Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Lindan Park Care Center Lp during CMS and state inspections, most recent first.
A resident with severe cognitive impairments and dysphagia was force-fed by a CNA, leading to a deficiency in abuse prevention. The CNA pushed the resident's head back and rapidly fed her, causing distress. Despite the resident's care plan requiring specific feeding techniques, the CNA's actions were observed by a surveyor, who intervened. Interviews revealed differing views on the feeding method, but the facility's policy emphasized resident protection, which was compromised.
The facility failed to inform residents on how to file grievances anonymously, affecting their ability to voice concerns without fear of reprisal. Observations and interviews revealed that residents and staff were unaware of the grievance process, and grievance forms were not easily accessible. The facility's policy states residents have the right to file grievances without fear, but this was not effectively communicated.
The facility failed to adhere to food service safety standards, with deficiencies in labeling, dating, and sealing food items in the kitchen. Unsealed and expired items were found in both dry storage and refrigerator areas, including a dented can and improperly stored perishables. Staff interviews revealed a lack of awareness and oversight, despite existing policies requiring proper food storage and rotation practices.
A facility failed to conduct an accurate PASARR screening for a resident with serious mental disorders, leading to a risk of not receiving necessary services. The MDS Nurse did not verify the PL-1 form's accuracy, and the DON was unaware of a process to double-check these forms, despite the facility's policy requiring preadmission screening.
The facility failed to complete discharge summaries and medication reconciliations for two residents, impacting their continuity of care post-discharge. One resident was discharged home, and another to a hospital, both without necessary documentation. The absence of a Social Worker and inconsistent assignment of responsibilities contributed to these deficiencies.
The facility failed to display required notifications for residents and their representatives on how to file a complaint, as observed during a survey. The absence of the Adult Protective Services posting was confirmed by the Administrator, who acknowledged responsibility for ensuring such postings are displayed. A sign was later created and posted after the issue was identified.
A resident with COPD and other health issues experienced a significant drop in oxygen levels, but the facility failed to notify the physician as required by policy. RN A discovered the drop and administered a breathing treatment, but did not inform the physician, which could delay medical intervention.
A resident with severe cognitive impairment and multiple health conditions was found with unexplained bruising on the inner thighs during ADL care. The LPN documented the injury and informed the ADON, but failed to notify the physician or responsible party as required by facility policy. The physician and responsible parties only learned of the injury after the resident was hospitalized for unrelated reasons.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained bruising on the inner thighs. The injury was discovered by an LVN and observed by the ADON, but required notifications to the administrator, DON, physician, responsible party, and state agency were not made within the required timeframe. The incident was reported to the state agency two days late, contrary to facility policy and regulatory requirements.
A resident's care plan inaccurately included a diagnosis of Parkinsonism, despite the absence of such a diagnosis in their medical records. Facility staff, including the DON and MDS Nurse, confirmed the error but could not determine its origin. This discrepancy highlights a failure to maintain accurate clinical records, as required by the facility's documentation policy.
Resident Force-Fed by CNA, Resulting in Abuse Deficiency
Penalty
Summary
The facility failed to protect a resident from physical abuse when a Certified Nursing Assistant (CNA) force-fed the resident, causing psychosocial harm. The incident occurred when the CNA forcefully pushed the resident's head back and rapidly fed her large spoonfuls of food, despite the resident's attempts to stop drinking and subsequent coughing and sputtering. The resident, who was non-verbal and had severe cognitive impairments, was dependent on staff for eating due to her medical conditions, including dysphagia and dementia. The resident's care plan indicated that she required total assistance for eating and had specific dietary needs, including a pureed diet and thickened liquids. The care plan also noted that the resident's head should be elevated during meals to prevent swallowing difficulties. Despite these instructions, the CNA's actions were observed by a surveyor, who intervened and reported the incident to the Director of Nursing (DON). Interviews with the DON, the Administrator, and the resident's family member revealed differing perspectives on the feeding technique used by the CNA. The family member acknowledged that the technique was aggressive but believed it was necessary to meet the resident's needs. However, the Rehabilitation Director and other staff members confirmed that no aggressive techniques were required for feeding the resident. The facility's policy on abuse, neglect, and exploitation emphasized the protection of residents' health, welfare, and rights, which were compromised in this incident.
