Above average — CMS composite of the measures below.
The next survey window likely opens 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 The Legacy At Willow Bend during CMS and state inspections, most recent first.
Improper Food Storage and Labeling in Kitchen: The kitchen had multiple food items in the refrigerator and freezer that were not dated, labeled, covered, or sealed appropriately. Observations found thawing meats, cheese, bacon, sweet potatoes, tater tots, carrots, and meat balls stored open or without required dates. The Dietary Manager, a Dietary Aide, and the Administrator all acknowledged that food items should be dated, covered, and sealed, and facility policy required proper dating and food handling.
A resident with an indwelling Foley catheter and dependence for transfers had the drainage bag placed on the bed above the bladder during a wheelchair-to-bed transfer. Staff observed urine flowing back toward the bladder, and both CNAs later acknowledged the bag should have remained below the bladder to prevent back flow and possible UTI.
A resident with throat cancer, dysphagia, and a G-tube had no physician orders for medication dilution or flush amounts between meds. During med pass, an LVN crushed and prepared multiple meds, used only about 2.5 cc of water per cup, gave the meds by gravity without flushing between them, and the tube became sluggish and clogged while omeprazole and duloxetine granules were being administered.
Failure to Prime Insulin Pens Before Administration: Two residents with DM2 received Humalog insulin from RNs who calculated the ordered doses and administered the injections without priming the insulin pens first. Both nurses stated they were supposed to prime the pen before each dose and forgot to do so. The DON confirmed priming was required before each injection and that failure to prime could result in the resident not receiving the prescribed amount of insulin.
The facility's kitchen failed to label and date food items in the freezer, and a dietary server did not use effective hair restraint, risking food contamination. The Dietary Manager acknowledged these issues, which violated the facility's policies and FDA Food Code standards.
The facility failed to provide necessary nail care for four residents, resulting in long and dirty fingernails. Despite staff being responsible for nail care, there was a lack of communication and awareness regarding the residents' needs. The DON expected nail care to be provided during shower times, but the facility's policy was not followed, leading to potential infection risks.
A facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy due to missing 'Oxygen in Use' signage on the resident's doorway. The resident, with conditions like congestive heart failure and acute respiratory failure, had orders for oxygen therapy. Staff interviews confirmed the absence of signage, which is required by facility policy, potentially compromising care quality and safety during emergencies.
A resident with a suprapubic catheter was at risk of infection when a CNA placed the catheter drainage bag above the bladder during wound care, causing urine backflow. Despite being trained, the CNA failed to follow the facility's policy of keeping the bag below the bladder. The resident, with neuromuscular bladder dysfunction, required extensive assistance, and the incident highlighted a lapse in adherence to proper catheter care procedures.
A facility failed to ensure proper pharmaceutical services, as observed with a medication cart where a resident's diazepam blister pack had broken seals and taped-over pills. RN B, responsible for the cart, did not check the blister packs during narcotic counts at shift changes. The DON stated that broken seals should lead to pill disposal, citing risks of drug diversion and infection control. The facility's policy required proper labeling and disposal of outdated drugs.
Two incidents of infection control lapses were observed in a facility. A CNA failed to perform proper hand hygiene during incontinence care for a resident, while another CNA did not wear a gown as required under Enhanced Barrier Precautions when assisting a resident with a Foley catheter. Both CNAs acknowledged their lapses, despite having received recent training. The facility's DON confirmed the expectations for infection control, highlighting a failure to consistently implement the program.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen reviewed for food and nutrition services. On observation in the walk-in refrigerator, boiled sweet potatoes covered in a baking tray had no date, one packet of bacon slices was left open without an open date, two packets of beef roast were thawing under plastic wrap without any date, and two packets of Swiss cheese slices wrapped in plastic wrap also had no date. In the walk-in freezer, about 30-40 frozen tater tots were left in an open brown bag, about a pound of frozen sliced carrots were left open in a cardboard box, and 20-30 frozen meat balls were left open in a brown box exposing them to frigid air. During interviews, the Dietary Manager stated that everyone in the kitchen was responsible for food storage, but cooks and he were ultimately responsible for covering and dating food items. He stated that foods should be appropriately dated, covered, and sealed, and that meats pulled from the freezer should have the date they were removed for thawing and a use-by date. A Dietary Aide stated all food items should be dated and covered appropriately and that foods out of their original packaging should have an open date. The Administrator stated all food in the kitchen should be dated and labeled and that cooks and the Dietary Manager were mainly responsible for it. Record review showed the facility policy required stock to be routinely dated when received, and the food handling policy stated food should be stored, prepared, handled, and served to minimize the risk of foodborne illness.
