Below 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 Plaza At Richardson during CMS and state inspections, most recent first.
A resident with hypotension, heart disease, and type 2 DM had multiple scheduled oral medications, including Dapagliflozin, Metformin, Midodrine, and Pantoprazole, that were administered late by a med aide, outside the facility’s one-hour medication window. The med aide gave the resident’s morning doses together after the resident had already eaten, then documented them on the MAR as if given on time and did not record them as late or notify the nurse. The DON confirmed expectations that medications be given within the prescribed time frame and that before-meal orders, such as Pantoprazole, be administered as ordered, consistent with facility policy requiring documentation when medications are given at other than the scheduled time.
A medication aide failed to perform hand hygiene and sanitize a wrist blood pressure cuff while checking a resident’s blood pressure and administering medications. The aide did not clean the cuff before use or before placing it back on the med cart and did not wash or sanitize hands before or after direct resident contact. In interviews, the aide acknowledged knowing hand hygiene was required but cited lack of hand sanitizer on the med cart, and the DON confirmed expectations for hand hygiene and equipment disinfection consistent with facility infection control policy.
A dependent female resident with a history of stroke, DM, and HTN, identified as high risk for falls and moderately impaired in decision making, was found lying in bed with side rails up while her call light was on the floor and out of reach, despite a care plan intervention requiring the call light to be kept within reach. The resident reported she used the call light for assistance but could not access it. A CNA acknowledged the call light should have been within reach and repositioned it on the bed rail, and the DON stated she expected call devices to be accessible to residents. The Administrator indicated the facility had no call light policy.
Surveyors found that food items in various storage areas were not properly labeled or dated, some foods showed signs of spoilage, and a dented can was present. The dishwashing process was not followed correctly, with utensils not fully sanitized before use. Additionally, hot and cold foods were not held at safe temperatures, and staff did not consistently check food temperatures before serving, as required by policy and federal regulations.
The facility did not maintain an effective pest control program, resulting in ongoing gnat infestations in two hallways and the kitchen. Staff and residents reported persistent issues with gnats, including sightings in food preparation areas and resident rooms. Residents were disturbed by the gnats, with one nearly ingesting a gnat while eating. Despite staff efforts and pest control visits, the infestation persisted, indicating a breakdown in the facility's pest management procedures.
Surveyors found that drugs and biologicals were not consistently stored in locked compartments, with an unlocked dialysis medication cart and unsecured dialysis fluids left in a resident's room, and an unattended Advair Diskus inhaler left in a common area near the nurse's station. Staff and leadership confirmed that both facility and contract nurses were responsible for medication security, but lapses occurred despite existing policies and training.
A resident with multiple medical conditions, including Parkinson's Disease and dysphagia, experienced regurgitation in his room, and the resulting food debris remained on the floor for nearly three hours. Staff interviews revealed confusion about responsibilities for cleaning, and the facility's policy requiring a clean and comfortable environment was not followed, resulting in the resident feeling uncomfortable and the room remaining unclean.
Expired gentle female intermittent catheters were found stored in the medication room, despite the facility's procedures requiring regular audits by the ADON and Central Supply Personnel. Staff interviews revealed inconsistent auditing practices and a lack of a specific policy for expired medical supplies, resulting in the failure to promptly remove and dispose of expired items.
Expired IV and PICC supplies, including catheters and connectors, were found stored in the facility's only medication room despite staff statements that regular audits should have removed them. Interviews with an LVN, DON, ADONs, and Central Supply Personnel revealed inconsistent auditing practices and a lack of a specific policy for expired medical supplies.
A CNA failed to perform hand hygiene after using a cellphone while feeding a resident with multiple complex medical conditions, in violation of facility policy requiring hand cleaning before and after meal assistance. The DON confirmed staff expectations for hand hygiene and no phone use during feeding.
A resident with severe cognitive impairment and total care needs experienced a femur fracture that was initially assessed as chronic and attributed to age and osteopenia. Despite the injury being diagnosed as an acute fracture requiring surgery, the incident was not reported to the State Agency within required timeframes, as facility leadership did not consider it suspicious or related to neglect, contrary to policy and regulatory requirements.