Failure to Inform Residents of Anonymous Grievance Filing Process
Penalty
Summary
The facility failed to adequately inform residents or their representatives on how to file grievances anonymously, affecting their ability to voice concerns without fear of discrimination or reprisal. This deficiency was identified through observations, interviews, and record reviews, which revealed that residents were not notified individually or through prominent postings about the grievance process. Specifically, three residents reviewed for knowledge of filing grievances were unaware of how to do so anonymously. Additionally, the grievance forms were not easily accessible, as observed when a surveyor struggled to open the frame containing the forms, and the forms fell out when the frame was finally opened. Interviews with residents during a confidential Resident Council meeting confirmed their lack of awareness regarding the location of grievance forms and the process for filing grievances anonymously. The Activities Director also demonstrated a lack of knowledge about the grievance forms' location and accessibility, further highlighting the facility's failure to ensure staff and residents were informed about the grievance process. The facility's Administrator indicated that grievances were typically filed verbally, suggesting a lack of emphasis on written or anonymous grievance procedures. The facility's policy on grievances, dated March 2017, states that residents have the right to file grievances without fear of reprisal, but the facility did not effectively communicate this right to its residents.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. The deficiencies included improper labeling and dating of food items in both the dry storage and refrigerator areas. Specifically, several items were found unsealed, such as bags of noodles, sugar, and turkey gravy mix, as well as a metal pan of red Jello and a white plate with a burger setup. Additionally, expired items were not removed, including a package of seasoning mix and a bag of Parmesan cheese. A dented can of diced pears was also found on the shelf, which should have been removed to prevent potential contamination. Interviews with the Dietary Manager and staff revealed a lack of awareness and oversight regarding the expired and unsealed items. The Dietary Manager acknowledged the oversight and stated that all staff were responsible for ensuring items were not expired or unsealed. However, the staff interviews indicated a gap in the implementation of these responsibilities, as they were unaware of the existing issues. The staff were expected to follow the First In, First Out (FIFO) method for stock rotation, but the presence of expired and improperly stored items suggested a failure in this practice. The facility's policy and procedure manual for food storage outlined the requirements for proper food storage, labeling, and rotation, which were not followed. The manual emphasized the importance of using plastic containers with tight-fitting covers or sealable bags for storing opened packages and ensuring all items were labeled and dated. The failure to comply with these procedures posed a risk of cross-contamination and foodborne illnesses, as noted in the report.
Failure to Conduct Accurate PASARR Screening
Penalty
Summary
The facility failed to refer a resident for a Level II PASARR review, which is necessary for residents with serious mental disorders or intellectual disabilities. This deficiency was identified for a resident who was admitted with diagnoses including depression, schizophrenia, and post-traumatic stress disorder. Despite these conditions, the resident's PASARR Level I screening incorrectly indicated no history of mental illness. The resident's quarterly MDS assessment showed severe cognitive impairment, and care plans noted deficits related to dementia, PTSD, and schizophrenia. Interviews with facility staff revealed that the MDS Nurse, responsible for entering PASARR information, did not verify the accuracy of the PL-1 form received from another facility. The Director of Nursing was unaware of any process to double-check the PL-1 forms, which placed the resident at risk of not receiving necessary PASARR services. The facility's policy requires preadmission screening to ensure appropriate placement and identify the need for specialized services, but this was not adhered to in this case.
Failure to Complete Discharge Summaries and Medication Reconciliation
Penalty
Summary
The facility failed to complete discharge summaries and medication reconciliations for two residents, which are essential components of discharge planning. Resident #58, a female with a history of dementia, hypertension, and other chronic conditions, was discharged home without a discharge summary or medication reconciliation. The facility's records indicated that her care plan and interventions related to discharge were canceled, and there was no documentation of a discharge summary or medication reconciliation in her clinical records. Similarly, Resident #59, a male with severe cognitive impairment and multiple health issues, was discharged to a hospital without a discharge summary or medication reconciliation. His care plan also showed canceled discharge planning interventions, and there was no evidence of a discharge summary or medication reconciliation in his records. Interviews with facility staff, including the MDS Nurse and the DON, revealed that the facility had been without a Social Worker for about two months, and the responsibility for completing discharge summaries had been inconsistently assigned to charge nurses. The facility's policy requires a discharge summary and post-discharge plan to be developed for residents anticipating discharge, which includes a comprehensive recapitulation of the resident's stay and a final summary of their status. However, due to the absence of a Social Worker and lack of oversight, these critical components were not completed for the two residents, potentially impacting their continuity of care post-discharge. Interviews with the Administrator and previous Social Worker highlighted the facility's challenges in maintaining consistent discharge planning processes, leading to the deficiencies identified in the report.