Improper Foley Catheter Positioning During Transfer
Penalty
Summary
The facility failed to ensure appropriate catheter care and services to prevent urinary tract infections for a resident with an indwelling Foley catheter. Resident #48 was an [AGE] year-old female admitted with diagnoses including hip fracture, obstructive uropathy, and muscle wasting, and she was dependent on staff for chair-to-bed transfers. Her care plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, and physician orders required Foley catheter care every shift for urinary retention. During an observed transfer from wheelchair to bed, CNA A and CNA B performed hand hygiene and wore PPE, but CNA B unhooked the catheter bag from the wheelchair and placed it flat on the bed above the resident’s bladder while the transfer was being completed. Urine was observed flowing back toward the resident’s bladder during the procedure. In interviews, CNA A stated the bag should always be kept below the bladder and that placing it above the bladder could cause urine to run backward and possibly cause infection. CNA B stated he should have emptied the drainage bag before transferring the resident to avoid back flow of urine and acknowledged that back flow could cause UTIs. The LVN and DON both stated the catheter bag and tubing should always remain below the bladder, including during transfers, and that failure to do so can increase the chance of infection.
G-tube Medication Administration Lacked Required Dilution and Flush Orders
Penalty
Summary
The facility failed to provide treatment and services to prevent complications of enteral feeding for one of two residents reviewed for feeding tubes. The resident was an [AGE]-year-old male admitted on 10/15/25 with a BIMS score of 13, indicating he was cognitively intact. His diagnoses included cancer of the oropharyngeal region and dysphagia, and he received 51% or more of his total calories through a feeding tube. His care plan stated he required tube feeding with Glucerna 1.5 bolus and Boost as ordered and that he would remain free of side effects or complications related to tube feeding. The physician order summary dated 12/03/25 included an enteral feed order and directed staff to flush the tube with 20-30 ml of water before and after each medication pass, but it did not include orders for the amount of water to dilute medications or the amount of water to flush between each medication. The medication administration record for December 2025 also did not indicate how much water to use for dilution or between medications. During observation of G-tube medication administration, the LVN prepared multiple crushed tablets and opened capsules, placed each medication in separate cups, and added approximately 2.5 ccs of water to each cup except the liquid hydrocodone-acetaminophen. The LVN then flushed the G-tube with 30 ccs of water and administered each medication by gravity without flushing with clear water between medications. When omeprazole and duloxetine granules were administered, the tube became sluggish and remained stuck in the tube. The LVN added 30 cc of water, milked the tube for approximately 15 minutes, withdrew medication from the tube twice, re-instilled it, and finally pushed approximately 10 cc of water through the tube to get the medication to progress. The LVN stated he diluted medications with 2.5 ccs of water and was supposed to flush before and after medication pass with 30 cc of water, and he acknowledged the orders did not specify dilution or flush amounts between medications. The DON, facility pharmacist, and administrator each stated that flushing between medications and proper dilution were important to prevent clogging, and the facility standards and guidelines required medications to be administered separately with flushing between medications and dilution of crushed and liquid medications.