Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Park In Plano during CMS and state inspections, most recent first.
Food items in the kitchen were found unlabeled and undated during survey observation, including chicken strips and frosting in the freezer and sliced toast in the prep area. The DM stated he was responsible for labeling and dating items and had overlooked them, and the ADM stated all food in the freezer was expected to be labeled and dated.
Failure to perform hand hygiene during incontinence care: A CNA provided peri-care to a resident with urinary and bowel incontinence, HF, ESRD, and DM, but repeatedly changed gloves without performing hand hygiene after cleaning the resident, applying barrier cream, and placing a clean brief. The CNA stated he forgot, while the IP and DON confirmed staff were expected to perform hand hygiene after glove changes and had received training on the process.
A cognitively impaired male resident with multiple comorbidities, fully dependent for several ADLs, was under the care of a private sitter from an outside agency. The sitter reported that when the resident began to act inappropriately by attempting to expose his genitals in a common area, she used her hand to tap or hit him to stop the behavior. An LVN heard a sound like a slap, observed the sitter’s arm extended toward the resident’s hand, and was told by the sitter that she had hit the resident’s hand to prevent him from touching his genitals. A bruise was later documented on the resident’s left hand, and imaging showed no fracture. The facility’s policies require that residents be free from abuse and that private sitters follow all facility policies, but the sitter’s actions resulted in physical abuse of the resident.
A resident with severe cognitive impairment and multiple comorbidities experienced two falls, including one with major injury, but the care plan was not updated to reflect these incidents or add new interventions. Staff interviews confirmed the care plan remained unchanged despite facility policy requiring updates after such events.
Two residents did not receive their prescribed medications within the required one-hour window before or after the scheduled times due to a Charge Nurse being short-staffed and responsible for more residents than usual. The late administration affected multiple medications, including those for hypertension, pain, infection, and nutritional supplementation. Staff interviews confirmed the delay was not typical practice and was linked to staffing shortages and increased workload.
A Charge Nurse failed to sanitize a blood pressure cuff and pulse oximeter between use on two residents, one with multiple chronic conditions and another with Alzheimer's disease. The equipment was used on both individuals without cleaning, contrary to facility policy and infection control expectations, as confirmed by interviews with nursing leadership and the administrator.
The facility failed to ensure a safe, clean, and homelike environment in five resident rooms, where air conditioning units were found with dirt-filled vents, and walls and refrigerators had visible stains. The new Housekeeping Supervisor and staff acknowledged the issues, which posed a risk of infection if not addressed.
A LTC facility failed to maintain an effective infection control program, with staff not adhering to hand hygiene and equipment sanitation protocols. Incidents included a CNA not performing hand hygiene before care, an LVN bringing a container of test strips into a resident's room, and another LVN not sanitizing a stethoscope or blood pressure cuff before use. These actions were recognized by staff as potential causes of cross-contamination and infection.
The facility failed to provide adequate personal hygiene care for residents unable to perform activities of daily living. A resident did not receive proper podiatry care, resulting in long and crusty toenails. Two other residents were found with long and dirty fingernails, with no documented attempts or refusals for nail care. Staff interviews revealed expectations for nail care during showers or when dirty nails were observed, but inconsistent monitoring and documentation led to the deficiency.
The facility's kitchen failed to meet food safety standards, with issues such as improper labeling of food items, unsealed frozen sausages, and an unclean ice machine. Additionally, a trash can in the kitchen was left uncovered, increasing contamination risks. The Dietary Manager acknowledged these issues, which were observed during a survey.
A resident with incontinence received improper perineal care from a CNA, who cleaned the area using wipes in a manner that did not follow the facility's policy of wiping from front to back. This improper technique, acknowledged by the CNA and confirmed by the DON, could lead to urinary tract infections.