The facility failed to ensure safe and orderly discharges for three residents, leading to inadequate preparation and communication. A resident with moderate cognitive impairment was discharged to a different address than provided, while another with severe cognitive impairment was transferred to a facility far from family without proper notice. A third resident was moved due to dissatisfaction with care, but the discharge process lacked communication, causing medication issues at the new facility.
The facility failed to effectively involve three residents and their responsible parties in the discharge planning process, leading to confusion and inadequate preparation for their transitions. A resident with moderate cognitive impairment was discharged without her preferences being considered, and the discharge address was not verified. Another resident with severe cognitive impairment was moved to a facility without the RP's full agreement, feeling rushed due to financial pressures. A third resident was transferred to a new facility chosen by the RP, but the process lacked proper communication, resulting in medication issues.
A resident with severe cognitive impairment experienced an incident where another resident sat on her lap, which was reported as a grievance. The facility failed to identify a Grievance Official, leading to the grievance not being properly investigated or addressed. The SW informed the DON and Administrator, but no thorough investigation or additional interventions were implemented.
The facility failed to properly store, label, and date food items in their kitchen, including an opened jar of barbeque sauce in dry storage, exposed brown sugar, and unlabeled peaches. Rotten tomatoes, expired jalapenos, and buttermilk were also found, posing a risk for foodborne illnesses. The Dietary Director acknowledged these oversights, which violated the facility's food storage policy.
A resident in a LTC facility missed seven doses of scheduled Oxycodone due to the facility's failure to obtain the medication from the hospice company. The resident, with a history of cancer-related pain, experienced unnecessary pain as a result. Despite receiving morphine for pain management, the resident preferred Oxycodone for scheduled doses. The acting DON and staff were unaware of the issue until a surveyor inquiry, highlighting a lack of communication and coordination with the hospice provider.
The facility failed to treat a resident with dignity during discharge, resulting in her being found unresponsive at home. The LVN did not complete a full assessment or document vital signs before discharge. Additionally, another resident was not provided a dignified dining experience as the ADON stood while assisting with meals, contrary to facility policy.
A resident with cognitive impairment and a history of stroke, schizophrenia, and anxiety disorder was found shaving with a disposable razor, which was against facility policy. Staff interviews confirmed that residents should not have access to such items due to safety risks. The facility's policy on hazardous areas emphasized the need to prevent such hazards.
A CNA failed to perform proper hand hygiene while providing incontinence care to a resident with severe cognitive impairment and multiple health conditions. The CNA did not wash or sanitize hands after removing gloves and before entering another resident's room, despite the availability of hand sanitizer. Interviews with the CNA, DON, and Administrator highlighted the importance of hand hygiene in preventing infection spread, as outlined in the facility's perineal care policy.
A facility failed to report an allegation of sexual abuse involving a resident to the State Survey Agency within the required timeframe. The resident, with multiple diagnoses including Parkinson's and dementia, initially reported inappropriate behavior by a CNA to a therapist. However, the resident later denied the allegations when questioned by the administrator, who conducted an internal investigation and did not report the incident to the state, contrary to facility policy and regulations.
A facility failed to update a resident's care plan to include a diagnosis of prostate cancer, despite the resident's history of the condition. The MDS Coordinator, new to the role, had not yet updated the care plan, risking neglect as staff might be unaware of the diagnosis. Facility policy mandates reporting changes in condition to the MDS Coordinator for care plan updates, which was not followed.
