesses, and/or the attending physician, resulting in invalid advance directives. Staff interviews revealed a lack of awareness about these documentation errors, and one resident was not listed on the code status list despite having a DNR order.
Call lights were not kept within reach for four residents. One resident with dementia and Parkinson’s had the call light on the floor, another resident with blindness and confusion had it hanging over a light fixture, a resident with CVA-related deficits had a broken clip causing the cord to dangle from the wall, and a resident with Alzheimer’s had the call light placed in a shoe on the floor. Care plans for each resident directed staff to keep the call light within reach.
Missed Incontinence Care and Scheduled Showers: A resident who was dependent on staff for toileting was found wet and soiled in bed, with staff unable to confirm timely incontinence care. Multiple residents with ADL care needs also missed scheduled showers, and records and interviews showed bathing was skipped on some occasions because towels were unavailable or because of staffing/supply issues. One resident reported going more than a week without a shower, and shower documentation showed several missed scheduled baths.
Unsanitary Bathroom Condition: Surveyors observed a bathroom with a large pile of feces on a board placed over the bathtub, dried feces smeared on the board, and a strong fecal odor. The RCN confirmed the condition, and housekeeping reportedly knew about it before lunch but planned to wait until after meal service to clean it.
PRN Psychotropic Order Continued Without Required Review A resident with moderate cognitive impairment and diagnoses including MDD, GAD, COPD, hypothyroidism, muscle wasting, and Type 2 DM had a PRN Lorazepam order for anxiety with no end date listed. Although pharmacy recommended discontinuation unless there was a clinical rationale to continue and the physician agreed, the record did not show the required rationale or 14-day evaluation for continued PRN psychotropic use. The MAR showed repeated Lorazepam administration across multiple months.
Failure to complete PASRR screening for a resident with documented dementia, bipolar disorder, and major depressive disorder. The MDS assessment showed the resident needed assistance with multiple ADLs, while the care plan included antipsychotic and antidepressant medication focuses and behavior concerns such as attention-seeking, accusatory behaviors, and false allegations. The MDS Nurse said the PASRR Level I from the hospital was entered as received, but no updated eval or PASRR Level II screening was completed.
Failure to Provide Ordered Skin Treatment: A resident with severe cognitive impairment and a left forearm abrasion did not receive the ordered daily A&D Ointment treatment. The bandage remained dated and the assigned weekend nurse stated the skin tear had not been treated as ordered because she was occupied with another resident who had a change in condition. The DON stated the facility expected skin treatments to be completed per physician orders.
Failure to Complete Ordered Wound Care for Two Residents: Two residents with pressure ulcers did not receive wound care consistent with MD orders. One resident with a stage 4 coccyx ulcer and another resident with stage 3 ulcers to the left ankle and foot were observed with missed or undressed wounds, and RN B stated she did not complete the wound care because she was busy and did not notify the ADON or DON. The ADON and DON stated they were not aware the care had not been completed until questioned by the surveyor.
A resident with dementia and gait/mobility issues, who needed partial assistance with personal hygiene, was found to have access to disposable razors in an open bedside drawer. He stated he used the razors to shave as needed, while staff assisted with other ADLs. The DON stated the resident should not have had access to razors and that staff should supervise and assist residents with shaving.
A resident with COPD, respiratory arrest history, and dependence on supplemental O2 was observed using a wheelchair-mounted portable tank that was empty despite a physician order for continuous oxygen. The resident stated she could not feel oxygen through her nasal cannula, and RN B confirmed the tank had run out. The DON stated residents with continuous oxygen orders were expected to always have access to oxygen.
Unsecured Multivitamins Found in Resident Room: A resident with dementia, gait impairment, and assistance needs had a bottle of multivitamins on his bedside table even though there was no order for self-administration. The resident said a family member had brought the vitamins to the facility, and the DON stated the resident was unable to safely self-administer medications and that the vitamins should have been secured in the med cart. The facility policy required medications and biologicals to be stored safely and securely and accessible only to authorized staff.
Infection control lapses were observed during care for two residents. An RN cleaned a resident with bowel and bladder incontinence, used the same gloves to apply a clean brief, and then failed to change gloves or perform hand hygiene after wound cleansing before applying a dressing. A CNA also cleaned an incontinent resident and applied a clean brief without hand hygiene. Both staff acknowledged hand hygiene was needed to prevent cross contamination.
A resident with severe cognitive impairment and multiple behavioral health diagnoses was denied access to her private bathroom, which was kept locked by staff due to concerns about her flushing inappropriate items. Instead, staff escorted her to a locked community restroom, limiting her independence and access to a homelike environment as required by facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Three residents with pressure ulcers did not receive necessary care, including the use of properly set or functioning low air loss mattresses and timely wound dressing changes. One resident's mattress was set for the wrong weight, while two others lacked required pressure-relieving mattresses despite having wounds. Staff interviews revealed confusion about responsibilities for mattress settings and ordering, and care plans did not consistently document required interventions.
Two residents did not have their blood pressure documented prior to receiving prescribed antihypertensive medications, as required by physician orders. Staff interviews confirmed the expectation to check and record blood pressure before administration, but medication administration records and care plans lacked this documentation. Facility policy required such monitoring, but it was not consistently followed.
The facility did not maintain complete and accurate documentation of wound care for three residents with complex medical needs, resulting in multiple missed entries in treatment records and nursing notes. Despite physician orders and care plans requiring regular wound care, the electronic charting system showed unresolved entries, and staff interviews confirmed that treatments may have been performed but not properly documented.
Three residents with significant medical needs did not consistently receive scheduled showers or bed baths due to a persistent shortage of towels, despite staff and management being aware of the issue. Staff interviews confirmed that the lack of towels prevented the provision of necessary ADL care, and residents reported missed showers without explanation. Grievances were filed regarding the lack of bathing services.
A resident with multiple chronic conditions reported symptoms of a UTI, but staff failed to assess, document, or follow up on her complaint in a timely manner. Communication breakdowns among nursing staff and lack of documentation resulted in no urine specimen being collected or physician orders being implemented, delaying appropriate care.
A resident with severe cognitive impairment lost nearly all personal clothing during her stay, despite her family providing labeled items at admission and after additional purchases. Staff interviews revealed inconsistent inventory practices, lack of documentation, and no missing items policy, resulting in the resident being left with only minimal clothing at the time of her death.
