Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Reserve At Richardson during CMS and state inspections, most recent first.
Resident Council Meetings Held Without Privacy: A confidential resident group meeting was normally held in an upstairs dining room that had no doors or solid walls separating it from the open nurses' station or nearby hallways. Residents said they did not feel able to speak freely because staff could hear them and people could walk in and out. The Activity Director said she continued using that space because it had always been held there, and the Administrator stated the meeting should have been held in a private area. The facility had no specific policy on Resident Council meeting privacy.
Medications and biologicals were left accessible in resident rooms and on a nurse cart. A resident with dry eye syndrome had eye drops in plain view on an overbed table, while other residents had topical analgesic gel, antifungal powder, and zinc oxide tubes left on side tables or drawers despite no documented self-administration assessments for several of them. An LVN also kept an opened bottle of probiotics in a cart drawer even though the label said to refrigerate after opening.
Food items in the kitchen were found undated, improperly sealed, and in some cases past their use-by dates. Surveyors observed pasta noodles exposed to air contaminants, multiple bags of graham pie crusts without dates, and other items such as brown sugar, lettuce, and frozen beef patties without visible expiration dates. The DM acknowledged the findings and stated he was responsible for ensuring labeling and storage policies were followed, while the AIT stated the kitchen was expected to follow facility food storage guidelines.
Staff did not consistently follow infection control practices during resident care involving a trach and G-tube, a pressure ulcer with a midline IV, an open wound during incontinent care, and a catheter/dialysis access. Observations showed an LVN failed to perform hand hygiene between glove changes and before sterile glove use, CNAs and the DOR did not wear gowns for high-contact care, and one staff member did not change gloves after handling soiled items. Interviews confirmed staff knew gowns and hand hygiene were expected for these care activities.
A resident with an indwelling catheter and moderate cognitive impairment had her catheter bag left visible from the hallway without a privacy cover. The bag and urine could be seen from outside the room, and the resident said she would be embarrassed if others saw it. Staff acknowledged the bag should have been covered or positioned out of view, and the facility policy required staff to help keep urinary catheter bags covered.
Failure to Protect Residents from Abuse: Two residents were involved in a resident-to-resident altercation in which one resident admitted to kicking the other in the leg/shin after a verbal exchange. The DON and AIT did not treat the event as abuse or report it to the state, and no progress notes documented the incident. One resident had severe dementia with a history of physical and verbal behaviors, while the other had intact cognition and no behavior issues on his care plan.
Failure to Report Alleged Resident Abuse: The facility did not report an alleged resident-to-resident abuse incident to the State Survey Agency within the required timeframe after one resident admitted to striking another resident. The DON and AIT treated the event as a grievance and did not consider it abuse, and no state report was found in TULIP. One resident had vascular dementia and moderate cognitive impairment, while the other had parkinsonism and intact cognition.
Failure to Investigate Resident-to-Resident Abuse Allegation: A resident admitted to striking his roommate, but the facility did not complete a thorough abuse investigation. The DON and AIT stated they treated it as a grievance and did not report it as abuse, and the SW was unaware of the incident. Records showed one resident had severe dementia and behavioral concerns, while the other had intact cognition; the facility policy required immediate investigation of suspected abuse and resident-to-resident altercations.
Unsafe Hoyer Transfer and Unattended Germicidal Wipes A resident with reduced mobility and moderate cognitive impairment was transferred by a CNA using a Hoyer lift without the required second staff member, and the resident was left suspended in the air while the CNA left the room. In a separate event, an LPN left a container of germicidal wipes on top of her cart with the lid open while moving in and out of resident rooms, leaving the wipes unattended as residents passed by.
A resident with a suprapubic catheter and another resident with an indwelling catheter did not receive proper catheter care when drainage bags were found touching the floor and, during clothing care, one bag was placed on top of the bed instead of remaining below the bladder. Staff interviews confirmed the bags should stay below the bladder and off the floor, and the facility policy required unobstructed urine flow and clean technique.
Failure to Check G-Tube Placement and Residual Before Meds: A resident with a g-tube, severe cognitive impairment, and continuous enteral feeding had medications and water flushed through the tube without the LVN first checking gastric residual or tube placement. The LVN acknowledged the omission, and the ADON, DON, and AIT stated that placement and residual checks were required before flushing and administering meds.
Improper Storage of PRN Oxygen Cannulas: Two residents with SOB and PRN O2 orders were observed with their nasal cannulas left unbagged when not in use. One resident said he had not been told to place the cannula in a bag and did not have one, while the other said she did not always use her O2. An LVN stated the cannulas should be bagged to prevent respiratory infection, and the DON, ADON, and AIT confirmed staff were expected to bag cannulas when not in use.
Expired insulin was found in a nurse’s cart for a resident with DM2 who had an order for NovoLog BID. The insulin KwikPen had been open beyond the 28-day limit, and an LVN acknowledged it should have been discarded earlier but was overlooked. The ADON, DON, and AIT stated staff were responsible for checking expiration dates before administration, and the facility policy required checking medication expiration dates.
Invalid OOH-DNR Forms Due to Improper Witness Signatures: The facility failed to keep accurate advance directive records for two residents because their OOH-DNR forms were not completed with qualified witnesses. One resident with severe cognitive impairment had both witnesses listed as family members, and another resident’s form was signed by the facility AIT and Social Worker. The DON and Administrator stated residents are full code until the DNR is completed and that staff are not allowed to sign the forms, and the facility had no OOH-DNR policy.
A resident's confidential medical information, including diagnosis and medication details, was left exposed and unattended on the nurse's station countertop by an ADON. The document was visible to anyone passing by, in violation of facility policy and HIPAA regulations. Facility leadership confirmed that such information should be protected and not accessible to unauthorized individuals.