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring and administering of medications for two residents receiving Humalog insulin. Resident #73 was a female with a diagnosis of Type 2 diabetes and an order for Humalog KwikPen 100 units/mL, 5 units before meals plus sliding-scale insulin. During observation, RN G obtained a fingerstick blood sugar of 388, calculated a total dose of 16 units, retrieved the insulin pen, and dialed in the dose without priming the pen first before administering the insulin. Resident #72 was a female with a diagnosis of Type 2 diabetes and an order for Humalog KwikPen 100 units/mL, with sliding-scale dosing that resulted in 4 units for a blood sugar of 232. During observation, RN F obtained the blood sugar, calculated the dose, retrieved the insulin pen, and dialed in 4 units without priming the pen before administering the insulin. Both nurses stated they were supposed to prime the pen before each dose and acknowledged they forgot to do so. The DON stated the insulin pen was to be primed before each injection and that failure to do so could result in the resident not receiving the prescribed amount of insulin. The report also noted that nursing staff had competency checks upon hire and annually, and that the expectation was for staff to follow manufacturer guidelines for insulin pen administration. The manufacturer instructions reviewed stated to prime before each injection and that failure to do so may result in too much or too little insulin being delivered.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, food items in the facility's walk-in freezer were not labeled or dated, which is a critical step in ensuring food safety and preventing food-borne illnesses. Observations revealed that various food items, including meat, Brussels sprouts, potato fries, and sweet potato fries, were stored in clear plastic bags without any labeling or use-by dates. This lack of proper labeling and dating was acknowledged by the Dietary Manager, who stated that it was the responsibility of all kitchen staff, including cooks, dietary aides, and the Food Service Manager, to ensure food items were appropriately labeled and dated. Additionally, the facility did not ensure that all dietary staff adhered to proper hygiene practices, as evidenced by Dietary Server G's failure to use an effective hair restraint while serving breakfast. Observations showed that her bangs and the hair at the back of her head were not secured under the hair restraint, which could lead to food contamination. Dietary Server G admitted that her hair net might have moved, resulting in her hair being exposed. The Dietary Manager confirmed that it was expected for all dietary staff to wear hair restraints effectively to prevent hair from contacting food, clean equipment, and utensils. The facility's policies, including 'Good Hygienic Practices for Food Service Employees' and 'Stock Dating,' were not followed, as evidenced by the lack of hair restraint and improper labeling and dating of food items. These policies are in place to ensure food safety and hygiene, as outlined by the Food and Drug Administration Food Code. The Dietary Manager acknowledged that in-services had been provided to kitchen staff regarding these practices, yet the deficiencies were still observed during the survey.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in four residents who had long and dirty fingernails, which were not cleaned or trimmed as required. The residents involved had varying degrees of cognitive impairment and required assistance with personal hygiene. For instance, one resident with moderate cognitive impairment expressed a desire for nail care, which was not offered during his stay. Another resident, with severe cognitive impairment, had long and dirty nails, and the private sitter did not inform the facility staff about the need for nail care. The facility's staff, including CNAs and nurses, were responsible for providing nail care, especially for diabetic residents. However, there was a lack of communication and awareness among the staff regarding the residents' needs for nail care. Interviews with staff members revealed that nail care was typically performed during shower times, but there were no specific days designated for this task. The staff acknowledged the risk of infection associated with not performing regular nail care, yet failed to ensure that the residents received the necessary attention. The Director of Nursing (DON) stated that nail care should be provided as needed, particularly during shower times, and that CNAs were responsible for this task unless the resident had diabetes. Despite this expectation, the facility's policy on personal care, which included daily cleaning and regular trimming of nails, was not adhered to. The lack of routine monitoring and communication among staff members contributed to the oversight in providing adequate nail care for the residents, potentially leading to infection control issues and skin breakdown.