A resident with a G-tube for dysphagia did not receive proper care during medication administration. The LVN failed to flush the G-tube before, between, and after medications, and did not clean the syringe used, risking infection and other complications. The facility's policy and physician orders were not followed, as confirmed by interviews with the LVN and DON.
A resident with coronary heart disease and an amputation required oxygen therapy, but the nasal cannula was improperly stored, risking infection. Staff confirmed the need for proper storage to prevent contamination, aligning with facility policy.
A facility failed to include weekly psychological services in a resident's care plan, despite physician orders and the resident's PTSD diagnosis. The MDS nurse and DON confirmed the oversight, acknowledging the care plan should have reflected these services to ensure appropriate care.
The facility failed to develop comprehensive care plans for two residents, one with acute respiratory failure and another with dementia and respiratory failure. Both residents lacked care plans for oxygen therapy, and one also lacked a plan for droplet precautions despite having physician orders and being on precautions. The absence of the MDS Nurse contributed to these deficiencies, as confirmed by the DON.
Two residents in the facility were found with their call lights out of reach, which could prevent them from obtaining assistance when needed. One resident, with severe cognitive impairment and a history of falls, had his call light on the floor, while another resident, with moderate cognitive impairment and hemiplegia, also had her call light out of reach. Staff acknowledged the importance of accessible call lights, but the facility lacked a specific policy, contributing to the deficiency.
A resident with moderate cognitive impairment and requiring total assistance for ADLs did not receive scheduled showers three times a week, as documented by only five shower sheets for the month. Staff interviews confirmed the inconsistency, and the resident expressed concerns about not receiving adequate hygiene care, posing risks of skin breakdown and infection.
A resident was observed serving herself hot coffee from an unsecured station, posing a burn risk. The facility relied on kitchen staff to check coffee temperatures, but nursing staff did not verify it. The policy allowed for coffee at 140 degrees, but no staff was present to supervise residents with coordination issues during the incident.
The facility failed to provide proper respiratory care for two residents. One resident's nasal cannula was improperly stored without being bagged, while another resident's oxygen concentrator lacked a humidification bottle, contrary to physician orders. These oversights were observed during a survey, and staff acknowledged the issues, emphasizing the importance of proper storage and monitoring to prevent respiratory infections and ensure effective oxygen therapy.
A resident was left with medications unattended by an LVN, contrary to facility policy. The resident, who was cognitively intact, had a care plan that did not allow for self-administration of medications. The facility's policy requires licensed personnel to ensure medications are taken before leaving the room, which was not followed in this instance.
A facility failed to maintain an effective Infection Prevention and Control Program when a CNA did not follow proper hand hygiene and glove-changing protocols during incontinent care for a resident with severe cognitive impairment. The CNA did not wash hands before care, failed to change gloves after touching soiled items, and did not perform hand hygiene before applying cream. Interviews with facility staff confirmed the expectation for adherence to infection control policies, highlighting the risk of cross-contamination and infection.
A resident with hypertension in an LTC facility received blood pressure medications outside of prescribed parameters multiple times, without proper documentation or physician notification. The DON was unaware of these errors, and the facility's medication administration policy lacked guidance on adhering to physician orders.
A resident with cognitive decline and difficulty swallowing was assisted with feeding by an LVN who stood over her due to a lack of available seating. This action was identified as a failure to maintain resident dignity, as staff should be seated while assisting residents during meals, according to the facility's policy on resident rights.