A nurse medication cart containing drugs and biologicals was left unlocked and unattended in a hallway, with a resident nearby. Staff interviews confirmed the cart should have been locked when not in use, and the responsible LVN admitted to leaving it unsecured while stepping away. Facility policy requires all medication storage compartments to be locked when unattended.
Three residents with severe cognitive impairment and high dependence on staff were found to have call lights that were not accessible, with devices either out of reach or on the floor. Staff interviews confirmed the expectation that call lights should always be within reach, and care plans for these residents included this intervention due to their fall risk and need for assistance. Facility policy also required call lights to be accessible, but this was not followed, resulting in a deficiency.
A resident with asthma and severe cognitive impairment did not have her nebulizer breathing mask properly stored in a bag when not in use, as required by facility policy and professional standards. Staff interviews confirmed the expectation for bagging the mask to prevent infection, but the mask was observed left unbagged after treatment.
Two residents were found with medications in their rooms, including nasal spray, eye drops, and antifungal powder, without physician orders or assessments for self-administration. Staff confirmed these medications should not have been accessible to residents and were not stored in locked compartments as required.
During incontinent care for a resident with diarrhea and ADL deficits, two CNAs failed to change gloves and perform hand hygiene after cleaning soiled areas and before handling a clean brief, contrary to facility infection control policy. Both staff and administration acknowledged the lapse in proper infection prevention procedures.
The facility failed to create comprehensive care plans for three residents, including one with emphysema using oxygen therapy, another with a catheter and on hospice care, and a third unable to use a call light due to physical and cognitive limitations. These omissions in care planning could lead to inconsistent care delivery and unmet needs.
The facility failed to provide appropriate respiratory care for several residents, leading to deficiencies in their care. A resident with emphysema used oxygen therapy without a physician's order, while another with sleep apnea had a CPAP mask improperly stored. Additionally, a resident with a PRN order for oxygen had unbagged tubing, and another lacked a physician's order for a CPAP machine, with the mask also unbagged. These issues reflect non-compliance with professional standards and facility policies.
The facility's kitchen failed to meet professional standards for food safety, with an ice scoop stored improperly, uncovered trash and tea dispenser, and unclean equipment. These deficiencies were observed during a survey, and staff acknowledged the risk of cross-contamination.
A resident with a moderate cognitive impairment and an indwelling catheter was observed in the dining area with a visible catheter bag, despite having a privacy bag that was not fully pulled down. The facility's policy requires catheter bags to be covered to maintain dignity, but the CNA responsible for transferring the resident did not ensure this. The ADON and DON acknowledged the oversight and confirmed the expectation for staff to properly use privacy bags.
A facility failed to update a comprehensive care plan timely for a resident with obstructive sleep apnea and severe cognitive impairment. The last care plan update was in June 2024, despite a physician's order for CPAP use in October 2023. Staff interviews revealed a lack of adherence to the policy requiring quarterly updates, leading to potential confusion in care provision.
A resident with severe cognitive impairment and a history of falls was found with bolster pads on her bed without physician orders. The DON confirmed the absence of orders, which is against the facility's policy requiring physician approval for such equipment.
A facility failed to have a physician's order for a resident's external catheter, used to aid in the healing of a pressure ulcer. The resident, who was cognitively intact, had been using the catheter since January without a documented order. Staff, including the LVN, ADON, and DON, acknowledged the oversight, which could lead to staff being unaware of necessary care interventions.
The facility failed to store probiotics for two residents according to the manufacturer's instructions, which required refrigeration after opening. Both a medication aide and an LVN administered probiotics that were improperly stored in a medication cart drawer instead of being refrigerated, as observed during a survey. The ADON and DON confirmed the oversight, which could affect the potency of the probiotics.
A facility failed to maintain an effective infection control program when a CNA did not change gloves after touching a resident's Foley catheter tubing during care. The resident, who had an indwelling catheter due to uropathy, was cognitively intact. The CNA initially followed proper hygiene protocols but failed to change gloves after handling the potentially contaminated tubing, contrary to facility policy. This oversight was acknowledged by the CNA and confirmed by the DON and ADON.
A resident with dementia and a history of falls eloped through an unsecured door in the dining area, leading to a fall down a stairwell and multiple serious injuries. The resident's care plan included frequent monitoring and fall precautions, but the door was not identified as a hazard, and the alarm was not responded to in time. Staff were aware of the resident's needs, but the facility failed to secure the door, resulting in the incident.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. A container of Beef Bullion paste past its expiration date was found in the refrigerated storage area, which could have exposed residents to foodborne illnesses. The facility's policy and FDA guidelines were not followed.
Resident Council Meetings Held Without Privacy
Penalty
Summary
The facility failed to provide a private meeting space for the residents' monthly council meetings for 11 of 11 confidential residents reviewed for resident council. During observation and interview on 05/20/2026 at 11:30 a.m., a confidential resident group meeting was held in a private therapy gym, and it was reported that the meeting was normally held in the upstairs dining room. The dining room had no doors or solid walls separating it from the open nurses' station or the two hallways leading into the area. Residents stated they did not feel they could express their opinions because staff could hear them and anyone could walk in and out of the dining room area. The Activity Director stated she had been hired in September 2025, knew the meeting should be held in a private area, but continued using the upstairs dining room because staff told her it had always been held there. The Administrator stated he expected the meeting to be held in a private area so residents could voice concerns and acknowledged the risk that the wrong person could hear something. The facility did not have a specific policy regarding privacy of Resident Council meetings.
