Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 The Healthcare Resort Of Plano during CMS and state inspections, most recent first.
A resident with a stage IV pressure ulcer, severe cognitive impairment, and dependence on staff for repositioning was not repositioned as required by her care plan and physician orders during a morning shift. Staff interviews and record review confirmed that the resident was left in the same position for an extended period, contrary to the facility's protocols for repositioning bedbound residents every two hours to prevent further skin breakdown.
A resident with hypertension and chronic kidney disease experienced a medication error due to incorrect transcription of a pharmacist's order. The facility staff continued administering the resident's home medication instead of the prescribed Losartan/HCTZ, due to a lack of communication and verification processes. This error involved multiple nursing staff and highlighted issues in the facility's medication administration procedures.
A resident with a high risk of wandering eloped from the facility after a contractor inadvertently allowed them to exit through a side door. The resident, who had a history of cognitive impairments and wandering behaviors, was found unsupervised across a major roadway. The facility failed to ensure the contractor was aware of the resident's elopement risk, leading to the incident.
A facility failed to document post-dialysis assessments for a resident with ESRD, despite having a care plan in place. Interviews with staff revealed a lack of awareness and oversight regarding the completion of dialysis communication forms and vital sign documentation. The facility's policy emphasized the importance of maintaining homeostasis and communication, which was not followed.
The facility failed to provide adequate pharmaceutical services, with LVNs not documenting narcotic administration timely, leading to potential medication errors and drug diversion. Discrepancies in narcotic logs and improper labeling of Lidocaine patches and IV medications were observed, risking overdosing and infection control issues.
The facility failed to store and label medications properly, as required by law. Two residents had medications left unsecured at their bedsides, despite not being assessed for self-administration. Additionally, a medication cart was found unlocked and unattended. These actions violated the facility's policies and posed risks to resident safety.
An LVN failed to disinfect a blood pressure cuff and insulin pen tips between residents during a medication pass, leading to a deficiency in the facility's infection prevention and control program. The involved residents had various medical conditions, including elevated blood pressure, fractures, and end-stage renal disease. The DON confirmed the expectation for staff to disinfect shared items between residents, which was not followed despite prior training.
A resident with a hearing deficit did not have this need addressed in her care plan, despite using a phone app to communicate. Staff interviews confirmed the oversight, and the DON acknowledged the care plan should have included this information. The facility's policy mandates comprehensive care plans, but this was not followed.
Failure to Reposition Bedbound Resident with Pressure Ulcer as Required
Penalty
Summary
The facility failed to ensure that a resident with a stage IV pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident, who had severe cognitive impairment and was dependent on staff for repositioning, was not repositioned as required by her care plan and physician orders during a morning shift. Both CNA A and CNA B, who were involved in the resident's care that day, confirmed that the resident was not repositioned until approximately 2:30 PM, despite the expectation and care plan directive for repositioning at least every two hours. Record review indicated that the resident had a history of pressure ulcers, severe protein-calorie malnutrition, and required two-person assistance for repositioning. The care plan and physician orders specified frequent repositioning and the use of mobility bars to aid in turning. Interviews with staff, including the charge nurse, ADON, and DON, confirmed that the standard practice was to reposition bedbound residents every two hours to prevent further skin breakdown and deterioration of existing wounds. However, on the day in question, the resident remained in the same position for an extended period, and staff did not follow the established protocols. Observations and interviews revealed that the resident was found in bed with a wound vac in place and had not been repositioned according to her care plan. Staff interviews indicated a lack of communication and follow-through regarding the resident's repositioning needs, with both CNAs and the charge nurse unaware that the resident had not been repositioned during the morning shift. The facility's policy required that residents' abilities in activities of daily living not deteriorate unless unavoidable, but this standard was not met in this instance.