A CNA at a facility took an unauthorized photo of a resident's private area during incontinence care, causing distress to the resident. The resident, who was cognitively intact, reported the incident to a family member, leading to police involvement. The CNA admitted to taking and deleting the photo. Staff and residents were aware of the policy against taking photos of residents.
The facility failed to maintain an effective infection control program during incontinence care for two residents. A resident with bowel and bladder incontinence did not receive proper care as CNA B failed to change gloves and perform hand hygiene after cleaning the resident. Another resident, severely cognitively impaired, was also at risk as CNA C did not perform hand hygiene after changing gloves. The DON confirmed the expectation for staff to change gloves and perform hand hygiene during care, as per the facility's handwashing policy.
The facility failed to provide adequate ADL care to residents due to staffing shortages. A resident reported delays in incontinent care, while two others did not receive scheduled showers. Staff confirmed the lack of sufficient personnel, impacting care and documentation. Management acknowledged the issue but had not addressed it effectively.
The facility failed to provide sufficient nursing staff, affecting the care of three residents. A resident reported long waits for incontinent care, while two others missed scheduled showers due to staffing shortages. Staff interviews confirmed that tasks were often incomplete, impacting residents' self-esteem and potentially leading to health issues. Management was aware of the problem, but no sufficient nursing staff policy was provided.
A resident's call light was found on the floor and out of reach, preventing them from requesting assistance. The resident, who was cognitively intact and at risk for falls, expressed difficulty in calling for help. The DON acknowledged that staff should have ensured call lights were within reach during rounds, and maintenance checks were conducted monthly. The call light policy was not provided before the surveyor's exit.
A resident's personal health information was exposed when an LVN left a laptop unlocked on a medication cart during a medication pass. The laptop, displaying the resident's medications, was unattended for 1-2 minutes, visible to staff and residents in the hallway. The resident had a history of heart failure, diabetes, and high blood pressure. The DON confirmed that the facility's policy requires screens to be locked or minimized when not in sight.
A CNA improperly handled a resident's leaking gastrostomy tube without notifying a nurse, risking complications. The CNA did not follow proper hygiene practices and acted outside her scope of practice. The resident had a history of heart failure, diabetes, and catheter-related infection. The facility's policies did not address the required competency for G tube care.
A facility failed to maintain accurate clinical records when a physician's visit notes for one resident were mistakenly documented in another resident's file. This error was not initially recognized by the staff, including the DON and Corporate Nurse. The Administrator noted the physician was new to the system and the nursing staff did not verify the accuracy of physician notes. The facility's documentation policy stresses accuracy and completeness, yet this incident shows a lapse in adherence to these standards.
A CNA in a long-term care facility failed to follow proper infection control procedures while managing a resident's leaking G-tube. The CNA did not wash hands or wear gloves, contrary to the facility's infection control policy. The DON, new to the facility, confirmed the lapse and the importance of hand hygiene to prevent infection spread.
A resident's call light was found non-functional, posing a risk of not receiving timely assistance. The resident, who was cognitively intact and at risk for falls, attempted to use the call light for help but it did not work. The DON confirmed the issue, and the Maintenance Director noted that call lights were checked monthly, but the malfunction was not detected. A call light policy was requested but not provided.
A resident's walker was damaged during transport, and despite notifying the social worker and therapy department, it was not repaired or replaced, leading the resident to attempt a temporary fix with zip ties. The walker remained unsafe, posing a risk of falls. Facility staff were either unaware or did not perceive the issue as a risk, and there was no policy for repairing assistive devices.
A resident with a gastrostomy tube did not receive the correct water flushes before and after medication administration, as required by physician orders. The LVN administering the medications failed to flush the tube between each medication, contrary to the specified orders. The DON confirmed the expectation to follow these orders to prevent medication interactions. The facility lacked a specific policy for medication administration via feeding tubes, contributing to the deficiency.
Failure to Report Allegation of Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect and abuse to the State Agency within the required timeframe. On 11/28/2025, law enforcement responded to the facility at 8:55 AM for a complaint of elder abuse after a resident reported that staff had not changed his brief in over five hours. The facility’s own abuse policy required that any person with reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state, and/or adult protective services, and that the administrator or designee must report qualifying incidents to HHSC within specified timeframes. Despite this, the allegation made on 11/28/2025 that the resident’s brief had not been changed in five hours was not reported to the State Agency. The resident involved was an adult male with a BIMS score of 15, indicating intact cognition, and diagnoses including congestive heart failure, Type II diabetes, hyperlipidemia, major depressive disorder, and hypertension. He used a manual wheelchair and required one-person assistance for transfers, turning, positioning, dressing, and toileting, and had frequent bowel incontinence requiring staff assistance with incontinent care. During an observation and interview on 1/20/2026, the resident stated he had called the police because it took five hours before someone came to change his brief. He reported that he was changed before breakfast, later used his call light for help changing his brief, and that although someone entered his room to bring his meal, they did not change him at that time. Interviews with staff confirmed that the allegation was known to facility leadership but not reported as required. The DON stated he was present when law enforcement responded, spoke directly with the officer about the abuse allegation, and then informed the administrator, whom he identified as the abuse coordinator responsible for reporting allegations to HHSC. The DON denied that the resident went five hours without care and stated the resident was changed before and after breakfast. CNA A, who worked both shifts that day, reported that the resident required assistance for bowel movements and could not clean himself, and stated that neither he nor other residents had to wait five hours to be changed. LVN B reported the resident was changed before breakfast around 8:00 AM and that residents are checked before each meal, denying the resident was left unattended for five hours. The current administrator, who assumed the role after the incident, stated that the event would have been a reportable allegation and acknowledged that such allegations must be reported to HHSC.
Failure to Provide Occupational Therapy Services as Ordered
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically Occupational Therapy (OT), to a resident as outlined in her plan of treatment. The resident, an older female with diagnoses including hypertensive heart disease with heart failure, polyneuropathy, and chronic pain syndrome, was admitted with significant self-care deficits and required a wheelchair for mobility. Her care plan identified the need to maintain or improve her current level of function, but did not specify interventions related to rehabilitation services. An OT evaluation and plan of treatment were completed, recommending OT three times per week for 60 days. However, the resident did not receive any OT services as recommended. The Occupational Therapy Discharge Summary was initiated but not completed or submitted on the same day as the evaluation. The Director of Therapy, who was not involved in the resident's care at the time, confirmed that the resident did not receive OT and was unable to determine why the services were not provided. Additionally, a Provider Notice of Adverse Benefit Determination indicated that the request for OT services was denied due to insufficient documentation of medical necessity. The facility was unable to provide a policy related to rehabilitation services when requested by the surveyor.