Medications and biologicals left accessible in resident rooms and on a nurse cart
Penalty
Summary
Drugs and biologicals were not consistently stored in locked or otherwise secure locations, and several residents had topical medications left in their rooms and within reach. Resident #78, who had dry eye syndrome and intact cognition with a BIMS score of 14, had Artificial Tears Ophthalmic Solution ordered for self-administration at bedside, but during observation the eye drops were sitting in plain view on the overbed table and visible from the hallway. The resident stated she kept them there and would apply them herself. Resident #70, who had a diagnosis of unspecified pain and intact cognition with a BIMS score of 15, had a topical analgesic gel observed on top of the side table in his room. There was no assessment in the clinical notes showing he was competent to self-administer medications. The resident stated the gel was for his hip and other painful areas, and that staff would get it from the tube and apply it, then leave it on his table. Resident #44, who had rash and other nonspecific skin eruptions and intact cognition with a BIMS score of 15, also had an antifungal powder tube left on top of her overbed table. Her record likewise did not show an assessment for self-administration or competency to manage medications. Additional observations showed a tube of zinc oxide on the side table of Resident #86, who had muscle weakness and intact cognition with a BIMS score of 14, and on the side table of Resident #29, who had severe cognitive impairment with a BIMS score of 05 and bowel and bladder incontinence. Resident #74, who had hemiplegia, hemiparesis, moderate cognitive impairment with a BIMS score of 10, and bowel and bladder incontinence, also had a tube of zinc oxide left on the side drawer in plain view. Staff interviews confirmed these products were left accessible in resident rooms after use and should not have been within reach of residents. In addition, a bottle of probiotics labeled to refrigerate after opening was found inside the drawer of an LVN cart even though it had been opened months earlier and had remained in the cart since opening. The LVN acknowledged the refrigeration instruction and stated it should not have been kept in the cart.
Food items were left undated, improperly sealed, and past use-by dates
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. During an observation in the kitchen, surveyors found one gallon bag of pasta noodles with an expiration date of 05/17 that was not properly sealed and was exposed to air contaminants, one gallon bag containing two graham pie crusts with no date or expiration date, one gallon bag containing three graham pie crusts with no date or expiration date, one bag of brown sugar dated 05/15/26 with no visible expiration date, one head of lettuce dated 05/18/26 with no visible expiration date, and one gallon bag containing two frozen beef patties dated 05/19/26 with no visible expiration date. During interviews, the DM acknowledged the surveyor observations and stated the items would be corrected. The DM stated that once items were opened, they should be properly sealed and dated, that he was responsible for ensuring policy was followed, and that he and one other kitchen aide were responsible for proper labeling. The AIT stated he oversaw all departments and expected the DM to ensure the kitchen followed all guidelines, including proper labeling of food items. Record review of the facility's Food Storage policy stated stock must be rotated using FIFO, food should be dated as it is placed on shelves if required by state regulation, and date marking should be visible on all high risk food to indicate when ready-to-eat TCS food should be consumed, sold, or discarded.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for four residents reviewed for infection control. During observation, interview, and record review, staff did not consistently use hand hygiene, gowns, or glove changes during resident care activities involving tracheostomy care, feeding tube care, wound-related care, catheter-related care, linen changes, transfers, and incontinent care. For one resident with a tracheostomy and gastrostomy tube, an LVN suctioned the resident, changed the trach ties, changed the inner cannula, changed the feeding formula, and changed the g-tube dressing. The LVN washed hands at the start, but during the care sequence she removed and replaced gloves multiple times without sanitizing hands between tasks, including when disconnecting the g-tube, removing the breathing mask, changing the trach ties, changing the formula, and changing the g-tube dressing. She also did not sanitize her hands before putting on sterile gloves. The resident’s record showed tracheostomy care, suctioning, and tube feeding orders, and the family member stated the LVN had not sanitized her hands between glove changes. For another resident with a pressure ulcer and midline IV, a CNA changed the resident’s linen while the resident was on enhanced barrier precautions, but the CNA did not wear a gown. For a resident with an open wound, two staff members provided incontinent care; neither wore gowns, and one staff member did not perform hand hygiene before gloving. During the care, gloves were removed and replaced at several points, but one staff member touched a soiled brief and then handled a clean brief without changing gloves. For a fourth resident with an indwelling catheter and dialysis access, a CNA transferred the resident and changed the resident’s clothing without wearing a gown. The records for these residents reflected wounds, a midline IV, a catheter, dialysis access, and enhanced barrier precaution-related care needs, and staff interviews confirmed the gown and hand hygiene expectations were not followed during the observed care.