Food Items Found Unlabeled and Undated in Kitchen Storage Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen. During an observation on 04/07/2026 at 9:35 a.m., surveyors found a plastic bag of chicken strips in the freezer that was not labeled or dated, a bag of frosting in the freezer that was not labeled or dated, and a plastic bag with 6 slices of toast in the prep area that was not labeled or dated. In an interview on 04/09/2026 at 10:24 a.m., the Dietary Manager stated he was responsible for making sure all items were labeled and dated and said he must have overlooked those items. He stated the risk to residents was that they could get sick. In an interview on 04/09/2026 at 11:05 a.m., the Administrator stated he expected all food in the freezer to be labeled and dated and said the risk to the resident was that something could be past its date and someone could risk getting sick. The facility policy stated open packages of food are to be stored in closed containers or sealed bags and dated when opened, and food must be covered when stored with a date label identifying what is in the container.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident reviewed for infection control. During observation of incontinence care for a resident with heart failure, end-stage kidney disease, and diabetes, who was frequently incontinent of urine and always incontinent of bowel, CNA A prepared supplies, positioned the resident, cleaned the resident's penis and scrotum, changed gloves, and did not perform hand hygiene. CNA A then cleaned bowel movement from the resident, changed gloves, and again did not perform hand hygiene. The observation continued as CNA A applied barrier cream to the buttocks and peri-area, changed gloves, and did not perform hand hygiene, then placed a clean brief, changed gloves, and did not perform hand hygiene before fastening the brief. In interview, CNA A stated he was supposed to perform hand hygiene when he changed gloves and said he did not do it because it slipped his mind. The Infection Preventionist and DON both stated staff were supposed to perform hand hygiene after glove changes and had completed hand hygiene training in March 2026. The facility policy stated hand hygiene is the primary means of preventing transmission of infection and is required after removing gloves.
Failure to Protect a Cognitively Impaired Resident From Physical Abuse by a Private Sitter
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a private sitter. The resident was an elderly male with diagnoses including urinary neoplasm, dementia, chronic kidney disease, and an aortic aneurysm. His MDS documented severe cognitive impairment with a BIMS score of 4, no history of verbal or physical behavioral symptoms toward others, no rejection of care, and total dependence on staff for toileting, showers, and lower body dressing, using a walker and/or wheelchair for mobility. On the day of the incident, the private sitter, employed through an outside agency, brought the resident to a common living area where other residents were watching a movie. According to the sitter’s written statement, the resident began to act inappropriately by attempting to expose his penis, and she responded by using her hand to “tap on him” to stop the behavior. She acknowledged in her statement that she was told to leave the facility because staff felt it was wrong for her to hit the resident’s hands. An LVN reported that while passing by the resident and the private sitter in the hallway, she heard an audible pop similar to a slap, then observed the sitter’s arm extended toward the resident’s hand. When questioned, the sitter told the LVN she had hit the resident’s hand to prevent him from touching his genitals. The social worker reported hearing what sounded like a slap and then learning from the LVN that the sitter had hit the resident. Subsequent nursing documentation noted a bruise on the top of the resident’s left hand, and an x-ray of the left arm showed no fracture or dislocation. The facility’s abuse/neglect policy and private sitter policy state that residents have the right to be free from abuse and that sitters must uphold all facility policies and procedures, but the sitter’s actions constituted physical abuse toward the resident.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following two separate falls, one of which resulted in a major injury. Despite the resident's history of Alzheimer's disease, diabetes, lumbosacral disc degeneration, and atherosclerotic heart disease, and a recent assessment indicating severely impaired cognition and a fall with major injury, the care plan was not updated to reflect the two recent falls. The care plan, last revised prior to the incidents, did not include new interventions or revisions after the falls occurred. Interviews with facility staff, including the Interim MDS Coordinator and the DON, confirmed that the care plan was not updated after the falls, even though facility policy and staff statements indicated that care plans should be revised following such events. The staff noted that all standard fall risk interventions were already in place and expressed uncertainty about what additional interventions could be added. The facility did not have an acute care plan policy, and the lack of timely care plan updates after significant changes in the resident's condition constituted the deficiency.