Late and Undocumented Medication Administration by Med Aide
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate and timely administration and documentation of medications for a resident. The resident had diagnoses including hypotension, hypertensive heart disease with heart failure, atherosclerotic heart disease, and type 2 diabetes, and was prescribed Dapagliflozin, Metformin, Midodrine, and Pantoprazole, among other medications. On the survey date at 10:18 AM, Med Aide B checked the resident’s blood pressure with a wrist cuff, obtaining a reading of 104/46, and then prepared the resident’s 8 AM and 9 AM medications together in a small cup. At 10:24 AM, Med Aide B administered six pills, including Dapagliflozin 5 mg, Pantoprazole 40 mg, Metformin 1000 mg, and Midodrine 10 mg, well outside the facility’s policy window for 8 AM medications. Review of the Medication Administration Record (MAR) for that month showed the 8 AM medications documented as given by Med Aide B without any notation that they were administered late. The electronic record contained no note indicating late administration. In an interview, Med Aide B acknowledged that the 8 AM and 9 AM medications were given late and stated he understood medications were to be given within one hour before or after the scheduled time, but he did not notify the nurse or document the late administration and reported he was unaware of how to document late medications in the electronic system. The DON stated she expected medications to be administered within the one-hour window on the MAR, noted that Pantoprazole should have been given prior to breakfast and that the resident had already eaten by the time it was administered, and indicated that the charge nurse should be notified when medications are not given on time. Facility policy required medications to be administered within one hour of the scheduled time and required circled initials and explanatory notes on the MAR when medications are given at other than the scheduled time, which was not followed in this case.
Failure to Perform Hand Hygiene and Sanitize Blood Pressure Cuff During Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during medication administration and vital sign monitoring. On 01/07/26 at 10:18 AM, surveyors observed Med Aide B check a resident’s blood pressure using a wrist blood pressure cuff without sanitizing the cuff and without performing hand hygiene before the procedure. After use, Med Aide B placed the wrist blood pressure cuff on top of the medication cart without sanitizing it and did not wash or sanitize hands before administering the resident’s medications. The facility’s policy, Fundamentals of Infection Control Precautions, states that hand hygiene is the primary means of preventing transmission of infection and is required before and after direct resident contact and upon and after contact with a resident’s intact skin, including when taking blood pressure. During an interview at 10:30 AM on the same day, Med Aide B acknowledged that he should have washed or sanitized his hands prior to taking the resident’s blood pressure and before and after administering medications, and stated there was no hand sanitizer on or in the medication cart, which he cited as the reason for not sanitizing his hands. He further stated he should have performed hand hygiene to prevent cross contamination and infection. At 10:40 AM, the DON confirmed that Med Aide B was expected to wash or sanitize his hands prior to checking blood pressure, prior to administering medications, and after medication administration, and that the blood pressure cuff should be sanitized before resident use and before being returned to the medication cart. Review of Med Aide B’s Medication/Administration Competency, dated 06/08/25, showed that his training included proper hand hygiene and correct timing of medication administration.
Inaccessible Call Light for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident’s call system was accessible at the bedside as required by the resident’s care plan. A female resident with a history of stroke, diabetes, and hypertension was dependent on staff for ADLs including dressing, hygiene, toileting, bathing, positioning, and transfers, and was assessed as moderately impaired in daily decision making. Her comprehensive care plan, last reviewed on 12/23/25, identified her as at high risk for falls related to gait and balance problems and included an intervention to keep the call light within reach and encourage her to use it for assistance as needed. On observation, the resident was lying in bed with positioning rails on both sides, and her call button was found on the floor below the bed, out of her reach. The resident reported that she used the call button to obtain staff assistance but could not reach it and was dependent on staff. A CNA stated that the call button must have fallen off the bed and acknowledged it should be within the resident’s reach, then wrapped the call button cord around the right positioning rail so it was accessible. The DON stated she expected residents’ call devices to be within reach while in bed and confirmed that this resident used her call light for assistance. The Administrator reported that the facility did not have a policy for call lights.