Visible Catheter Bag Compromised Resident Dignity
Penalty
Summary
The facility failed to treat Resident #87 with dignity when the resident’s catheter bag was left visible from the hallway without a privacy bag. Resident #87 was a re-admitted female with neuromuscular dysfunction of the bladder, moderate cognitive impairment with a BIMS score of 12, and an indwelling catheter documented on the MDS assessment and care plan. A physician’s order directed staff to monitor the Foley catheter every shift for leakage, blockage, sediment buildup, or low output. During an observation, Resident #87 was in bed awake with the catheter bag hanging on the side frame of the bed, and the bag and urine inside were visible from the hallway. The resident stated the catheter was new to her and that she would not appreciate others seeing it because it would embarrass her. Staff interviews confirmed the bag was visible, that the resident should have had the catheter bag covered or positioned out of view, and that the visibility of the bag was a dignity issue. The facility policy stated that staff shall help residents keep urinary catheter bags covered.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for two residents reviewed for abuse and neglect. The deficiency involved Resident #54 and Resident #6, where Resident #54 struck Resident #6 on the leg/shin during an altercation. Resident #54 had diagnoses including hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, severe vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. His care plan identified a potential for physical behaviors such as hitting or trying to punch related to anger and poor impulse control, and a separate care plan identified potential verbally abusive behaviors related to mental/emotional issues. Resident #6 had diagnoses including secondary parkinsonism, bradykinesia, rigidity, tremor, and neuromuscular dysfunction of the bladder. His quarterly MDS reflected intact cognition with a BIMS score of 15, and his care plan did not indicate behaviors toward staff or other residents. The record review found no progress note entries for either resident documenting the incident on the date it occurred. The grievance record showed the Ombudsman reported that Resident #54 admitted striking Resident #6 after Resident #6 was in his way while Resident #54 was trying to leave the room. During interviews, the Ombudsman stated she informed the DON of the incident and that staff initially separated the residents and later changed rooms the same day. The DON stated she did not consider the event abuse and said it would not be reported to the state because it was handled as a grievance. The AIT also stated he did not investigate the incident and did not report it because he did not think it was abuse. Resident #6 stated Resident #54 called him names and kicked him in the shin, and Resident #54 later stated he did kick Resident #6 and that staff moved him to another hall.
Failure to Report Alleged Resident Abuse
Penalty
Summary
The facility failed to ensure that an alleged resident-to-resident abuse incident was reported immediately, and no later than 2 hours after the allegation was made, to the administrator and to the State Survey Agency. The deficiency involved two residents, one of whom had diagnoses including hemiplegia and hemiparesis following a subarachnoid hemorrhage, vascular dementia, psychotic disturbance, mood disturbance, and anxiety, with a quarterly MDS showing moderate cognitive impairment and a BIMS score of 12. The other resident had secondary parkinsonism, bradykinesia, rigidity, tremor, and neuromuscular dysfunction of the bladder, with a quarterly MDS showing intact cognition and a BIMS score of 15. The record showed that the resident grievance dated 05/05/26 was initiated via the Ombudsman regarding the two residents. During interview, the Ombudsman stated the first resident admitted to striking the second resident in the leg, and that both residents were spoken with. The second resident stated that the first resident called him a homosexual and that he was okay, not hurt, and had no issues or concerns. The Ombudsman stated she advised the DON of the incident, and the residents were initially separated with a room change later the same day. During interview, the DON stated that if there were a resident-to-resident altercation, the first action would be to separate the residents, assess them, and notify the physician and responsible party. The DON stated the incident was handled as a grievance and was not reported to the state because she did not feel it was abuse. The AIT stated he did not complete an investigation and did not report it because he did not think it was abuse. Review of TULIP on 05/21/26 showed no self-reported incident regarding allegations of neglect for the second resident. The facility policy stated that alleged violations involving abuse must be reported immediately, but no later than 2 hours after the allegation is made, if the events involve abuse.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to have evidence that an allegation of abuse involving Resident #6 was thoroughly investigated after Resident #6 was struck on the leg by Resident #54. The incident was brought to the facility’s attention on 05/05/2026 through a grievance initiated by the Ombudsman, but the record showed no self-reported incident regarding the allegation of neglect for Resident #6 in TULIP. During interviews, the Ombudsman stated Resident #54 admitted to striking Resident #6 in the leg, and Resident #6 stated he was okay and not hurt. Resident #54’s record showed diagnoses including hemiplegia and hemiparesis following a subarachnoid hemorrhage, vascular dementia severe without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. His quarterly MDS dated 02/16/26 reflected moderate cognitive impairment with a BIMS score of 12. His care plan included potential verbal abusive behaviors related to mental/emotional issues and later potential physical behaviors such as hitting or trying to punch related to anger and poor impulse control. Resident #6’s record showed diagnoses including secondary parkinsonism, bradykinesia, rigidity, tremor, and neuromuscular dysfunction of the bladder, and his quarterly MDS dated 02/13/2026 reflected intact cognition with a BIMS score of 15. During interviews, the DON stated the residents were separated and a room change was done later the same day, but also stated the event was not reported to the state because staff did a grievance and did not consider it abuse. The AIT confirmed he did not complete an investigation and also stated he did not think it was abuse, so he did not report it. The SW stated she was not aware of the incident. The ADMIN later confirmed the AIT did not complete an investigation and stated that after looking into it, the matter perhaps should have been reported. The facility policy required an immediate investigation of suspected abuse or resident-to-resident altercations, including interviewing involved persons and providing complete documentation.
Unsafe Hoyer Transfer and Unattended Germicidal Wipes
Penalty
Summary
The facility failed to ensure the environment remained free of hazards when a CNA transferred a resident with reduced mobility using a Hoyer lift by herself and left the resident suspended in the air without supervision. Resident #87 was a re-admitted female with reduced mobility, a BIMS score of 12 indicating moderate cognitive impairment, and a care plan that directed transfer via Hoyer lift. During observation, the CNA prepared the resident for transfer, attached the sling, raised the resident, and moved the lift toward the recliner without another staff member guiding the lift. She then left the room, leaving the resident dangling in the air, and later returned with an LVN to complete the transfer. The CNA and LVN stated during interview that the transfer should have involved another staff member. The CNA said she knew Hoyer transfers required two-person assistance but performed the transfer alone because she was in a rush. She said she should have called another staff member before raising the resident. The LVN said she was not aware the transfer had already started and said the CNA should have called for assistance before moving the lift to ensure the transfer was safe. The facility also failed to keep a container of germicidal wipes from being left unattended on top of an LVN's cart. During observation, the LVN repeatedly left the wipes container on the cart while going in and out of resident rooms, and at one point left the lid open with wipes visibly exposed while turning her back to the cart. The cart was later observed parked outside the nurses' station with the container still on top and the lid still open, while residents were passing by. The LVN stated she forgot to place the wipes inside the cart drawer when she went into a resident's room, and she acknowledged that residents might be able to get hold of the wipes. The DON, ADON, and Administrator-in-Training stated that Hoyer transfers should be done by two staff and that germicidal wipes should not be left within reach of residents.