Missing Required Postings for Complaint Filing
Penalty
Summary
The facility failed to post the required notifications for residents or their representatives on how to contact someone to file a complaint. During observations conducted on March 5, 2025, between 10:00 AM and 3:00 PM, it was noted that the required Adult Protective Services posting was missing throughout the facility. An interview with the Administrator at 3:50 PM on the same day confirmed the absence of the posting. The Administrator acknowledged her responsibility for ensuring that the required postings are displayed. The Facility Surveyor/Liaison provided the Administrator with a link to order the necessary posting, and the Administrator subsequently created a sign and posted it on the wall.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in condition, which is a requirement under their policy. On January 26, 2025, RN A discovered that the resident's oxygen levels had dropped to 77% at 5:16 AM. Despite this significant change, the physician was not notified. RN A repositioned the resident and administered a breathing treatment, which increased the oxygen levels to 83-85%. However, the facility's policy mandates that the physician be informed of such changes, which did not occur in this instance. The resident in question was a male with multiple health issues, including chronic obstructive pulmonary disease (COPD), heart disease, and diabetes, among others. His care plan indicated moderate cognitive impairment and a need for assistance with activities of daily living. The resident was oxygen-dependent due to COPD, and his usual oxygen level while sleeping was around 85%. Despite the drop in oxygen levels, RN A did not perceive any immediate respiratory distress, as the resident's breathing appeared normal. Interviews with RN A and the physician revealed that the facility's policy was not followed. The physician stated that he was not informed of the resident's oxygen level drop to 77%, which he considered significant enough to warrant notification. The facility's policy requires notifying the physician of significant changes in a resident's condition, which includes a major decline that would not resolve without intervention. This oversight could potentially delay necessary medical intervention and affect the resident's health.
Failure to Notify Physician and Responsible Party of Injury of Unknown Origin
Penalty
Summary
The facility failed to notify a resident's physician and responsible party in accordance with policy when an injury of unknown origin was discovered. During ADL care, a nurse identified a large area of purplish-blue discoloration on the resident's bilateral inner thigh, but the resident, who had severe cognitive impairment and multiple comorbidities including dementia, diabetes, and poor impulse control, could not explain the cause. The nurse documented the finding and informed the Assistant Director of Nursing (ADON), but did not notify the physician, responsible party, administrator, or Director of Nursing as required. Interviews revealed that the ADON was aware of the injury but assumed the nurse would complete all necessary notifications and documentation. The administrator was not informed of the injury until several days later, after returning from a holiday absence. The physician and responsible parties were only made aware of the injury after the resident was admitted to the hospital for unrelated treatment. Both responsible parties learned of the injury from sources outside the facility, and the physician was not notified until the resident was transferred to the hospital. The facility's policy required immediate reporting and notification of injuries of unknown origin to the appropriate parties, including the physician and responsible party. However, this process was not followed, resulting in a delay in communication and potential delay in medical intervention for the resident. The deficiency was identified through record review, staff and responsible party interviews, and review of facility policy.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner for a resident with multiple complex medical conditions, including dementia, diabetes, schizophrenia, and severe cognitive impairment. The resident, who required assistance with activities of daily living, was found to have a large area of purplish-blue discoloration on both inner thighs during ADL care. The resident was unable to explain the cause of the discoloration, and there was no open area noted. The injury was discovered and documented by an LVN, who informed the Assistant Director of Nursing (ADON) at the time. Despite the discovery of the injury, the required notifications to the administrator, DON, physician, responsible party, and the state agency were not made within the mandated 24-hour timeframe. The ADON, who was present when the injury was discovered, relied on the LVN to document and report the incident, but did not follow up to ensure that the notifications were completed. As a result, the administrator and DON were not informed of the injury until two days later, after the holiday period had ended, and the report to the Texas Health and Human Services was submitted late. A review of the facility's abuse and neglect reporting policy confirmed that staff are required to immediately report injuries of unknown origin to the appropriate parties and state agencies, in compliance with federal and state regulations. The failure to follow this policy resulted in a delay in reporting the incident, as the responsible staff member did not complete the necessary notifications and documentation as required.
Inaccurate Diagnosis in Resident Care Plan
Penalty
Summary
The facility failed to maintain accurate clinical records for a resident, as evidenced by an incorrect diagnosis of Parkinsonism included in the resident's care plan. The resident, a male with multiple diagnoses including Multiple Sclerosis, Major Depressive Disorder, and Bipolar Disorder, did not have Parkinsonism listed in his medical records or MDS assessments. Despite this, the care plan was updated to reflect limited physical mobility related to Parkinsonism, which was not a diagnosis the resident had. Interviews with facility staff, including the DON, Director of Therapy, MDS Nurse, and the resident's Nurse Practitioner, confirmed that the resident did not have a diagnosis of Parkinsonism. The MDS Nurse and other staff were unable to determine how the incorrect diagnosis was added to the care plan. The facility's policy on charting and documentation emphasizes the need for complete and accurate records, which was not adhered to in this case, potentially leading to incorrect care for the resident.
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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.
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Nursing homes near Richardson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Remington Transitional Care Of Richardson | 1.3 mi | ★★★★★ | 1 | 0 |
| The Plaza At Richardson | 1.6 mi | ★★★★★ | 3 | 0 |
| The Reserve At Richardson | 1.7 mi | ★★★★★ | 19 | 0 |
| Richardson Nursing And Rehabilitation | 2.2 mi | ★★★★★ | 7 | 0 |
| Legend Oaks Healthcare And Rehabilitation Garland | 2.4 mi | ★★★★★ | 4 | 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.