Failure to Provide Scheduled Showers and Bed Baths for Dependent Residents
Penalty
Summary
The facility failed to ensure that two residents who were dependent on staff for activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Both residents required maximal or total assistance with showering or bathing, as documented in their care plans and MDS assessments. Despite this, the residents reported not being offered showers or bed baths consistently according to their scheduled days, with one resident stating he had not received a shower in over a week and another indicating inconsistent provision of bed baths, despite his preference and need due to right side weakness. Record reviews revealed missing shower sheets for both residents for the month in question, indicating a lack of documentation and follow-through on scheduled hygiene care. Interviews with staff, including CNAs and an LVN, confirmed that showers and bed baths were not consistently provided. The LVN responsible for ensuring showers were completed admitted to not following up on missing shower records, and the DON was unaware that the residents had not been receiving their scheduled hygiene care. Staff also indicated that there was a reliance on evening shower staff, and if showers were not provided, this was not always communicated or documented appropriately. Facility policy required that residents receive assistance with bathing according to their individualized care plans to promote comfort, cleanliness, and skin integrity. However, the lack of consistent provision and documentation of showers and bed baths for these dependent residents constituted a failure to meet these standards, as evidenced by resident and staff interviews, missing records, and direct observations.
Failure to Ensure Valid Completion of Advance Directives
Penalty
Summary
The facility failed to ensure that residents' rights to formulate and have valid advance directives were upheld for three of eight residents reviewed. Specifically, the Out of Hospital-Do Not Resuscitate (OOH-DNR) forms for these residents were not completed correctly, lacking required signatures from the resident or their representative, witnesses, and/or the attending physician, which rendered the documents invalid. For example, one resident's DNR form was missing a second required signature, another's form lacked both the second signature and the physician's signature, and a third resident's form was missing a witness signature and was signed by a Family Nurse Practitioner instead of the attending physician as required by the form instructions. Record reviews showed that these residents had significant medical histories, including conditions such as hemiplegia following stroke, dementia, atrial fibrillation, Alzheimer's disease, diabetes, and hypertension. Their care plans indicated DNR orders, and their electronic records reflected DNR code status. However, the deficiencies in the completion of the OOH-DNR forms meant that their wishes regarding resuscitation were not properly documented or legally valid. Additionally, one resident was not listed on the facility's code status list, despite having a DNR order in the chart. Interviews with facility staff, including an LVN, the ADON, and the DON, revealed a lack of awareness regarding the incomplete DNR documentation. The ADON stated that the social worker typically reviewed DNRs, but in their absence, she had taken on the responsibility and was unaware of the errors. The DON also indicated that he and the ADON checked the documents for accuracy but did not know why the deficiencies occurred. The facility's policy and the state OOH-DNR form instructions were reviewed, confirming the requirements for valid completion that were not met in these cases.
Call Lights Left Out of Residents’ Reach
Penalty
Summary
The facility failed to ensure the call light system was maintained within reach for four residents who were reviewed for call light access. During observation and record review, Resident #14’s call light was found on the floor at the foot of the bed, Resident #3’s call light was hanging over a light fixture above the bed, Resident #21’s call light cord had become unattached from the clip and was dangling from the wall, and Resident #69’s call light was found in a shoe on the floor near the bed. In each instance, the call light was out of the resident’s reach when observed by surveyors. Resident #14 was a female with severely impaired cognitive function, Parkinson’s Disease, dementia, hypertension, and muscle weakness. Her care plan included keeping the call light within reach and encouraging her to use it for assistance. She was observed in bed with the call light on the floor at the end of the bed, and it remained there during a later observation. An LVN stated the resident did not use her call light and staff checked on her every 30 minutes to an hour. Resident #3 was a male with intact cognitive functioning, heart failure, Type 2 diabetes, cataracts, visual loss to both eyes, difficulty walking, and unsteadiness on his feet. His care plan directed staff to keep the call light within reach. He was observed in bed with the call light hanging over a light fixture above the bed, and he stated he could not locate it in his bed. The LVN confirmed the call light was out of reach and stated the resident was blind and confused. Resident #21 was a female with intact cognitive functioning, Parkinson’s Disease, TIA/CVA history, anxiety, hemiplegia, hemiparesis, muscle wasting, and muscle weakness. Her care plan directed staff to place the call light cord within easy reach and keep it in reach when in the room. She was observed with the call light hanging down the wall and not clipped near her reach. She reported the clip had been broken for about a week, that she had told several staff, and that she had been using a reach extender to bring the call light closer when it detached. Resident #69 was a female with severely impaired cognitive function, Alzheimer’s Disease, hypertension, depressive disorder, dysphagia, and muscle weakness. Her care plan directed staff to keep the call light in reach. She was observed lying in bed with the call light placed inside her shoe on the floor near the bed.
Missed Incontinence Care and Scheduled Showers
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was dependent on staff for toileting and was always incontinent of bowel and bladder. The resident’s quarterly MDS reflected severe cognitive impairment, and the care plan directed staff to check him every two hours, assist with toileting, and provide pericare with every incontinent episode. During an observation, the resident was found in bed with a foul smell, and his brief and the linen he was lying on were wet. The RN stated she was not aware what time the resident had last been provided incontinent care, and the CNA assigned to the resident stated she had not completed rounds at the time he was found heavily soiled. Staff interviews confirmed expectations to keep the resident dry and provide timely incontinent care to prevent skin breakdown, infection, and soiled linens. The facility also failed to provide showers according to scheduled bathing days for multiple residents. One resident with intact cognition, substantial/maximal assistance needs for bathing and transfers, and a care plan calling for staff assistance with bathing was scheduled for showers three times weekly, but the shower record showed missed scheduled baths and the resident reported going more than a week without a shower and being told there were not enough towels. Another resident with moderate cognitive impairment, diabetes, COPD, depression, anxiety, and dependence for personal hygiene and showering was also scheduled for showers three times weekly, but the shower record showed only a few baths during the month and no documented shower refusals. That resident reported not being bathed regularly and said staff told her they were out of towels each time showers were missed. A third resident with impaired balance and limited mobility was care planned for bathing assistance three times weekly and as necessary, but the shower record showed showers were not provided on the scheduled days. A shower sheet documented that one scheduled shower was not given because there were no towels. A fourth resident with moderate cognitive impairment and partial/moderate assistance needs for showering was scheduled for showers three times weekly, but the shower record showed missed scheduled baths and a shower sheet documented that a shower was not given due to no towels. Staff interviews stated that residents were supposed to receive showers per schedule, that refusals were documented, and that showers could be missed when the facility was short staffed or low on supplies, including towels.