Improper Catheter Bag Positioning and Floor Contact
Penalty
Summary
The facility failed to ensure appropriate catheter care for a resident with a suprapubic catheter and for another resident with an indwelling catheter. Resident #3 had a diagnosis of neuromuscular dysfunction of the bladder, severe cognitive impairment with a BIMS score of 05, and a suprapubic catheter documented in the MDS, care plan, and physician orders. During an observation, Resident #3 was found in bed with the catheter bag hanging on the bed railing and touching the floor. An LVN observed the bag touching the floor, stated it should be off the floor because it could result in UTI, and raised the bed so the bag was no longer touching the floor. Resident #87 had a diagnosis of neuromuscular dysfunction of the bladder, moderate cognitive impairment with a BIMS score of 12, and an indwelling catheter documented in the MDS, care plan, and physician orders requiring the urinary drainage bag to remain below the level of the bladder at all times. During an observation while CNA F changed the resident’s clothing, the catheter bag was placed on top of the bed and remained there, with urine observed in the catheter tubing. During another observation, the resident’s catheter bag was on the floor while the resident sat in a recliner. An LVN stated the bag should have been secured to prevent it from falling to the floor and that it should always be below the bladder to prevent backflow and infection. Interviews with staff confirmed the expected catheter care practices. CNA F stated she placed the catheter bag on top of the bed while dressing Resident #87 and should have returned it to the railing after threading it through the resident’s pants leg. She also stated the bag had been left on the floor because it kept falling and she forgot to tell the nurse. The DON, ADON, and LVNs stated catheter bags should always be below the bladder and off the floor, and the facility policy reflected that the drainage bag must be positioned lower than the bladder at all times and kept off the floor.
Failure to Check G-Tube Placement and Residual Before Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one resident with a gastrostomy tube. Resident #85 was a male admitted with gastrostomy status, severe cognitive impairment with a BIMS score of 00, and an order for continuous tube feeding. His care plan included checking gastric residual and tube placement, and physician orders required auscultation for tube placement before feeding and medication administration, as well as checking residual prior to feeding and holding the feeding if residual was greater than 150 cc. During observation, an LVN turned off the feeding machine, disconnected the g-tube from the formula, flushed the tube with 30 cc of water, and administered medications one by one with flushing between each medication. The LVN did not check for gastric residual or g-tube placement before giving the medications. In interviews, the LVN stated she should have checked residual and placement before medication administration, and the ADON, DON, and Administrator-in-Training stated that g-tube placement and gastric residual should be checked before flushing and administering medications.
Improper Storage of PRN Oxygen Cannulas
Penalty
Summary
The facility failed to ensure that two residents who were ordered oxygen therapy had their nasal cannulas stored properly when not in use. Resident #46, a cognitively intact male with shortness of breath and an order for oxygen via nasal cannula or face mask as needed to maintain O2 sats greater than 90%, was observed seated in his chair with his nasal cannula lying on top of his bed. During interview, he stated he used oxygen occasionally, went to therapy without oxygen, and had not been told to place his nasal cannula in a bag and did not have a bag for it. Resident #87, a female with moderate cognitive impairment, shortness of breath, and an order for oxygen via nasal cannula or face mask as needed to maintain O2 sats greater than 90%, was observed in bed with her nasal cannula unbagged on top of the oxygen concentrator. She stated she did not always use her oxygen. During interview, an LVN stated the nasal cannula should be bagged to prevent respiratory infection and then disconnected the cannulas from both residents and discarded them. The DON, ADON, and Administrator-in-Training each stated the expectation was for staff to bag the nasal cannula when not in use, and the facility policy stated to keep oxygen cannulas and tubing used PRN in a plastic bag when not in use.
Expired Insulin Left in Medication Cart
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when Resident #67’s expired insulin was left in a nurse’s cart. Resident #67 was a cognitively intact male with diabetes mellitus and an order for NovoLog insulin injections twice daily for DM2. His care plan directed staff to administer diabetes medication as ordered, and the resident’s insulin KwikPen was observed in the cart with an open date of 04/10/2026. During observation and interview, an LVN stated the insulin was expired because it was past 28 days from opening and should have been discarded on 05/08/2026, but it remained in the cart until it was found and discarded during the survey. The LVN said she had overlooked checking the expiration date. The ADON, DON, and Administrator-in-Training all stated that expired insulin should not remain in the carts and that staff were responsible for checking medication expiration dates before administration. The facility policy also directed staff to check the expiration date on medications.
Invalid OOH-DNR Forms Due to Improper Witness Signatures
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 2 residents reviewed for Advanced Directives because their OOH-DNR forms were not completed correctly and were therefore invalid. Resident #20 was a female with diagnoses including unspecified dementia, senile degeneration of the brain, anxiety disorder, and chronic kidney disease; her quarterly MDS showed a BIMS score of 00, indicating severe cognitive impairment, and her care plan identified her as DNR. Her OOH-DNR was signed by a qualified relative, but both witnesses were family members, and the resident’s relative confirmed in interview that both witnesses were related to the resident. Resident #66 was a cognitively intact female with diagnoses including rhabdomyolysis, hypertension, and acute kidney failure; her MDS showed a BIMS score of 15, and her care plan also identified her as DNR. Her OOH-DNR was signed by the facility’s AIT and the facility Social Worker. The DON stated residents are full code until the DNR is completed and that the social worker checks the forms for accuracy before upload, while the Administrator stated staff are not allowed to sign the DNRs. The facility did not have a policy regarding OOH-DNRs.