Failure to Administer Medications Within Required Time Frame Due to Staffing Shortages
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for two of three residents reviewed. Specifically, the Charge Nurse did not administer multiple prescribed medications to two residents within the required one-hour window before or after the scheduled medication times. This included medications such as ascorbic acid, carvedilol, prostat, calcium acetate, and robaxin for one resident, and ciprofloxacin and gabapentin for another. The late administration was confirmed through observation, record review, and interviews with staff. The residents involved had complex medical histories, including conditions such as osteomyelitis, morbid obesity, chronic respiratory failure, end stage renal disease, hypertension, pain, acute heart failure, COPD, depression, and neuropathy. The medication administration records and physician orders indicated specific times for medication administration, which were not adhered to on the morning in question. The Charge Nurse acknowledged that the medications were administered late, as indicated by the red color coding in the electronic medication administration system, and attributed the delay to being short-staffed and having a higher resident load than usual. Interviews with the Charge Nurse, Assistant Director of Nursing, Director of Nursing, and Administrator revealed that the late medication administration was not standard practice and that the facility was experiencing staffing shortages at the time. The staff confirmed that the protocol required medications to be administered within one hour of the scheduled time, and that the delay was due to increased workload and lack of timely communication regarding the need for assistance. The facility's policy on medication administration emphasized adherence to the five rights of medication, including the right time, to maximize therapeutic effectiveness.
Failure to Sanitize Reusable Equipment Between Residents
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices when a Charge Nurse did not sanitize a blood pressure cuff and pulse oximeter between use on two residents. Specifically, after taking the vital signs of one resident with multiple diagnoses including acute heart failure, COPD, and hypertension, the Charge Nurse placed the equipment back on the medication cart without sanitizing it. She then used the same unsanitized equipment to check the vital signs of another resident diagnosed with Alzheimer's disease, hypothyroidism, and hypertension. Interviews with the Charge Nurse, Assistant Director of Nursing, Director of Nursing, and Administrator confirmed that the expectation and facility policy require sanitizing reusable equipment between residents. The Charge Nurse admitted to forgetting this step and acknowledged the risk of cross-contamination. The facility's infection control policy, last revised in March 2024, specifies that reusable equipment must be appropriately cleaned and disinfected to prevent the transmission of disease and infection.
Facility Fails to Maintain Clean and Safe Environment in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in five of the twelve rooms reviewed. Observations revealed that the air conditioning units in these rooms had vents filled with black and brown dirt debris. Additionally, one room had a unit cover separating from the wall with visible dirt and grime, and dark stains were noted on the wall near a wastebasket. Another room had dark stains on the wall alongside the resident's bed, and reddish stains were found inside the mini fridge. Interviews with the housekeeping staff and the administrator confirmed the issues. The Housekeeping Supervisor, who was new to the facility, acknowledged the concerns and planned to address them with his staff. The Housekeeping/Laundry Aid confirmed responsibility for cleaning the walls, air conditioning units, and refrigerators in resident rooms. The administrator, upon reviewing the pictures of the deficiencies, recognized the potential risk of infection if these issues were not addressed. The facility's policy on general cleaning emphasized maintaining cleanliness and an odor-free environment, which was not adhered to in this instance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple instances of non-compliance with hand hygiene and equipment sanitation protocols. One incident involved a CNA who did not perform hand hygiene before providing care to a resident who was vomiting, despite acknowledging the importance of hand hygiene in preventing infections. Another incident involved an LVN who brought a whole container of test strips into a resident's room, which she later admitted could lead to cross-contamination. Further deficiencies were observed with another LVN who failed to sanitize the diaphragm of a stethoscope before checking a resident's g-tube placement. Additionally, this LVN did not sanitize the blood pressure cuff or perform hand hygiene before administering medications to several residents. These actions were acknowledged by the LVN as potential causes of cross-contamination and infection. Another CNA failed to change gloves and perform hand hygiene while providing incontinent care to a resident. The CNA admitted to not changing gloves before touching a new brief, which she recognized as a lapse in infection control practices. The facility's Director of Nursing and Administrator acknowledged these issues, emphasizing the importance of hand hygiene and equipment sanitation in preventing infections.