Deficient Food Storage, Labeling, Sanitation, and Temperature Control in Kitchen
Penalty
Summary
Surveyors identified multiple failures in the facility's kitchen related to food storage, preparation, and sanitation practices. Observations revealed that opened food items in the stand-by refrigerator, walk-in refrigerator, walk-in freezer, and dry storage were not consistently labeled or dated. Specific examples included a carton of soy milk with a broken seal and no date, bags of produce and bread without labels or use-by dates, and saran-wrapped packages of cheese and cake mix lacking proper dating. Additionally, a dented can of yams was found in dry storage, and some food items showed signs of spoilage, such as a molding carrot. Further deficiencies were observed in the dishwashing process. The three-compartment sink was not used according to established protocols, as evidenced by the assistant dietary manager attempting to use a serving spoon that had not been properly sanitized. Food particles were present in the rinse compartment, and the sanitizing solution was not initially prepared or tested correctly. The posted instructions required dishes to be immersed in sanitizer for at least one minute at the correct concentration, but this was not followed during the surveyor's observation. Temperature control for prepared foods was also inadequate. Hot foods on the steam tray line, such as pureed pinto beans, were held at temperatures below the required threshold, and cold foods like banana pudding cups were not maintained at safe temperatures. Staff interviews confirmed that temperature checks were not consistently performed prior to serving, and there was a lack of knowledge regarding proper holding temperatures and procedures. These failures were documented through direct observation, staff interviews, and review of facility policies and federal food safety regulations.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnat flies in two of the three hallways reviewed and in the facility's only kitchen. Multiple observations documented gnats flying around the hand washing sink, in resident rooms, common areas, and near food preparation areas such as the deep fryer and steam tray table. Staff interviews confirmed ongoing issues with gnats, with reports of staff attempting to manage the problem by pouring bleach down drains and setting traps, while awaiting pest control services. The pest control log indicated heavy gnat activity in specific hallways and common areas, and the facility's policy required regular pest control measures and maintenance of structural barriers to prevent pest entry. Residents reported being bothered by the gnats, with one resident stating that a gnat flew into her mouth while eating, causing distress. Another resident expressed agitation due to the persistent presence of gnats in his room and noted that complaints to staff had not resolved the issue. Staff interviews revealed that maintenance was responsible for pest control and that the problem was attributed to food left in resident rooms. Despite monthly pest control visits and additional treatments, gnats continued to be observed throughout the facility, indicating a failure to effectively implement the pest control program as outlined in facility policy.
Failure to Secure Medications and Biologicals
Penalty
Summary
Surveyors observed that the facility failed to store all drugs and biologicals in locked compartments and did not restrict access to authorized personnel only. Specifically, an unlocked dialysis medication cart containing intravenous medications, including Heparin and Zemplar, was found in a resident's room. Additionally, dialysis fluids were left unsecured on the resident's bedroom floor. The resident, who had end-stage renal disease and severe cognitive impairment, reported that an outside agency used the cart and fluids for in-room dialysis, and was unaware that the medications and fluids were left unlocked. Facility staff, including the RN and DON, confirmed that both the contract dialysis nurse and facility nursing staff were responsible for ensuring these items were secured, but acknowledged the oversight. Another incident involved an unsecured and unattended Advair Diskus inhaler found in a common area near the nurse's station. The inhaler, which was not labeled with a resident's name and had 57 doses remaining, was left in the basket of a vital sign machine with no staff or residents present. When shown the medication, an LVN acknowledged that it should have been locked on a cart and immediately removed it to secure storage. Facility leadership, including the ADM and DON, stated that nurses and medication aides were responsible for maintaining medication security and that environmental rounds were conducted to monitor for unsecured medications. A review of facility policy confirmed that medications and biologicals are to be stored safely and securely, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. Despite this policy and staff training, the survey identified lapses in medication security, with medications left unlocked and unattended in both resident rooms and common areas.