Resident Medical Information Left Unattended and Exposed at Nurse's Station
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's personal and medical records when the Assistant Director of Nursing (ADON) left a piece of paper containing sensitive medical information exposed and unattended on top of the nurse's station countertop. The document included the resident's name, medical record number, physician's name, proposed course of therapy, medication name, and the condition being treated, which was psychotic behavior. The paper was left facing the hallway with no staff present at the nurse's station, making the information visible to anyone passing by. The resident involved was an elderly female diagnosed with depression and unable to complete a cognitive assessment interview. Her care plan included medication management for depression, and her physician's order specified the use of Quetiapine Fumarate. The ADON acknowledged leaving the document exposed and recognized that this action constituted a violation of confidentiality and HIPAA regulations. Both the Director of Nursing (DON) and the Administrator confirmed that resident health information should not be exposed or accessible to unauthorized individuals, as per facility policy.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A nurse medication cart was observed parked outside the nurse's station, unlocked and unattended, with drawers containing medications accessible and facing the hallway. A resident in a wheelchair was sitting approximately ten steps from the open cart. Multiple staff interviews confirmed that the cart should have been locked when not in use, and that it was not clear who was responsible for the cart at the time it was left unattended. The facility's policy requires all drugs and biologicals to be stored in locked compartments when not in use, and for carts to not be left unattended if open or accessible. Further interviews revealed that the LVN responsible for the cart left it unlocked while going to the restroom, acknowledging that the cart should have been secured before leaving it unattended. Staff, including the ADON, DON, and Administrator, all stated that the expectation is for all medication carts to be locked when not in use to prevent unauthorized access. The facility's policy, dated December 2024, reiterates the requirement for all compartments containing drugs and biologicals to be locked when not in use.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of three residents were accessible, as required by their care plans and facility policy. Observations on the specified date revealed that one resident's call light was hanging on the bed railing and not within reach, another resident's call light was found on the floor and out of reach, and a third resident's call light was also on the floor behind a side table. All three residents had severe cognitive impairments and required significant assistance with daily activities, including personal hygiene, transfers, and mobility. Their care plans specifically included interventions to keep call lights within reach due to their risk for falls and dependence on staff for assistance. Interviews with staff, including a CNA, LVN, and two ADONs, confirmed that call lights should always be within reach of residents, especially those who are dependent or have limited mobility. Staff acknowledged that they had not noticed the call lights were inaccessible during their rounds and recognized the importance of ensuring accessibility to address residents' needs and prevent incidents such as falls. The facility's policy also required that call lights be within easy reach of residents who are in bed or confined to a chair. Record reviews for each resident showed that their care plans included the intervention to keep call lights within reach, and there was no documentation indicating any refusal by the residents to have their call lights accessible. The deficiency was identified through direct observation, interviews, and review of care plans and facility policy, demonstrating a failure to reasonably accommodate the needs and preferences of the residents as required.
Improper Storage of Nebulizer Mask for Resident Requiring Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with asthma and severe cognitive impairment, who required respiratory care including nebulizer treatments, was not provided with safe and appropriate storage of her respiratory equipment. During observation, the resident's nebulizer breathing mask was found connected to the machine and not stored in a bag when not in use, contrary to professional standards and the facility's own infection prevention policy. The resident was unable to state where the mask was kept after treatments, indicating a lack of awareness or involvement in the storage process. Interviews with nursing staff and facility leadership confirmed that the expectation was for the breathing mask to be bagged after each use to prevent infection and cross-contamination, regardless of whether the treatment was administered daily or as needed. The facility's policy specifically required respiratory therapy equipment, such as nebulizer circuits, to be stored in a plastic bag when not in use. The failure to follow this protocol was observed and acknowledged by staff, resulting in a deficiency related to the safe and appropriate provision of respiratory care.
Failure to Secure Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as required, for two residents. Both residents were found to have medications in their rooms without proper authorization or assessment for self-administration. Specifically, one resident had a nasal spray and a cup with powder on her side table, and the other had Systane eye drops and antifungal powder at her bedside. Neither resident had a physician's order or care plan indicating they were permitted to self-administer these medications, nor was there an assessment documenting their ability to do so. Record reviews showed that both residents were cognitively intact, with BIMS scores of 15, and had various medical diagnoses including asthma, bipolar disorder, allergic rhinitis, and depression. However, their care plans did not include interventions or permissions for self-administration of medications. Additionally, there were no physician orders for the nasal spray or eye drops found in the residents' rooms, and no assessments had been completed to determine their capability for self-administration. During interviews, staff members acknowledged that medications should not be left in residents' rooms due to the risk of accidental overdose or misuse. Staff also confirmed that the medications observed should have been administered by nursing staff and not left accessible to the residents. The facility's policy requires all drugs and biologicals to be stored securely and separately from other substances, which was not followed in these instances.