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate care for residents who were unable to perform activities of daily living, specifically in maintaining good personal hygiene. Resident #11, a male with moderate cognitive impairment and dependent on staff for personal hygiene, did not receive proper podiatry care. Observations revealed that his toenails were long with a thick crust, indicating a lack of regular foot care. Despite the nursing staff's responsibility to monitor and ensure the resident's feet were manicured to prevent infection, no podiatry appointment was scheduled until after the issue was identified by a staff member. Residents #27 and #29, both with severe cognitive impairments and dependent on staff for personal hygiene, were found with long and dirty fingernails. Resident #27, who had hemiplegia and hemiparesis, showed no documented attempts or refusals for nail care in his progress notes. During an incident where Resident #27 was vomiting, staff failed to notice his unkempt nails. Similarly, Resident #29, who had Parkinsonism, was observed with dirty nails containing a black substance, with no documented attempts or refusals for nail care. Interviews with staff, including CNAs and the DON, revealed that nail care was expected to be performed during showers or when dirty nails were observed. However, there was a lack of consistent monitoring and documentation of nail care for these residents. The DON acknowledged that long and dirty nails could lead to infections and affect residents' dignity, emphasizing the need for staff to ensure proper nail care. Despite these expectations, the facility's failure to provide necessary services for personal hygiene was evident in the conditions of the residents' nails.
Food Safety and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specific deficiencies included the improper labeling of food items stored in the refrigerator and freezer, where items such as cooked meat, tortillas, pie shells, and French bread lacked the necessary month, date, and year labels. Additionally, a large box of frozen sausages was found unsealed, exposing it to airborne contaminants. These lapses in labeling and sealing could lead to cross-contamination and foodborne illnesses among residents. Further observations revealed that the ice machine in the dining area was not adequately cleaned, with visible white and brown dirt stains inside the door and black dirt on a plastic piece above the ice. Moreover, a large trash can containing food and trash in the kitchen area was left uncovered, increasing the risk of airborne contamination. Interviews with the Dietary Manager (DM) and the Administrator confirmed awareness of these issues, with the DM acknowledging the need for more frequent cleaning and proper labeling practices. The facility's policy and FDA guidelines emphasize the importance of proper food storage and labeling to prevent contamination, which were not followed in this instance.
Improper Perineal Care Technique Observed
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, which could lead to urinary tract infections. The resident, an elderly female with a diagnosis of generalized muscle weakness and moderate cognitive impairment, was observed receiving improper perineal care from a CNA. The CNA cleaned the resident's perineal area using wipes in a manner that did not adhere to the facility's policy of wiping from front to back, which is essential to prevent contamination and infection. During the observation, the CNA was seen cleaning the resident's perineal area from back to front, then front to back, and back to front again, using the same wipes. This improper technique was acknowledged by the CNA, who admitted that the correct method was to clean from front to back to avoid transferring germs from the rectal area to the urethral area. The Director of Nursing confirmed that the improper cleaning technique could lead to urinary tract infections, and the facility's policy clearly outlined the correct procedure to prevent such infections.
Failure to Follow G-Tube Medication Administration Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a gastrostomy tube (G-tube). The resident, a male with severe cognitive impairment and diagnosed with dysphagia, required tube feeding. The facility's failure was observed during a medication administration process where the Licensed Vocational Nurse (LVN) did not follow proper procedures for flushing the G-tube before, between, and after administering medications. The LVN also failed to clean the syringe used for medication administration, which was observed to have residuals, potentially leading to bacterial growth and infection. The resident's care plan and physician orders specified the need for flushing the G-tube with water before and after medication administration, as well as between each medication, to prevent clogging and ensure proper medication delivery. However, during the observed medication administration, the LVN did not adhere to these orders. The LVN used a syringe that had not been cleaned after previous use and did not flush the G-tube as required, which could lead to complications such as infection, dehydration, and drug-to-drug interactions. Interviews with the LVN and the Director of Nursing (DON) confirmed the failure to follow proper procedures. The LVN admitted to not cleaning the syringe and not flushing the G-tube as per the physician's orders. The DON acknowledged the importance of cleaning the syringe after each use to prevent contamination and the necessity of flushing the G-tube to maintain its patency and prevent complications. The facility's policy on enteral medication administration also outlined these procedures, which were not followed during the incident.