Failure to Timely Clean Resident Room After Regurgitation Incident
Penalty
Summary
A deficiency occurred when a resident's bedroom floor was not cleaned of regurgitated food for nearly three hours, from 11:50 AM to 2:40 PM. The resident, a male with diagnoses including Parkinson's Disease, encephalopathy, prostate cancer, unspecified dementia, and a psychotic disorder with hallucinations, was observed to have dried regurgitated food on both sides of his bed. The resident, who was cognitively intact and had dysphagia, reported feeling 'nasty' due to the presence of the regurgitated food, which had been there for an extended period. Staff interviews revealed that the CNA assigned to the hallway was unaware of the mess and stated that CNAs were responsible for ensuring resident rooms were kept clean and free from food or liquids on the floor. The LVN confirmed that both CNAs and housekeeping were responsible for maintaining cleanliness, with housekeeping making morning rounds and being available on a PRN basis. The DON and Administrator both stated that staff were expected to report and address spills or debris promptly, with the Administrator specifying that debris should not remain on the floor for over an hour. A review of facility records showed a recent complaint regarding room conditions, and the facility's policy emphasized the right of residents to a safe, clean, and comfortable environment. Despite these policies and expectations, the regurgitated food remained on the resident's floor for several hours, indicating a failure to maintain a sanitary and homelike environment as required.
Expired Catheters Not Removed from Medication Room
Penalty
Summary
The facility failed to ensure that expired gentle female intermittent catheters were removed from the medication room, as required by their internal auditing procedures. During an observation, unopened catheters with a manufacturer expiration date of 06-01-24 were found stored in the medication room. Interviews with staff revealed that the medication room was supposed to be audited for expired supplies daily by the ADON and twice weekly by Central Supply Personnel, with oversight by the DON. However, the presence of expired supplies indicated that these audits were not consistently or effectively performed. Staff members acknowledged that expired supplies should have been disposed of immediately and recognized the risk of infection associated with their use. Further interviews revealed inconsistencies in the auditing process and a lack of a specific policy addressing expired medical supplies. Central Supply Personnel stated that a monthly clean sweep was performed, in addition to twice-weekly checks, but was unaware of the expired supplies found. The DON and other staff members admitted to being unaware of the expired supplies and cited possible oversight. Additionally, an RN confirmed that there was no policy specifically covering expired medical supplies. These findings demonstrate a breakdown in the facility's processes for monitoring and removing expired medical supplies from resident care areas.
Expired IV and PICC Supplies Not Removed from Medication Room
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids by not removing expired IV and PICC supplies from the only medication room. During an observation and interview, multiple expired supplies were found, including Insyte Autoguard IV Catheters of various gauges and expiration dates, Invision Plus Needleless IV Connectors, and Stat Lock PICC Plus Stabilization Devices. These expired items were discovered despite the facility's stated procedures for regular auditing of the medication room by the ADON, Central Supply Personnel, and oversight by the DON. Interviews with staff revealed inconsistencies and lapses in the auditing process. The LVN present acknowledged that expired supplies should have been disposed of daily, and the DON, ADONs, and Central Supply Personnel each described different frequencies and responsibilities for auditing the medication room. Central Supply Personnel stated that a monthly clean sweep was performed, with additional twice-weekly checks, but was unaware of the expired supplies present. Additionally, it was reported that the facility did not have a specific policy addressing expired medical supplies.
Failure to Perform Hand Hygiene During Resident Feeding
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to perform proper hand hygiene while feeding a resident. During an observation, the CNA was seen texting on her cellphone while feeding the resident and did not use hand sanitizer before resuming assistance. The CNA later confirmed in an interview that she did not typically use her phone during feeding and acknowledged she did not sanitize her hands after using her phone before assisting the resident. The resident involved was a male with multiple diagnoses, including dementia, muscle wasting and atrophy, protein-calorie malnutrition, dysphagia, hypertensive heart disease, cerebral atherosclerosis, constipation, pain, muscle weakness, and benign prostatic hyperplasia. Facility policy required staff to use alcohol-based hand cleaner or soap and water before and after assisting a resident with meals, and staff were not permitted to use phones while feeding residents. The Director of Nursing confirmed that staff were expected to follow these protocols.