Failure to Follow Hand Hygiene and Glove Change Protocol During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinent care for one resident diagnosed with diarrhea and requiring assistance for toileting due to an ADL self-care performance deficit. During the observed care, two CNAs initially performed hand hygiene and donned gloves. However, when one CNA needed new gloves, the other CNA removed her gloves, retrieved new gloves from a box without sanitizing her hands, and then continued care. After cleaning the resident's bottom, the CNA did not change her gloves or perform hand hygiene before handling a clean brief and placing it under the resident. Both CNAs acknowledged during interviews that gloves should have been changed and hand hygiene performed after contact with soiled areas and before touching clean items. The ADON and Administrator confirmed that the staff did not follow facility policy, which requires hand hygiene before donning gloves and after removing them, as well as changing gloves when moving from dirty to clean tasks. The failure to follow these procedures was directly observed and confirmed through staff interviews and record review.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which could potentially place them at risk of not receiving necessary care. Resident #2, a cognitively intact female with emphysema and respiratory failure, was observed using oxygen therapy without a corresponding care plan or physician order. Despite her regular use of oxygen, her care plan did not reflect this need, indicating a lack of documentation and planning for her respiratory support. Resident #74, a cognitively intact male with an unstageable pressure ulcer and AIDS, was using a condom catheter and receiving hospice care, yet his care plan did not include these critical aspects of his care. Observations confirmed the presence of a catheter, and interviews with staff revealed an oversight in care planning, as the resident's catheter use and hospice admission were not documented in his care plan. This lack of documentation could lead to inconsistencies in care delivery. Resident #182, a male with Alzheimer's disease, quadriplegia, and contractures, was unable to use the call light due to his physical and cognitive limitations. However, his care plan did not address this inability, which could result in staff not conducting more frequent checks. The DON acknowledged the oversight, noting that the resident's inability to use the call light should have been care planned to ensure staff awareness and timely response to his needs.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, leading to deficiencies in their care. Resident #2, diagnosed with emphysema and respiratory failure, was using oxygen therapy without a physician's order. Despite the resident's regular use of oxygen, there was no care plan or physician order documented for this therapy, which was observed during an interview and record review. Resident #19, who suffers from obstructive sleep apnea, had a CPAP mask that was not stored properly. The mask was found unbagged on a table, contrary to the facility's policy that requires such equipment to be bagged when not in use to prevent contamination. This oversight was noted during an observation and confirmed through interviews with staff, who acknowledged the risk of respiratory infection due to improper storage. Resident #39, who had a PRN order for oxygen due to shortness of breath, had oxygen tubing left unbagged in his room. The tubing was not stored in a plastic bag as required when not in use, posing a risk of infection. Similarly, Resident #67, who required a CPAP machine for sleep apnea, did not have a physician's order for the machine, and the CPAP mask was found unbagged. These deficiencies highlight a lack of adherence to professional standards and facility policies regarding respiratory care and equipment management.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. The ice scoop was improperly stored inside the ice machine, and it had brownish stains, indicating it was not cleaned. Additionally, a large trash can in the kitchen area was left uncovered, and a tea dispenser was not covered, exposing its contents to potential airborne contaminants. These observations suggest a lack of proper sanitation practices in the kitchen. Further inspection revealed that kitchen equipment was not adequately cleaned. A microwave had brownish stains along its inner walls, and a deep fryer had thick, dried-up grease on its inner walls. Interviews with the Dietary Manager in Training and the Dietician confirmed awareness of these issues, and they acknowledged the risk of cross-contamination due to these deficiencies. The facility's policy on Food Safety and Sanitation mandates compliance with local, state, and federal standards, which were not met in this instance.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that the privacy bag on the resident's catheter was properly positioned to cover the catheter bag and its contents. During lunchtime, the resident was observed in the dining area with the catheter bag visibly hanging from the back of the wheelchair, despite having a privacy bag that was not fully pulled down. This oversight was noted by the Assistant Director of Nursing (ADON), who acknowledged the issue and indicated that the staff responsible for transferring the resident should have ensured the catheter bag was fully covered. The resident involved was a male with a moderate cognitive impairment and an indwelling catheter due to obstructive and reflux uropathy. The facility's policy on dignity and quality of life mandates that urinary catheter bags be covered to maintain resident dignity. Interviews with the Certified Nursing Assistant (CNA) who transferred the resident and the Director of Nursing (DON) confirmed that the catheter bag should not have been visible, and the expectation was for staff to ensure privacy bags are properly used when residents are outside their rooms.
Failure to Update Comprehensive Care Plan Timely
Penalty
Summary
The facility failed to ensure the timeliness of a comprehensive care plan for a resident diagnosed with obstructive sleep apnea, who required significant assistance and support in daily life due to severe cognitive impairment. The resident's last quarterly care plan was completed on 06/12/2024, and no updates were made until 03/11/2025, despite the resident's ongoing need for a CPAP machine as indicated by a physician's order dated 10/26/2023. This oversight in updating the care plan was acknowledged by the Assistant Director of Nursing (ADON) and the MDS Nurse, who admitted that the care plans were supposed to be reviewed quarterly to ensure residents' needs were met. Interviews with facility staff, including the ADON, MDS Nurse, Director of Nursing (DON), and the Administrator, revealed a lack of adherence to the facility's policy requiring quarterly updates to comprehensive care plans. The staff recognized that without timely care plans, there could be confusion regarding the care provided to residents, as the care plans guide staff on the latest goals and interventions. The deficiency was attributed to an oversight, and the staff responsible for auditing care plans acknowledged the need for improvement in ensuring that care plans are completed and updated as required.
Lack of Physician Orders for Fall Prevention Equipment
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards by not obtaining physician orders for bolster pads used for fall prevention. The resident in question, a female with severe cognitive impairment and a history of falls, was observed with bolster pads on her bed. However, a review of her records revealed no physician orders for these pads, which were intended as an intervention for her fall risk. During an interview, the Director of Nursing (DON) acknowledged the absence of physician orders for the bolster pads, despite initially believing they were in place. The facility's policy on restraints specifies that such equipment should only be used for the safety and wellbeing of residents and requires physician orders. The lack of orders for the bolster pads could potentially result in injury if the resident attempted to get out of bed.