Medication Transcription Error Leads to Incorrect Administration
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for a resident, leading to a medication error. The resident, who had a history of primary hypertension, hypertensive urgency, and stage 3 chronic kidney disease, was prescribed a medication change from Irbesartan/HCTZ 300-12.5 mg to Losartan/HCTZ 100-12.5 mg. However, the order was incorrectly transcribed as Losartan 300 mg and Hydrochlorothiazide 12.5 mg, and the resident continued to receive the home medication of Irbesartan/HCTZ 300-12.5 mg instead of the prescribed Losartan/HCTZ. Multiple nursing staff, including LVNs and an RN, documented administering the incorrect medication from the resident's home supply over several days. The error was compounded by a lack of communication and verification processes, as the facility's pharmacy did not have the prescribed combination and performed a therapeutic interchange without proper notification and approval from the facility. The nursing staff failed to follow the correct procedures for medication administration, including verifying the medication against the MAR and obtaining necessary approvals for home medications. Interviews with facility staff, including the DON, ADON, and NP, revealed a breakdown in communication and adherence to medication administration policies. The facility allowed residents to bring home medications, but the process for verifying and approving these medications was not consistently followed. The pharmacy's therapeutic interchange was not effectively communicated to the facility, leading to continued administration of the incorrect medication. This deficiency in pharmaceutical services posed a risk of medical complications for the resident due to potential discrepancies in therapeutic dosages.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident identified as being at high risk for wandering. On the day of the incident, a contractor working on the facility's air conditioning system inadvertently allowed the resident to exit through a side door without notifying the staff. The resident was later found unsupervised across a major roadway by facility staff. This incident occurred despite the resident's care plan indicating a need for supervision and structured activities due to cognitive impairments and a history of wandering. The resident had been admitted to the facility with a traumatic brain injury, including subdural and subarachnoid hemorrhages, which contributed to cognitive impairments and wandering behaviors. Prior to the incident, the resident had been assessed multiple times for elopement risk, with scores indicating a high risk. Progress notes documented the resident's restlessness, confusion, and attempts to leave the facility, highlighting the need for close supervision and intervention. The facility's failure to ensure the contractor was aware of the resident's elopement risk and the need for supervision led to the resident's unsupervised exit. The incident report noted that the contractor, trying to be helpful, used his badge to let the resident out, unaware of the potential risk. This lapse in communication and supervision placed the resident at risk for serious injury, as evidenced by the resident being found across a busy roadway.
Failure to Document Post-Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate post-dialysis care, consistent with professional standards of practice. Specifically, the facility did not complete post-dialysis assessments for a resident after returning from dialysis treatment. The resident, a male with a BIMS score of 15 indicating no cognitive impairment, had multiple diagnoses including metabolic encephalopathy and chronic pancreatitis, and required hemodialysis due to end-stage renal disease (ESRD). Despite having a care plan that outlined necessary interventions and monitoring post-dialysis, the facility's electronic health records showed no documentation of the resident's post-dialysis vital signs. Interviews with facility staff, including an LVN, the ADON, and the DON, revealed a lack of awareness and oversight regarding the completion of dialysis communication forms and post-dialysis vital sign documentation. The LVN responsible for the resident's care admitted to being unaware that the post-dialysis vitals were not documented, although he assured that the vitals were taken. Both the ADON and DON expressed expectations for nurses to complete and submit these forms, but they were not aware that this was not being done. The facility's policy on dialysis care emphasized the importance of maintaining homeostasis and ongoing communication with the dialysis facility, which was not adhered to in this case.