Failure to Timely Report Alleged Neglect and Injury of Unknown Source
Penalty
Summary
The facility failed to report an allegation of neglect involving a female resident with severe cognitive impairment, multiple comorbidities, and total dependence for activities of daily living. The resident complained of left knee pain, which was assessed by an LVN, and an x-ray was ordered after notifying the physician. The x-ray revealed a chronic fracture of the distal femur, and the resident was subsequently transferred to the hospital, where an acute oblique distal left femoral diaphyseal fracture was diagnosed, requiring surgical intervention. Despite these findings, the incident was not reported to the State Agency within the required timeframes. Interviews with the DON and Administrator revealed that the incident was not reported because the fracture was believed to be chronic and attributed to the resident's age and osteopenia, and thus not considered suspicious or related to abuse or neglect. The facility's abuse policy and relevant provider letters require immediate reporting of incidents involving neglect, exploitation, or mistreatment, including injuries of unknown source, but the facility did not follow these protocols in this case.
Inadequate Discharge Planning for Residents
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for the safe and orderly transfer or discharge of three residents. Resident #1, a female with moderate cognitive impairment and multiple health conditions, was discharged to a private residence with home health services arranged. However, there was a lack of documentation regarding her preferences for discharge planning, and the social worker did not have direct contact with the resident or her representative due to a previous poor relationship. The discharge process was rushed due to financial liability concerns, and the resident ended up at a different address than the one provided. Resident #2, a female with severe cognitive impairment and multiple health issues, was discharged to another nursing facility. The facility did not document the resident's preferences for discharge planning, and the social worker's communication with the resident's representative was inadequate. The representative felt pressured to accept a facility chosen by the facility, which was far from the family, and was not informed of the discharge date until the day of the transfer. The facility's failure to properly involve the resident's representative in the discharge planning process led to a lack of coordination and communication. Resident #3, a female with moderate cognitive impairment and various medical conditions, was discharged to a different skilled nursing facility due to dissatisfaction with care. The resident's representative chose the new facility, but the discharge process was poorly managed, with inadequate communication and no discharge meeting to discuss the transition, medications, or clinical information. This resulted in issues with medication orders at the new facility. The facility's discharge planning process did not adequately consider the residents' and their representatives' preferences and needs, leading to disorganized and potentially unsafe discharges.
Ineffective Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for three residents, which did not focus on the residents' discharge goals and did not allow them to be active partners in their transition. Resident #1, a female with moderate cognitive impairment and multiple health conditions, was discharged without her preferences for discharge planning being reflected in her care plan. The social worker (SW) did not have direct contact with Resident #1 or her responsible party (RP) due to a previous poor relationship, and the discharge address provided was not verified, leading to confusion about the resident's actual discharge location. Resident #2, who had severe cognitive impairment and required maximal assistance with activities of daily living, was discharged to a facility chosen by the SW without the RP's full cooperation or agreement. The RP was not informed of all available nursing facilities and felt rushed into a decision due to financial pressures on the facility. The RP was surprised by the discharge date and felt that the facility's choice of a new nursing facility was not suitable due to its distance from the family. Resident #3, with moderate cognitive impairment and dissatisfaction with the care received, was moved to a different skilled nursing facility chosen by the RP. However, the discharge process lacked proper communication and a formal discharge meeting, resulting in issues with medication orders at the new facility. The SW claimed to have followed the facility's discharge procedures, but the RP reported inadequate communication and planning, which could negatively affect the resident's health and psychosocial status.