Unsanitary Bathroom Condition
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for the bathroom located in room [ROOM NUMBER]A/B. During observation on 08/26/25 at 1:08 PM, surveyors found a large pile of feces on top of a board placed over the bathtub, along with dried feces that appeared to have been smeared on the board. A strong odor of feces was present in the bathroom at the time of the observation. During interview on 08/26/25 at 1:10 PM, the Regional Compliance Nurse confirmed the presence of feces in the bathroom and obtained cleaning supplies and gloves to clean it. In a later interview on 08/26/25 at 2:38 PM, he stated housekeeping staff knew about the feces in the bathroom and had seen it before the lunch meal service, but planned to wait until after meal service was completed to clean it. Review of the facility's Resident Rights policy reflected that residents have the right to a safe, clean, comfortable, and homelike environment and that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior.
PRN Psychotropic Order Continued Without Required 14-Day Review
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders were limited to 14 days and were not renewed without an evaluation by the attending physician or prescribing practitioner. For one resident, the record showed an order for Lorazepam 0.5 mg by mouth every 12 hours as needed for anxiety, started on 06/20/2025, with no end date listed. The resident’s record also included a pharmacist recommendation on 05/02/2025 to discontinue the Lorazepam unless there was a clinical rationale to continue it, and the physician agreed with the recommendation on 06/05/2025, but no rationale for continuation was documented. The resident was an [AGE]-year-old female admitted to the facility on [DATE] with moderate cognitive impairment, reflected by a BIMS score of 9. Her diagnoses included COPD, hypothyroidism, muscle wasting and atrophy, major depressive disorder, generalized anxiety disorder, and Type 2 diabetes. Her care plan identified the use of antidepressant, antipsychotic, and anti-anxiety medications, with interventions to administer medications as ordered, monitor for side effects and effectiveness, and discuss ongoing need for use of medication with the MD and family. The monthly MAR showed repeated administration of Lorazepam throughout June, July, and August 2025. During interview on 08/26/2025, the Regional Compliance Nurse stated the ADON was responsible for following up with gradual dose reductions and that residents on PRN antipsychotic medications were to be assessed every 14 days for continued use. The nurse also stated the facility would begin auditing pharmacy recommendations and that the risk of continuing PRN medications past 14 days was that residents might no longer benefit from the medication.
Failure to Complete PASRR Screening
Penalty
Summary
The facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one resident reviewed for PASRR services. Resident #8’s quarterly MDS assessment documented a male resident with intact cognitive functioning and diagnoses including dementia in other diseases classified elsewhere, other bipolar disorder, and major depressive disorder. The resident required setup assistance with eating and oral hygiene and substantial assistance with toileting hygiene, footwear, personal hygiene, showering/bathing, and upper and lower body dressing. Record review showed the resident’s PASRR Level I screen, dated 06/14/24, stated he did not have a history of mental illness. However, the comprehensive care plan dated 07/14/2025 included a medication focus for antipsychotic medications, an antidepressant medication focus, and a behavior problem focus describing attention-seeking and accusatory behaviors, false allegations, negative statements about staff, excessive calling out, and other behaviors. During interview, the MDS Nurse stated the PASRR Level I was received from the hospital on admission and was documented as it was, but the resident did not receive an updated evaluation upon or after admission and did not receive a PASRR Level 2 screening. The Regional Compliance Nurse stated the MDS Nurse was responsible for PASRR screenings and was unaware how the screening was missed.
Failure to Provide Ordered Skin Treatment
Penalty
Summary
The facility failed to ensure Resident #33 received ordered treatment for a skin abrasion on her left forearm in accordance with the physician's order and the resident's care needs. Resident #33 was a female admitted with diagnoses including Alzheimer's disease, unspecified dementia, and abnormalities of gait and mobility. Her MDS assessment showed a BIMS score of 03, indicating severe cognitive impairment. On 08/19/25, nursing documentation noted a small abrasion to her left forearm, and on 08/20/25 the physician ordered A&D Ointment to be applied to both arms every day until healed. On 08/24/25, observation showed Resident #33 had a bandage on her left arm dated 08/20/25, and she was unable to provide a reliable interview because of cognitive impairment. The assigned weekend nurse stated the skin tear appeared not to have been treated since the bandage date and confirmed the order required daily treatment. She stated she had not treated the abrasion on 08/23/25 because she was occupied with another resident who had a change in condition, and she planned to treat it later that morning. The DON stated the facility's expectation was for skin treatments to be completed per physician's orders.
Failure to Complete Ordered Wound Care for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with pressure ulcers received wound care consistent with physician orders. Resident #79 had diagnoses including type 2 diabetes, dementia, anemia, gangrene, non-pressure chronic ulcer, and need for assistance with personal care, and was documented as having a stage 4 pressure ulcer to the coccyx with an order for daily cleansing, Dakins-moistened gauze, and covered dressing. Resident #54 had diagnoses including hypertension, dementia, muscle weakness, need for assistance with personal care, and non-pressure chronic ulcer of the right heel and midfoot, and had orders for stage 3 pressure ulcers to the lateral left ankle and lateral left foot with daily cleansing, collagen, calcium alginate, and bordered foam dressings. On 08/24/25, Resident #79 told the surveyor that wound care had not been completed and stated the last wound care was done on Friday, adding that wound care was often not completed on weekends. During observation later that day, the resident had wounds to the sacrum and right toes, and the sacral wound did not have a dressing on it before wound care was performed. During observation of Resident #54, the resident was in bed and had wounds to the left foot with dressings dated 8/22/25, and the wound to the left buttock did not have a dressing on it. RN B stated she did not complete wound care for the residents on 08/23/25 because she was busy and did not inform anyone that the wound care was not completed. She stated she was expected to complete wound care per orders and, if unable, was supposed to notify the ADON or DON, but did not do so. The ADON stated he was not aware the wound care had not been completed until the surveyor questioned RN B, and the DON stated he expected the charge nurse to notify on-call staff or the night nurse if wound care could not be completed, but that did not occur. The facility policy stated nursing personnel would continually aim to maintain skin integrity, tone, turgor, and circulation to prevent breakdown, injury, and infection.