Inadequate Pharmaceutical Services and Documentation Failures
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by the improper documentation and handling of narcotic medications by the nursing staff. Licensed Vocational Nurse (LVN) D did not document the administration of narcotic medications in a timely manner for several residents, including those receiving Tramadol, Hydrocodone-Acetaminophen, and Lidocaine patches. This failure to document immediately after administration was against the facility's policy and could lead to medication errors, drug diversion, and delays in medication administration. Additionally, discrepancies were found in the narcotic administration records for other residents. The narcotic logs did not match the actual count of medications in the blister packs, indicating a lack of proper documentation and potential for narcotic diversion. LVN F admitted to administering medications without signing off on the narcotic administration record, which could result in inaccurate narcotic counts and potential medication errors. Furthermore, the facility failed to ensure that Lidocaine patches and intravenous medications were properly labeled with the date, time, and initials of the administering nurse. This oversight was observed in multiple residents, including those with Lidocaine patches and intravenous medications. The lack of labeling could lead to overdosing, skin irritation, and infection control issues, as the staff would not be able to accurately track the duration of medication application or administration.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and labeled according to professional principles, as required by State and Federal laws. This deficiency was observed in the cases of two residents and one medication cart. Resident #143, a newly admitted elderly female with a diagnosis of primary open-angle glaucoma, had her Brimonidine Tartrate Ophthalmic Solution and Restasis Ophthalmic Emulsion left unsecured at her bedside. Despite having no care plan for self-administration, these medications were not stored in the medication cart or room as required. Similarly, Resident #146, an elderly female with intact cognition and a diagnosis of allergic rhinitis and chronic kidney disease, had Fluticasone Propionate Nasal Spray and Potassium Chloride tablets left on her bedside table. The resident reported that the nurse left the medications there, and she did not take all the pills provided. The nurse admitted to not supervising the medication administration properly, which is against the facility's policy. Additionally, a medication cart in the West Hall was found unlocked and unattended, posing a risk of unauthorized access to medications. The nurse responsible for the cart acknowledged forgetting to lock it, despite being aware of the policy requiring medication carts to be locked when not in use. The Director of Nursing confirmed that neither resident had been assessed for self-administration, and the facility's policies on medication storage and labeling were not followed.
Infection Control Deficiency Due to Inadequate Equipment Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN D during a morning medication pass. LVN D did not perform hand hygiene or disinfect the blood pressure cuff between residents, specifically when checking the blood pressure of three residents. Additionally, LVN D failed to disinfect the insulin pen tips before administering insulin to one of the residents. These actions were observed during the medication pass and were confirmed through interviews with LVN D, who admitted to not disinfecting the equipment between residents due to being focused on passing medication. The residents involved included a male with elevated blood pressure and vertebral fractures, a female with a displaced femur fracture and severe cognitive impairment, and a male with end-stage renal disease and lumbar vertebra fracture. The Director of Nursing (DON) confirmed that the expectation was for staff to disinfect shared items between residents to prevent contamination and infection spread. Despite having attended training on infection control, LVN D did not adhere to the facility's infection prevention and control policy, which mandates effective cleaning and disinfecting of equipment between each resident use.
Failure to Address Hearing Deficit in Resident's Care Plan
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, identified as Resident #194, who had a hearing deficit. Despite the resident's admission record indicating unspecified bilateral hearing loss, the care plan did not address this issue. The resident, who had a BIMS score of 14 indicating no cognitive impairment, used a phone app to convert spoken words into text for communication. This method was her preferred way to communicate with staff and others, yet it was not documented in her care plan. Interviews with staff, including an LVN and the DON, confirmed the resident's hearing deficit and her use of the phone app for communication. The DON acknowledged that the care plan should have included this information and noted that the facility uses an interdisciplinary team (IDT) approach for care plans. However, there was uncertainty about who was responsible for ensuring the care plan included the resident's hearing needs. The facility's policy requires the IDT to develop comprehensive care plans that address all identified needs, but this was not adhered to in this case.
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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 Plano
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Care At Highland Springs | 1 mi | ★★★★★ | 6 | 2 |
| Landmark Of Plano Rehabilitation And Nursing Cente | 1 mi | ★★★★★ | 19 | 0 |
| Life Care Center Of Plano | 1.3 mi | ★★★★★ | 2 | 0 |
| Carrara | 1.6 mi | ★★★★★ | 6 | 0 |
| The Hillcrest Of North Dallas | 1.6 mi | ★★★★★ | 1 | 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.