Lack of Physician Order for External Catheter
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence. Specifically, the facility did not have a physician's order for the use of an external catheter (condom catheter) for a resident diagnosed with an unstageable pressure ulcer to the sacrum. The resident, who was cognitively intact, had been using the catheter since January, but there was no documented order for its use as of March. Observations and interviews revealed that the resident had a catheter bag hanging at the side of the bed, and staff members, including the LVN, ADON, and DON, acknowledged the absence of a physician's order for the catheter. The facility's policy requires that all treatments, including catheter use, have a written order from a licensed prescriber. The lack of an order could lead to staff being unaware of the necessary interventions for the resident's care, potentially compromising the resident's health and safety.
Improper Storage of Probiotics
Penalty
Summary
The facility failed to ensure that probiotics for two residents were stored according to the manufacturer's instructions, which required refrigeration after opening. This deficiency was observed during medication administration for two residents, both of whom were receiving probiotics as part of their treatment plans. The probiotics were stored in a medication cart drawer instead of being refrigerated, as indicated on the product label. For the first resident, a female with a history of constipation and nausea, the medication aide did not notice the refrigeration requirement on the probiotic bottle. The aide admitted to not reading the instructions on the medication label, which led to the improper storage of the probiotics. Similarly, for the second resident, a male with severe cognitive impairment and diagnosed with diarrhea and flatulence, the LVN also failed to store the probiotics in the refrigerator as required. The LVN acknowledged the oversight after reading the label during the surveyor's observation. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were informed of the issue and confirmed that probiotics requiring refrigeration were not stored properly, which could affect their potency. The facility's policy on medication storage, which mandates refrigeration for medications requiring it, was not followed in these instances, leading to the deficiency.
Infection Control Deficiency Due to Improper Glove Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not change gloves after touching the drainage tubing of a resident's Foley catheter during incontinent care. This oversight was observed during care provided to a resident who had an indwelling catheter due to obstructive and reflux uropathy. The resident was cognitively intact and capable of normal cognition, as indicated by a BIMS score of 15. During the care process, the CNA initially followed proper hand hygiene and glove use protocols by washing hands, donning gloves, and sanitizing hands after removing gloves. However, after touching the catheter tubing, which is considered potentially contaminated, the CNA failed to change gloves before continuing with the care. This lapse in protocol was acknowledged by the CNA, who admitted that the tubing is presumed dirty and that gloves should have been changed to prevent cross-contamination. The facility's policy on infection control guidelines clearly states that gloves should be changed when moving from a dirty site to a clean one to prevent cross-contamination. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both confirmed the expectation for staff to change gloves and sanitize hands when transitioning from handling potentially contaminated materials to clean tasks. The failure to adhere to these guidelines during the care of the resident with a Foley catheter represents a deficiency in the facility's infection control practices.
Resident Elopement and Fall Due to Unsecured Door
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident, leading to an elopement incident. The resident, who had a history of dementia, repeated falls, and cognitive impairment, was able to exit through an unsecured door in the dining area. This door led to a corridor and a fire exit door, which connected to a stairwell. The resident experienced an unwitnessed fall down the stairs, resulting in multiple serious injuries, including fractures to the wrist, face, and nasal area. The resident's care plan identified her as at risk for falls and wandering, with interventions such as frequent monitoring, re-direction, and fall precautions. However, on the day of the incident, the resident was able to leave the dining area unsupervised. Staff were aware of her care needs, but the door she exited through was not secured, and the alarm was not responded to in time to prevent the fall. Interviews with staff revealed that the resident was at her baseline behavior on the day of the incident, and no unusual behaviors were noted. The facility had not previously identified the door as a potential hazard, as no residents had attempted to exit through it before. The incident highlighted a lapse in the facility's safety protocols, as the resident was able to access an area that should have been secured to prevent such accidents.
Failure to Discard Expired Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. During an observation and interview with the Dietician, a 16-ounce container of Beef Bullion paste was found in the refrigerated storage area with a date reading 11/07/23. The container had been opened on an unknown date, and the Dietician explained that the date on the container was the date the facility received the Beef Bullion paste. The Dietician immediately discarded the container in front of the investigator. The Dietician later revealed that if the Beef Bullion paste was past its expiration date and had gone bad, it could have exposed vulnerable residents to foodborne illnesses and potentially caused harm if residents became ill. In an interview with the DON, it was emphasized that it is important to discard any foods past their expiration date in the kitchen to prevent exposing residents to illness. The facility's policy on Frozen and Refrigerated Foods Storage, revised in November 2017, requires items stored in the refrigerator to be dated upon receipt unless they contain a manufacturer use-by, sell-by, or best-by date. The FDA Food Code also mandates that refrigerated, ready-to-eat time/temperature control for safety food must be clearly marked to indicate the date by which the food shall be consumed, sold, or discarded. The facility failed to adhere to these guidelines, leading to the deficiency noted in the report.
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What surveyors actually found near you
We read the 1,014 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.
Illustrative
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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 Plaza At Richardson | 0.4 mi | ★★★★★ | 3 | 0 |
| Richardson Nursing And Rehabilitation | 0.8 mi | ★★★★★ | 7 | 0 |
| Cottonwood Creek Healthcare Community | 1.3 mi | — | 7 | 0 |
| Lindan Park Care Center Lp | 1.7 mi | ★★★★★ | 0 | 0 |
| Remington Transitional Care Of Richardson | 1.8 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.