Resident Had Access to Disposable Razors
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for Resident #73, who was admitted with diagnoses including dementia, abnormalities of gait and mobility, and need for assistance with personal care. His MDS assessment reflected a BIMS score of 15, indicating he was cognitively intact, and he was identified as requiring partial or moderate assistance with personal hygiene, including shaving. His care plan dated 07/14/25 did not identify any focus areas, goals, or interventions related to shaving. During observation on 08/24/25, Resident #73 was ambulating in his room and appeared clean, well-groomed, and appropriately dressed, with no signs of distress. Two disposable razors were observed in an open drawer of Resident #33's bedside table. In interview, Resident #73 stated he used the disposable razors in the drawer of his bedside table to shave his face as needed, while facility staff assisted him with all other ADLs. The DON stated Resident #73 should not have had access to razors and that staff should supervise and assist residents with ADLs such as shaving.
Failure to Provide Continuous Oxygen as Ordered
Penalty
Summary
The facility failed to ensure Resident #80 received respiratory care consistent with her physician order for continuous oxygen. Resident #80 was an [AGE]-year-old female with diagnoses including COPD with acute exacerbation, respiratory arrest, and dependence on supplemental oxygen. Her MDS reflected a BIMS score of 11, indicating moderate cognitive impairment, and she was identified as requiring oxygen therapy. Her physician order, effective 08/20/25, directed continuous oxygen at 2-5 liters per minute for ineffective air exchange, and her care plan identified continuous oxygen via nasal cannula at 2 liters per minute with a goal of no signs or symptoms of poor oxygen absorption. During observation, Resident #80 was seen ambulating in her wheelchair with a portable oxygen tank hanging from it, and the oxygen level indicator showed the tank was empty. When interviewed, she stated she could not feel any oxygen coming from her nasal cannula and needed the tank replaced. RN B confirmed the resident had an order for continuous oxygen therapy and that the portable tank in use had run out of oxygen and was empty. RN B stated she had checked the tank earlier that morning and oxygen was being delivered at that time. The DON stated the expectation for residents with continuous oxygen orders was that they always have access to oxygen.
Unsecured Multivitamins Found in Resident Room
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and accessible only to authorized personnel when Resident #73 had an unsecured bottle of multivitamins in his room. Resident #73 was an [AGE]-year-old male admitted with diagnoses including dementia, abnormalities of gait and mobility, and need for assistance with personal care. His MDS assessment dated 06/25/25 showed a BIMS score of 15, indicating he was cognitively intact, and his physician’s orders dated 08/26/25 did not include an order for him to self-administer medications. During observation on 08/24/25 at 10:53 AM, Resident #73 was seen ambulating in his room and had a bottle of multivitamins on his bedside table. When interviewed, he stated he did not self-administer the multivitamins and said a family member had brought them to the facility at some point, but he was unsure why they were on his bedside table. The DON stated at interview that Resident #73 was unable to safely self-administer medications and that the multivitamins should have been secured in the facility’s medication cart. The facility policy stated medications and biologicals are to be stored safely and securely and accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications.
Infection Control Lapses During Incontinent and Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 6 residents reviewed for infection control. During observation, RN B provided care to Resident #79, who had diagnoses including hypertensive heart disease with heart failure, Type 2 diabetes, muscle weakness, dementia, and gait abnormalities, and who was documented as having bowel and bladder incontinence. While providing incontinent care, RN B cleaned the resident, used the same gloves to apply a clean brief, and then completed hand hygiene only after finishing that task. RN B then provided wound care to the resident’s sacral wound. After cleaning the wound, RN B did not perform hand hygiene or change gloves before applying the clean dressing. In interview, RN B stated she was supposed to change gloves and clean her hands after cleaning the resident during incontinent care before applying the clean brief, and also supposed to clean her hands and change gloves after cleaning the wound before applying the clean dressing, but she forgot. She stated hand hygiene and glove changes were needed to prevent cross contamination. A separate observation showed CNA C providing incontinent care to Resident #2, who had diagnoses including hypertension, muscle weakness, dementia, and need for assistance with personal care, and who was documented as requiring total assistance with toileting and being always incontinent of bowel and bladder. CNA C cleaned the resident, who was soiled with bowel and urine, and then applied a clean brief without any hand hygiene. In interview, CNA C stated she knew she was supposed to complete hand hygiene after cleaning the resident, but she did not have hand sanitizer, and said she was supposed to complete hand hygiene regardless of changing gloves to prevent cross contamination.
Resident Denied Access to Bathroom Due to Locked Door
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident with multiple cognitive and behavioral diagnoses, including Frontotemporal Neurocognitive Disorder, dementia, muscle weakness, bipolar disorder, depression, manic disorder, impulse disorder, and cognitive communication deficit. The resident was assessed as severely cognitively impaired. During observation and interviews, it was found that the resident's private bathroom was locked by facility staff. The Maintenance Director and DON stated this was done because the resident had a history of flushing inappropriate items, such as clothes and briefs, which had previously caused plumbing issues and backups in the memory care unit. Instead of access to her own bathroom, the resident was escorted by staff to a community restroom in the memory care unit, which was also kept locked and only accessible by staff. The facility's policy on resident rights requires that residents be treated with respect and dignity in an environment that promotes quality of life and allows for safe and independent access to personal spaces. The locked bathroom restricted the resident's access to her own bathroom, contrary to these requirements.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Appropriate Pressure Ulcer Care and Pressure-Relieving Devices
Penalty
Summary
The facility failed to provide necessary pressure ulcer care and prevent new ulcers from developing for three residents reviewed for treatment and services related to pressure ulcers. For one resident with a stage 4 coccyx pressure ulcer, the low air loss mattress was set incorrectly at a weight of 280 pounds, despite the resident weighing approximately 160-180 pounds. The resident reported discomfort with the mattress, and staff interviews revealed uncertainty about who was responsible for setting and monitoring the mattress settings. Documentation showed that the mattress was supposed to be checked every shift, but the incorrect setting persisted. Two other residents with sacral or buttock wounds did not have functioning low air loss mattresses available to promote healing. Observations confirmed that these residents were in bed without the required pressure-relieving mattresses, despite having wounds that required such interventions. Staff interviews indicated a lack of clarity regarding the process for ordering and setting up low air loss mattresses, and the care plans did not consistently reflect the need for these devices as interventions for wound care. Additionally, one resident's wound dressing was not changed daily as ordered, and care plans lacked specific details about the type of pressure ulcer or treatment orders. Staff interviews revealed inconsistent knowledge about the purpose and management of low air loss mattresses, including who was responsible for ensuring correct settings and timely provision. The facility's policy required high-risk individuals to be placed on pressure-reducing devices, but this was not consistently implemented, resulting in residents being at risk for developing new or worsening pressure ulcers.