Improper Storage of Nasal Cannula for Resident
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care was provided with such care in accordance with professional standards and the resident's care plan. Specifically, the nasal cannula used by the resident for oxygen delivery was not properly stored when not in use. On observation, the nasal cannula was found sitting on top of the oxygen concentrator without being bagged, which could lead to cross-contamination and respiratory infection. The resident, who had coronary heart disease and an above-the-knee amputation, required assistance during transfers and used oxygen on an as-needed basis. Interviews with staff, including an LVN and the DON, confirmed that the nasal cannula should have been bagged to prevent contamination. The LVN acknowledged the oversight and replaced the nasal cannula with a new one, while the DON emphasized the importance of bagging the nasal cannula when not in use. The facility's policy on oxygen administration also highlighted the need for safe and effective delivery of oxygen and infection prevention, which was not adhered to in this instance.
Failure to Include Psychological Services in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). Despite the resident receiving weekly psychological services based on physician orders, the care plan did not reflect these services. The resident, who had a severe cognitive impairment with a BIMS score of 08, was admitted to the facility and had an active diagnosis of PTSD. The absence of a care plan for the psychological services was confirmed during interviews with the MDS nurse and the Director of Nursing (DON), who acknowledged that the care plan should have included the psychologist's services to ensure the resident was receiving appropriate care. The facility's policy on comprehensive care planning requires the development of a care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. However, the care plan for this resident did not include the necessary details about the weekly psychological services, which could place the resident at risk of not receiving the necessary care and services. The MDS nurse mistakenly believed that the psychiatrist's care planning was sufficient, despite the resident also seeing a psychologist. This oversight was identified during a record review and interviews with facility staff.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which is a requirement to ensure that residents receive the necessary care and services. Resident #1, a male diagnosed with acute respiratory failure and hypoxia, did not have a care plan for oxygen therapy despite having a physician's order for oxygen administration. Observations revealed an oxygen concentrator at the resident's bedside, and interviews with staff confirmed the absence of a care plan for oxygen therapy, which could lead to confusion among staff regarding the resident's care. Resident #20, a female with dementia and respiratory failure, also lacked a care plan for oxygen therapy and droplet precautions, despite having a physician's order for oxygen and being placed on droplet precautions after testing positive for RSV. Observations showed that the resident was receiving oxygen and that droplet precautions were in place, but these were not reflected in the care plan. Interviews with the DON confirmed the oversight and highlighted the importance of having an updated care plan to ensure proper care and communication with the resident's family. The facility's policy on comprehensive care planning emphasizes the need for documented care plans to guide the care and services provided to residents. However, due to the absence of the MDS Nurse, who was responsible for overseeing care plans, these deficiencies occurred. The DON acknowledged the importance of having complete and detailed care plans to prevent confusion and ensure that residents receive appropriate care.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that the call lights were within reach and accessible for two residents, which could place them at risk of being unable to obtain assistance when needed. Resident #1, a male with severe cognitive impairment and a history of falls, was observed with his call light on the floor, out of reach. Despite his impaired vision, staff members acknowledged that the call light should have been accessible to him. CNA C initially stated that the resident did not need the call light due to his blindness, but later acknowledged the importance of having it within reach. LVN B also confirmed that the call light should be accessible to residents regardless of their condition. Resident #5, a female with moderate cognitive impairment and left-side hemiplegia, was also found with her call light on the floor, out of reach. She expressed that sometimes the call light was moved where she couldn't reach it, although she felt safe and well-cared for otherwise. CNA C and LVN B both recognized the importance of keeping the call light within reach, emphasizing that it is crucial for residents to be able to call for assistance, especially in emergencies. Interviews with the Interim Administrator and the DON highlighted the expectation that staff should ensure call lights are always within reach of residents. The facility did not have a specific policy on call lights, as confirmed by the Interim Administrator. The lack of a policy and staff oversight contributed to the deficiency, as staff failed to consistently ensure that call lights were accessible to residents, potentially compromising their ability to call for help when needed.