Failure to Address Grievance Due to Lack of Grievance Official
Penalty
Summary
The facility failed to identify a Grievance Official responsible for overseeing the grievance process, which led to a grievance for a resident not being properly investigated or addressed. The resident, who had severe cognitive impairment due to Non-Alzheimer's Dementia, experienced an incident where another resident sat on her lap during a visit by her representative. The grievance was reported to the Social Worker (SW), who noted the incident in the Grievance Tracking Log and informed the Director of Nursing (DON) and the Administrator. However, the SW did not conduct a thorough investigation or implement additional interventions beyond the existing requirement for 24-hour staff presence in the Memory Care Unit. Interviews revealed that the DON was unaware of the grievance and did not know who the Grievance Official was, while the Administrator, who was supposed to be the Grievance Official, was not informed of the grievance. The facility's policy stated that the Administrator or their designee should oversee the grievance process, receive and track grievances, and lead necessary investigations. The lack of communication and oversight resulted in the grievance not being properly addressed, potentially leaving the resident's concerns unresolved.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen. During an inspection, several issues were identified, including improperly stored, labeled, and dated food items. Specifically, an opened jar of barbeque sauce was found in dry storage despite instructions to refrigerate it after opening. Additionally, a 25-pound bag of brown sugar was left exposed, and a plastic cup filled with peaches in the refrigerator was not labeled or dated. Rotten tomatoes with visible bruising and open holes were found in the walk-in refrigerator, along with an opened jar of jalapenos with a black substance around the lid and an expired date. An opened container of buttermilk was also found with an expired date, and a container of sliced vegetables in the freezer was covered but not labeled or dated. The Dietary Director acknowledged responsibility for ensuring expired and rotten foods were discarded and admitted that the expired and rotten items found were an oversight. She explained that staff members prepping food were responsible for labeling leftovers or prepared foods with the contents and preparation date. The director also noted that the barbeque sauce should have been refrigerated, and the brown sugar was awaiting a storage bin. The facility's Food Receiving and Storage policy mandates that all foods stored in the refrigerator or freezer be covered, labeled, and dated, aligning with the Food and Drug Administration Food Code requirements. These failures could potentially place residents at risk for foodborne illnesses.
Failure to Provide Timely Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in the resident missing seven doses of scheduled pain medication. The resident, who was under hospice care, was supposed to receive Oxycodone every four hours for pain management. However, the facility did not obtain the medication from the hospice company in a timely manner, leading to the resident experiencing unnecessary pain. The issue was identified after a surveyor inquiry prompted the delivery of the medication. The resident involved was an elderly female with a history of cancer, cancer-related pain, hypertension, depression, and anxiety. She had severe cognitive impairment and required scheduled and PRN pain medication. Despite the facility's care plan emphasizing the need for immediate response to pain complaints and evaluation of pain interventions, the resident's scheduled Oxycodone doses were not administered from the afternoon of one day through the afternoon of the next day. During this period, the resident received morphine for pain management, but she expressed a preference for Oxycodone and used morphine for breakthrough pain. Interviews with facility staff revealed a lack of communication and coordination with the hospice company responsible for delivering the medication. The acting DON, who had been in the position for only five days, was unaware of the medication delivery issue until informed by the surveyor and the resident. The facility's usual DON was on leave, and the acting DON, along with other staff members, failed to ensure the timely reordering and delivery of the resident's pain medication. The hospice company acknowledged the delay in medication delivery and implemented a new policy requiring nurses to personally check medication stocks.
Failure to Uphold Resident Dignity During Discharge and Dining
Penalty
Summary
The facility failed to ensure that Resident #218 was treated with dignity and respect during the discharge process. Resident #218, a female with Alzheimer's disease, anemia, type 2 diabetes mellitus with diabetic neuropathy, dementia, and legal blindness, was discharged from the facility to her home. The discharge process was mishandled as the resident was not picked up at the scheduled time, leading to a late-night transport. The Licensed Vocational Nurse (LVN) responsible for Resident #218 did not complete a full assessment or document vital signs before discharge, as she was unaware of the need to do so. The resident was found unresponsive upon arrival at her home, and the hospice nurse confirmed her death. Additionally, the facility failed to provide Resident #25 with a dignified dining experience. Resident #25, a male with Alzheimer's disease, non-Alzheimer's dementia, and depression, required assistance with meals. During a lunch meal service, the Assistant Director of Nursing (ADON) assisted Resident #25 while standing, which is against the facility's policy that emphasizes feeding residents with attention to safety, comfort, and dignity. The ADON acknowledged that standing while feeding a resident could compromise their dignity. These deficiencies highlight the facility's failure to uphold resident rights and dignity, as outlined in their policies. The lack of proper documentation and assessment during Resident #218's discharge and the inappropriate feeding method for Resident #25 demonstrate a disregard for the residents' dignity and quality of life.