Failure to Document Blood Pressure Prior to Administration of Antihypertensive Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of blood pressure medications for two residents. For one resident with multiple diagnoses including hypertensive heart disease and atrial fibrillation, Carvedilol was prescribed with specific parameters to hold the medication if blood pressure was below 110/60 or pulse below 60. However, on nine occasions, there was no documentation that blood pressure was obtained prior to administering the medication, as required by the physician's order. Review of the resident's care plan also revealed no discussion of his blood pressure medication or related health condition. For another resident with diagnoses including Parkinson's disease and low blood pressure, Midodrine was prescribed with instructions to hold the medication if systolic blood pressure was greater than 120. On four occasions, there was no documentation of blood pressure readings prior to administration, and the care plan did not address the blood pressure medication or related condition. In both cases, review of the medication administration records and nursing progress notes did not show evidence that the required blood pressure checks were performed or documented before medication was given. Interviews with facility staff confirmed that it was standard practice to document blood pressure prior to administering such medications and to hold the medication if parameters were not met. Staff also indicated that the electronic charting system should prompt for blood pressure entry, but errors in order entry could bypass this requirement. Facility policy required monitoring and documentation of specific items such as blood pressure when ordered, but this was not consistently followed for the residents in question.
Failure to Document Wound Care Administration in Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents who required wound care, as evidenced by missing documentation of wound care administration on multiple occasions. For one resident with a history of dementia, gangrene, chronic foot ulcers, diabetes, malnutrition, and rheumatoid arthritis, there was no documentation of wound care provided on four specific dates in June, despite physician orders and a care plan indicating the need for daily wound management. The resident's treatment administration record (TAR/WAR) and nursing progress notes did not reflect any reason for the missed documentation or whether the care was provided. Another resident, with diagnoses including diabetes, aphasia, stroke, anoxic brain damage, and dysphagia, also had missing documentation for wound care on three dates in June. This resident required substantial assistance with activities of daily living and had a physician order for sacral wound care. The TAR/WAR did not show that wound care was signed off on the specified dates, and there was no additional documentation in the nursing notes to explain the omissions. Observation confirmed the presence of a wound dressing, but the required documentation was incomplete. A third resident, with a history of cellulitis, chronic leg ulcers, gout, and lymphedema, had no documentation of wound care on four dates in May, despite multiple physician orders for wound management of several leg and toe ulcers. The care plan did not address all of the resident's wounds, and the TAR/WAR and nursing progress notes lacked entries for the missed dates. Interviews with nursing staff revealed that wound care documentation was expected to be completed in the electronic charting system, and missing entries would remain flagged until resolved. However, the system showed unresolved entries, and staff acknowledged that treatments may have been performed but not documented.
Failure to Provide Scheduled Showers Due to Towel Shortage
Penalty
Summary
The facility failed to ensure that three residents who were unable to perform activities of daily living (ADLs) independently received necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Record reviews and interviews revealed that these residents did not consistently receive scheduled showers or bed baths during the month of May 2025, despite care plans indicating the need for substantial or maximal staff assistance. Documentation showed missed or inconsistent bathing dates, and residents reported not being offered showers as scheduled, with no explanations provided for the missed care. Interviews with staff, including a CNA and an RN, confirmed that showers were not always provided due to a lack of available towels, an issue that had been ongoing and reported to management. The CNA stated that on certain days, such as 5/27/25, no scheduled showers were offered because towels were not available until late in the shift. The RN corroborated that aides had reported the towel shortage and that management, including the ADON, was aware of the problem. The ADON acknowledged the lack of towels and stated that she had reported it to the Administrator, but no action had been taken to resolve the issue. Residents involved had significant medical histories, including conditions such as hypertension, diabetes, stroke, hemiplegia, Parkinson's disease, and cognitive impairment, necessitating assistance with ADLs. Despite being well-groomed at the time of observation, residents expressed dissatisfaction with the inconsistency of their bathing schedules and the lack of communication regarding missed showers. Grievance records for April and May also reflected complaints about not being provided with showers.
Failure to Provide Timely UTI Assessment and Care
Penalty
Summary
A deficiency occurred when a resident who reported symptoms of a urinary tract infection (UTI) did not receive timely assessment, treatment, or care in accordance with professional standards, the care plan, and her expressed preferences. The resident, who had a history of hypertension, type 2 diabetes, stroke, amputation, and progressive neurological conditions, reported to staff that she was experiencing frequent urination and burning sensations. Despite informing a nurse of these symptoms, there was no documentation in the resident's progress notes, 24-hour report, or physician orders regarding her complaint or any follow-up actions. Multiple staff interviews revealed a breakdown in communication and documentation. The charge nurse for the 2-10 shift stated she was not informed of the resident's symptoms or any change in condition, and the LVN who was told of the symptoms did not document the complaint, notify the charge nurse, or follow through with obtaining a urine specimen as ordered by the primary care provider. The Assistant Director of Nursing (ADON) was also unaware of the resident's change in condition and only became aware when laboratory personnel requested a urine specimen that had not been collected. The facility's policy required immediate physician notification and documentation for significant changes in status, which was not followed in this case. The lack of timely assessment, documentation, and follow-up resulted in the resident not receiving appropriate care for her reported UTI symptoms. The failure to act according to physician orders, facility policy, and professional standards of practice led to a delay in diagnosis and treatment for the resident.