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, the resident was scheduled to receive showers three times a week, but records showed that she only received five showers in the entire month of October. Interviews with the resident and staff confirmed that the resident often did not receive her scheduled showers, and there was a lack of documentation to account for the missed showers. The resident expressed concerns about not receiving the scheduled showers, although she appeared clean and without odors during the interview. The resident, who had a moderate cognitive impairment and required total assistance for transfers, toileting, and bathing, was at risk of skin breakdown and infection due to the lack of consistent hygiene care. Staff interviews revealed that the CNAs were required to complete shower sheets for all residents, whether a shower was provided or refused, but this was not consistently done. The Director of Nursing acknowledged the issue and noted that the resident sometimes refused showers, but there was no explanation for the missing documentation. The facility's policy emphasized the importance of regular bathing for maintaining skin health and personal hygiene.
Unsecured Coffee Station Poses Burn Risk
Penalty
Summary
The facility failed to ensure a safe environment for residents by not securing a self-serve coffee station, which posed a risk of burns. An observation noted an unknown resident serving herself hot coffee from a cart placed in front of the nurse's station. The coffee was tested and found to be hot enough to cause burns. Interviews with staff, including a CNA and the DON, revealed that the coffee cart had been in place for a year without incidents, but the temperature was not consistently checked by nursing staff, relying instead on the kitchen staff. The facility's policy indicated that coffee should be served at 140 degrees unless otherwise warranted by resident preferences or safety concerns. The policy also outlined that residents with risk factors for burns should be evaluated for additional safety precautions, such as supervision or using cups with lids. However, during the incident, no staff was present to supervise the resident serving herself. The DON acknowledged the presence of residents with skin integrity issues and coordination problems, who were typically served by staff, but this was not the case during the observation. The facility's policy did not have a specific temperature regulation, leaving the decision to the administration, which failed to balance resident preferences with safety adequately.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in their care. Resident #2, diagnosed with chronic obstructive pulmonary disease, had a nasal cannula that was improperly stored on top of an oxygen concentrator without being bagged. This oversight was observed during a survey, and the resident mentioned that she seldom used the oxygen and was unaware of the need to bag the nasal cannula. LVN A acknowledged the issue, disposed of the nasal cannula, and stated she would replace it and ensure it was bagged when not in use. The Interim Administrator and the DON both confirmed that the nasal cannula should be kept clean to prevent respiratory infections and that it was the staff's responsibility to ensure proper storage. Resident #6, who had chronic respiratory failure with hypoxia, was observed using an oxygen concentrator without a humidification bottle attached. This was contrary to the physician's orders and the resident's care plan, which required the use of a humidifier to prevent nasal and throat dryness. LVN B noted that the resident had removed the humidifier bottle, and the DON confirmed that the staff had educated the resident about the importance of the humidifier. However, due to the resident's cognitive impairment, she did not remember this, and the staff was responsible for monitoring her oxygen therapy. The facility's policy on oxygen administration emphasized maintaining oxygenation with safe and effective delivery and preventing infection. However, there was no specific policy provided regarding the bagging of nasal cannulas. The Interim Administrator acknowledged the lack of a specific policy on this matter. These deficiencies in respiratory care could potentially place residents at risk for respiratory infections and inadequate oxygen therapy.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was provided medications and pharmaceutical services to meet their needs. Specifically, a Licensed Vocational Nurse (LVN) left the resident's medications inside the resident's room, which was against the facility's policy. The resident, who was cognitively intact with a BIMS score of 15, had a comprehensive care plan that did not indicate the ability to self-administer medications. The resident's medications included Neurontin, cyanocobalamin, multivitamin, docusate sodium, and metformin, which were left unattended by the LVN. The LVN admitted to leaving the medications with the resident and acknowledged that it was not the first time this had occurred. The facility's policy requires that medications be administered by licensed personnel and that the nurse must ensure the resident takes the medication before leaving the room. Interviews with the Interim Administrator and the Director of Nursing (DON) confirmed that staff should not leave medications unattended due to the risk of the resident not taking them or potential misuse. The DON emphasized the importance of ensuring residents take their medications before staff leave the room.