Failure to Provide Appropriate Respiratory Care Due to Missing Oxygen Signage
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as evidenced by the absence of 'Oxygen in Use' signage on the resident's doorway. The resident, an elderly male with multiple health conditions including congestive heart failure and acute respiratory failure, was admitted to the facility with orders for oxygen therapy to maintain oxygen saturation above 92%. Despite these orders, the necessary signage to indicate oxygen use was not placed on the resident's door, which is a requirement according to the facility's policy. Interviews with staff, including an LVN and the Director of Nursing (DON), confirmed that the signage was missing and acknowledged the importance of such signage for ensuring quality care and safety. The LVN, who was new to working with the resident, noted that the absence of signage could lead to decreased quality of care. The DON emphasized that the lack of signage could pose risks during emergencies or evacuations, as staff might not be aware of the resident's dependency on oxygen therapy. The facility's policy clearly states that signage should be placed on the doorway of rooms where oxygen is in use, highlighting a lapse in adherence to established protocols.
Improper Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a risk of urinary tract infections. During a wound care procedure, a CNA placed the resident's catheter drainage bag on the bed, above the bladder level, causing urine to flow back towards the bladder. This action was contrary to the facility's policy, which requires the catheter bag to be positioned below the bladder to prevent backflow and potential infection. The resident involved was an elderly female with neuromuscular dysfunction of the bladder, requiring extensive assistance for mobility and transfer. Interviews with the staff involved revealed that both the RN and CNA were aware of the proper procedure for catheter care but failed to adhere to it during the incident. The CNA admitted to being trained to keep the catheter bag below the bladder but could not explain why she placed it on the bed. The DON confirmed that not maintaining the correct position of the catheter bag could lead to urinary tract infections and stated that the facility conducts skills competency checks to ensure staff are knowledgeable in catheter care.
Failure in Medication Security and Handling
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the handling and securing of medications. During an observation of Nurses Cart Hall 500, it was found that the blister pack for a resident's diazepam 5 mg tablets had six broken seals, with the pills still inside the blisters taped over. RN B, responsible for the medication cart, acknowledged that the narcotic count was done at shift change, but she did not check the blister packs during the count. She was unaware of when the blister pack seals were broken or who might have damaged them and taped them over. RN B stated that the nurses and medication aides were responsible for checking the medication blister packs for broken seals during the narcotic count at shift change. The Director of Nursing (DON) stated that if a blister pack medication seal was broken, the pill should be discarded, and it was unacceptable to keep a pill in an opened blister pack. The DON highlighted the potential risks of drug diversion and infection control issues. The facility's policy on the storage of medication indicated that drug containers with missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storing, and discontinued, outdated, or deteriorated drugs should be returned to the dispensing pharmacy or destroyed. The DON also mentioned that the Assistant Director of Nursing (ADON) and the DON were supposed to check the carts weekly for monitoring.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two separate incidents involving residents. In the first incident, a Certified Nursing Assistant (CNA) failed to perform proper hand hygiene while providing incontinence care to a resident. The CNA did not change gloves or sanitize hands after removing a dirty brief and before applying a clean one, which is a breach of infection control protocols. The CNA acknowledged the lapse in hand hygiene and stated that he had received training on the importance of hand hygiene two months prior. In the second incident, another CNA did not wear appropriate Personal Protective Equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions due to the presence of a Foley catheter and oxygen use. Although the CNA performed hand hygiene and donned gloves, she failed to wear a gown while assisting the resident with a transfer, which involved direct contact. The CNA admitted to not being familiar with the resident's care requirements and recognized that her actions constituted a lapse in infection control. Both incidents were observed and reported by the Director of Nursing (DON), who also serves as the facility's infection preventionist. The DON confirmed that staff are expected to adhere to infection control protocols, including hand hygiene and the use of PPE during high-contact care activities. The facility had conducted recent in-service training on these topics, but the lapses observed indicate a failure to consistently implement the infection control program, thereby placing residents at risk of infection.
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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) |
|---|---|---|---|---|
| Stonemere Rehabilitation Center | 3.2 mi | ★★★★★ | 3 | 0 |
| Accel At Willow Bend | 3.3 mi | ★★★★★ | 24 | 0 |
| Prestonwood Rehabilitation & Nursing Center Inc | 4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Plano | 4.1 mi | ★★★★★ | 2 | 0 |
| Landmark Of Plano Rehabilitation And Nursing Cente | 4.3 mi | ★★★★★ | 19 | 0 |
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