Failure to Safeguard Resident's Personal Clothing
Penalty
Summary
The facility failed to ensure a resident's right to retain and use personal clothing, resulting in the loss of nearly all of the resident's clothing during her stay. Upon admission, the resident, who had severe cognitive impairment due to dementia and an anxiety disorder, was provided with three weeks' worth of labeled clothing by her family. By January, all of these clothes had disappeared, and the resident was found dressed in a hospital gown. The family had to purchase additional clothing for the resident, which also went missing, leaving her with only one or two pairs of pajamas at the time of her passing. There was no record of grievances filed by the family regarding the missing clothing. Interviews with staff revealed inconsistent and inadequate processes for inventorying and labeling residents' clothing. While some staff believed inventories were completed and uploaded into electronic health records, there was no inventory record for this resident. Staff also reported a lack of a system for documenting clothing added or removed during the resident's stay, and the facility did not have a missing items policy. The administrator confirmed that the family requested a refund for the missing clothing but was told a receipt was required. The facility's policy on misappropriation of resident property was reviewed, but there was no evidence of its effective implementation in this case.
CNA Takes Unauthorized Photo of Resident
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA took a private photo of the resident without consent. The incident occurred when the resident, who was cognitively intact with a BIMS score of 15, required assistance with incontinence care. The resident reported that the CNA was upset about having to perform the care and took a photo of the resident's private area, allegedly to show the DON that the day shift should have changed the resident. This action was taken without the resident's consent and caused significant distress to the resident. The resident did not initially report the incident to the facility but informed a family member, leading to police involvement. The DON and Administrator were informed of the incident, and the CNA admitted to taking and subsequently deleting the photo. Interviews with other staff and residents indicated awareness of the policy against taking photos of residents. The facility's policy on abuse, revised in 2017, states that residents have the right to be free from abuse, neglect, and exploitation.
Inadequate Infection Control During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during incontinence care for two residents. Resident #1, who was cognitively intact and had a history of hip fracture and diarrhea, required maximum assistance with toileting due to bowel and bladder incontinence. During an observation, CNA B did not change gloves or perform hand hygiene after cleaning the resident's peri-area and buttocks before applying a clean brief. CNA B believed that hand hygiene was only necessary before and after care, not during the process. Resident #2, who was severely cognitively impaired with diagnoses including diabetes, stroke, and non-Alzheimer's dementia, was completely dependent on staff for toileting. During incontinence care, CNA C changed gloves but did not perform hand hygiene after cleaning the resident's peri-area and buttocks. CNA C stated that hand hygiene was only necessary if there was visible bowel movement on the gloves. The facility's Director of Nursing confirmed that staff were expected to change gloves and perform hand hygiene during incontinence care to minimize infection risk. The facility's handwashing policy, dated 2012, emphasized the importance of frequent handwashing.
Staffing Shortages Lead to Inadequate ADL Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This deficiency was observed in three residents who required assistance with ADLs, including showers, bed baths, and timely incontinent care. The lack of consistent care was attributed to staffing shortages, which were acknowledged by both the staff and management. Resident #1, a female with multiple health conditions including local infection of the skin, obesity, and incontinence, reported delays in receiving incontinent care, sometimes waiting 2-3 hours after using the call light. Despite being well-groomed at the time of observation, the resident expressed concerns about the facility's staffing issues, which were known to management but not addressed. Resident #2, a 96-year-old female with moderate cognitive impairment and dependency on assistance for showers and toileting, also reported not receiving scheduled showers due to insufficient staffing. Resident #3, who required extensive assistance with ADLs and had a history of traumatic subdural hemorrhage and kidney disease, stated that care was often delayed, and bed baths were not provided as scheduled. Interviews with staff, including a CNA and an LVN, confirmed that the facility was understaffed, leading to incomplete ADL care and documentation. The Assistant Director of Nursing (ADON) and the Administrator acknowledged the staffing issues and their impact on resident care, with the ADON admitting to failing to follow up on shower completions as planned.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the experiences of three residents. Resident #1, a female with multiple diagnoses including morbid obesity and muscle weakness, reported waiting 2-3 hours for incontinent care despite using her call light. She indicated that staffing issues were known to management but remained unaddressed. Resident #2, a 96-year-old female with a history of stroke and other neurological conditions, required maximum assistance with daily activities. She reported not receiving scheduled showers, attributing this to insufficient staffing. Resident #3, who had a traumatic subdural hemorrhage and other health issues, also experienced delays in care, including missed bed baths, and noted that staffing shortages had been a long-standing problem. Interviews with staff members corroborated the residents' accounts of inadequate staffing. CNA A, who was often assigned to 15 to 22 residents, confirmed that not all tasks were completed due to the lack of staff, resulting in missed showers and incomplete documentation. LVN B also acknowledged that daily living activities were not consistently completed, citing insufficient staff to meet residents' needs. Both staff members expressed that the lack of care could negatively impact residents' self-esteem and lead to potential health issues such as skin breakdown. The facility's management, including the ADON and the Administrator, were aware of the staffing deficiencies. The ADON admitted to not following up on shower completions and acknowledged the ongoing staffing issues. The Administrator, who had been in the facility for two months, recognized the impact of staffing shortages on residents' quality of life but had not yet provided a sufficient nursing staff policy. Resident advisory council minutes further highlighted concerns about delayed call light responses, missed showers, and insufficient staff in the dining room, underscoring the widespread nature of the staffing problem.
Resident Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's needs were reasonably accommodated, specifically regarding the resident call system. On a specific date, a resident's call light was found on the floor and out of reach, preventing the resident from requesting assistance. The resident, who was cognitively intact with a BIMS score of 14, expressed difficulty in calling for help due to the call button being inaccessible. The resident had a history of being at risk for falls, and the care plan included ensuring the call light was within reach as an intervention. During an interview, the Director of Nursing (DON) acknowledged that staff should have been checking to ensure call lights were within reach during rounds. The DON also mentioned that maintenance checks were conducted monthly to ensure call lights were functioning properly. Despite a request for the call light policy, it was not provided before the surveyor's exit.