Inadequate Infection Control During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA D during the provision of incontinent care to a resident. The resident, a female with severe cognitive impairment and incontinence, was observed receiving care without proper hand hygiene and glove changes by CNA D. The CNA did not wash her hands before starting care, failed to change gloves after touching the trash can, and did not perform hand hygiene before putting on new gloves. These actions were contrary to the facility's infection control policies and procedures. During the care process, CNA D cleaned the resident's front part from back to front, assisted the resident to roll over, and continued cleaning after a bowel movement without changing gloves. She then handled a new brief without changing gloves and did not perform hand hygiene before applying cream to the resident's bottom. After completing the care, she did not wash her hands before leaving the room. The CNA acknowledged her failure to follow proper hand hygiene and glove-changing protocols, recognizing the risk of cross-contamination and infection. Interviews with the Interim Administrator, DON, and LVN A confirmed the expectation for staff to adhere to infection control policies, including hand hygiene and glove changes. The facility's policies emphasized the importance of washing hands and changing gloves when contaminated. The staff's failure to follow these procedures could contribute to cross-contamination and infection, as noted by the Interim Administrator and DON.
Failure to Administer Blood Pressure Medications Correctly
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of blood pressure medications. A resident, who was cognitively impaired and diagnosed with hypertension, was prescribed metoprolol tartrate and hydralazine with specific parameters for administration. However, the medications were administered outside of these parameters on multiple occasions in August 2024, despite the resident's diastolic blood pressure being below the threshold specified in the physician's orders. The nurses involved did not document any communication with the physician regarding these deviations, and there were no nursing notes related to the resident's blood pressure on the days the errors occurred. Interviews with the nursing staff revealed a lack of adherence to the protocol for notifying the physician when blood pressure readings were outside the prescribed parameters. The Director of Nursing (DON) was unaware of the medication errors and acknowledged that the nursing notes were reviewed in morning meetings, but issues could be overlooked if not documented. The facility's medication administration policy did not address the proper administration of medication according to physician orders, contributing to the oversight.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity during meal assistance. An LVN was observed standing over a resident while assisting her with feeding in the dining area. The resident, who had a history of cognitive decline, difficulty swallowing, and lack of coordination, was not feeding herself, prompting the LVN to assist her by placing food in her mouth with a utensil. The LVN stated that there was no chair available, which is why she decided to stand while assisting the resident. The Director of Nursing and the Administrator both acknowledged that staff should be sitting while assisting residents during meals to maintain resident dignity. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not adhered to in this instance. The incident was identified as a potential violation of resident rights and dignity, as standing over a resident during meal assistance could diminish their quality of life.
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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) |
|---|---|---|---|---|
| Collinwood Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 2 | 0 |
| Life Care Center Of Plano | 3.3 mi | ★★★★★ | 2 | 0 |
| The Healthcare Resort Of Plano | 3.3 mi | ★★★★★ | 1 | 0 |
| Landmark Of Plano Rehabilitation And Nursing Cente | 3.6 mi | ★★★★★ | 19 | 0 |
| Remington Transitional Care Of Richardson | 3.8 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.