Resident Access to Hazardous Item
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically by allowing a resident access to a disposable razor. The resident, a female with a history of stroke, schizophrenia, and anxiety disorder, was identified as moderately cognitively impaired and required assistance with personal hygiene tasks. Despite this, she was observed shaving her chin with a disposable razor, which she stated was provided by an unknown staff member. This incident occurred while the resident was lying in bed, and she mentioned that staff usually assisted her with shaving but were busy at the time. Interviews with facility staff, including an RN and the Administrator, confirmed that residents were not supposed to have access to disposable razors due to the risk of injury. The facility's policy on hazardous areas, devices, and equipment, dated July 2017, emphasized the importance of identifying and addressing hazards to ensure resident safety. The presence of the razor in the resident's room was a clear violation of this policy, as it posed a potential risk for injury or harm to the resident.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of a CNA during the care of a resident. The CNA did not perform hand hygiene while providing incontinence care to a resident with severe cognitive impairment and multiple health conditions, including hypertension, peripheral vascular disease, end-stage renal disease, non-Alzheimer's dementia, and aphasia following a stroke. The CNA was observed changing the resident's brief and cleaning him without washing or sanitizing his hands after removing gloves. He then proceeded to another resident's room without performing hand hygiene, despite the availability of hand sanitizer in the hallway. Interviews with the CNA revealed a lack of adherence to proper hand hygiene protocols, as he admitted to not using hand sanitizer due to its absence in the room and forgetting to wash his hands between resident rooms. The Director of Nursing and the Administrator both emphasized the importance of hand hygiene in preventing the spread of infections, stating that CNAs are expected to wash their hands between residents. The facility's policy on perineal care, which the CNA had been trained on, also outlined the necessity of washing hands thoroughly before and after care.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the State Survey Agency within the required two-hour timeframe. The incident involved a resident who reported to a therapist that a CNA had licked and nibbled his ear and inappropriately touched him during a shower. The therapist informed the facility's administrator, who conducted an internal investigation but did not report the allegation to the state, as required by regulations. The resident involved was a male with multiple diagnoses, including Parkinson's Disease, dementia, and a cognitive communication deficit, and had a BIMS score indicating moderate impairment. Despite the resident's initial report to the therapist, he later denied the allegations when questioned by the administrator. The administrator also conducted safe surveys with other residents, who did not report any abuse, and allowed the CNA to return to work with restrictions. The facility's policy requires immediate reporting of abuse allegations to state authorities, but the administrator chose not to report the incident, believing there was no risk after his investigation. The social worker expressed concern that not reporting the incident infringed on the resident's rights, but the administrator decided to handle the situation internally, contrary to the facility's policy and state regulations.
Failure to Update Resident Care Plan with Prostate Cancer Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan for a resident was not updated to reflect the diagnosis of prostate cancer, despite the resident having a history of this condition. This oversight was identified during a review of the resident's care plan, which had an initial date and a revision date, neither of which addressed the prostate cancer diagnosis. The MDS Coordinator, who had been in the position since October 2023, acknowledged that the care plan was not updated due to her still acclimating to her duties. She recognized the risk of neglecting the resident's needs because staff might not be aware of the prostate cancer diagnosis. The facility's policy requires changes in a resident's condition to be reported to the MDS Assessment Coordinator for review and updating of the care plan, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,058 citations issued within 25 miles in the last 12 months — including the 38 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Richardson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Reserve At Richardson | 0.4 mi | ★★★★★ | 19 | 0 |
| Richardson Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 7 | 0 |
| Cottonwood Creek Healthcare Community | 1.2 mi | — | 7 | 0 |
| Lindan Park Care Center Lp | 1.6 mi | ★★★★★ | 0 | 0 |
| Remington Transitional Care Of Richardson | 2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.