Confidentiality Breach During Medication Pass
Penalty
Summary
The facility failed to protect the confidentiality of a resident's personal health care information during a medication pass. An LVN left a laptop unlocked and open on a medication cart, exposing the resident's personal information, including medications, to staff and residents in the hallway. This incident occurred while the LVN was responding to a call light in the resident's room, leaving the computer unattended for approximately 1-2 minutes. The medication cart was positioned two doors down from the resident's room, with the screen facing the hallway, making the information visible to passersby. The resident involved was a male with a history of acute combined systolic and diastolic heart failure, type 2 diabetes mellitus with unspecified complications, and high blood pressure. The Director of Nursing confirmed that the facility's policy requires computer screens to be locked or minimized when not in sight during medication passes to prevent unauthorized access to patient information. The failure to adhere to this policy resulted in a breach of the resident's right to secure and confidential personal and medical records.
Inadequate Handling of Gastrostomy Tube by CNA
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a gastrostomy feeding tube. A CNA, identified as CNA C, was observed handling the resident's leaking G tube without proper hygiene practices, such as washing hands or wearing gloves initially. CNA C attempted to manage the situation by closing the end of the G tube to prevent further leaking, but did not alert a nurse to assess the resident's condition. This action was outside the CNA's scope of practice and posed a risk of complications for the resident. The resident involved was a male with a history of acute combined systolic and diastolic heart failure, type 2 diabetes mellitus, high blood pressure, and an infection related to an indwelling urethral catheter. The resident was cognitively intact, as indicated by a BIMS score of 12. The facility's policy on gastrostomy tube care did not address the competency required for such care, and the CNA's job description did not include G tube care. The Director of Nursing confirmed that CNA C should have notified a nurse and not attempted to assess the G tube, acknowledging the risk of unrecognized complications.
Inaccurate Documentation of Physician Notes
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, resulting in inaccurate documentation for one of the residents reviewed. Specifically, the physician visit notes for one resident were mistakenly documented in the file of another resident. This error was discovered during a review of the electronic nursing notes, which revealed that the physician notes for several dates contained information pertaining to a different resident, including their name, date of birth, vital signs, history, reason for visit, assessment, and plan. Interviews with the Director of Nursing, Corporate Nurse, and Administrator revealed a lack of awareness regarding the documentation error. The Administrator attributed the mistake to the physician being new to the system and stated that the nursing staff did not verify the accuracy of physician notes, as they were not responsible for ensuring their accuracy. The facility's policy on documentation emphasizes the importance of accuracy and completeness in clinical records, yet this incident highlights a failure to adhere to these standards, potentially placing residents at risk for medication and treatment errors.
Infection Control Lapse in G-Tube Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to proper infection control procedures while tending to a resident's G-tube. The resident, a male with a history of acute combined systolic and diastolic heart failure, type 2 diabetes mellitus, and high blood pressure, experienced a leaking G-tube. The CNA, identified as CNA C, responded to the situation without washing her hands or wearing gloves, which are essential practices to prevent cross-contamination and infection. She picked up the G-tube with bare hands, placed gloves on the resident's bed, and later discarded the gloves after capping the G-tube. The Director of Nursing (DON), who was new to the facility, was unaware of the last infection control training for staff. The DON acknowledged that CNA C should have washed her hands and worn gloves before handling the G-tube and should have informed a nurse about the leak. The facility's infection control policy, dated 2019, emphasizes the importance of hand hygiene to prevent the spread of infections. Despite previous infection control training sessions, the incident highlights a lapse in adherence to these protocols, potentially putting residents at risk of infection.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to ensure that a working call system was available for a resident, which could place residents at risk of not receiving necessary care and services. Specifically, the call light for a resident was not functioning on the date of observation. The resident, who was cognitively intact with a BIMS score of 14, had a care plan indicating a risk for falls and required assistance with personal care. The care plan included interventions such as ensuring the call light was within reach and encouraging its use for assistance. However, during an interview and observation, the resident attempted to use the call light to call staff for assistance but found it was not working. The Director of Nursing (DON) was informed of the issue and confirmed that the call light was not operational. The Maintenance Director later revealed that call lights were checked monthly, and Resident #3's call light had been checked at the beginning of the month. Despite this, the call light was not functioning when needed. The DON acknowledged that staff should have been checking the call lights during rounds to ensure they were working and within reach. A call light policy was requested from the Administrator but was not provided before the survey exit.
Failure to Repair Resident's Walker
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards by not repairing or replacing a damaged walker used by a resident for mobility. The resident, who was cognitively intact and had diagnoses including cellulitis, lymphedema, and morbid obesity, reported that the padded backrest of his walker was broken during transport in February 2024. Despite informing the social worker and the therapy department, the walker remained unrepaired, leading the resident to attempt a temporary fix using zip ties. However, the walker continued to malfunction, making it unsafe and frightening for the resident to use. Interviews with facility staff revealed a lack of communication and action regarding the broken walker. The social worker acknowledged being informed of the issue but did not perceive it as a risk due to the resident's limited mobility. The Director of Rehabilitation was unaware of the problem and was focused on obtaining a motorized wheelchair for the resident. The Director of Nursing only became aware of the issue after the surveyor's inquiry and recognized the increased risk of falls associated with a malfunctioning walker. The facility did not have a policy for the repair of assistive devices, as confirmed by the administrator during the exit conference.
Failure in Gastrostomy Tube Management
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not provide the correct water flushes before and after medication administration through a gastrostomy tube for a resident. The resident, an elderly male with type 2 diabetes, dysphagia, and major depressive disorders, required a feeding tube due to swallowing problems. The resident's care plan and physician orders specified that the feeding tube should be flushed with 30 ml of water before and after medication and feedings, and with at least 5 ml of water between each medication. During an observation, a Licensed Vocational Nurse (LVN) administered medications via the resident's feeding tube but failed to flush the tube between each medication, contrary to the physician's orders. The LVN initially stated that she did not need to flush between medications and was unaware of the specific order to do so. Upon review, she acknowledged the oversight. The Director of Nursing (DON) confirmed that the nurse was expected to follow the physician's orders to prevent medication interactions and ensure proper administration. The facility did not have a specific policy for medication administration via feeding tubes, which contributed to the deficiency.
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Illustrative
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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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) |
|---|---|---|---|---|
| Life Care Center Of Plano | 0.4 mi | ★★★★★ | 2 | 0 |
| The Healthcare Resort Of Plano | 1 mi | ★★★★★ | 1 | 0 |
| Carrara | 1.1 mi | ★★★★★ | 6 | 0 |
| The Hillcrest Of North Dallas | 1.4 mi | ★★★★★ | 1 | 0 |
| Continuing Care At Highland Springs | 1.7 mi | ★★★★★ | 6 | 2 |
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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.