Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Victoria Gardens Of Allen during CMS and state inspections, most recent first.
Two cognitively intact residents with dementia and other medical conditions, both dependent or needing assistance for toileting, were not provided timely toileting assistance when requested. Video showed an agency CNA telling a resident she could not be taken to the bathroom because the CNA could not lift her alone and the nurse was passing meds, and instructing the resident to use her brief instead, while another resident in the room cried and later reported having wet the bed. Staff interviews confirmed that residents should never be told to urinate or have a bowel movement in their briefs and should be assisted promptly with toileting, and leadership acknowledged this as a violation of resident rights and dignity, despite the admission agreement promising assistance with ADLs including toileting.
Surveyors found a medication cart and a treatment cart left unlocked and unattended near the nursing station, with drawers facing the hallway and containing drugs and biologicals such as sterile water, wound dressings, topical agents, and hydrogen peroxide. An LVN reported stepping away from the medication cart for an emergency and stated the treatment cart was routinely left unlocked for emergencies, while acknowledging that residents with dementia could access medications. An RN and the DON both stated that medication and treatment carts must be locked at all times and that the nurse assigned to the cart is responsible for securing it, including when the cart is at the nursing station.
A resident with Bipolar Disorder, GAD, PTSD, and insomnia did not have an accurate PASRR PL1 screening and did not receive a PASRR PL2 eval. Her care plan showed BH services for PTSD, anxiety, and mood disorder, along with crying, excessive worry, irritability, and paranoia. The MDS nurse said the hospital completed the PASRR and it was not checked for accuracy on admission.
A resident with diabetes, a partial toe amputation, and a diabetic foot ulcer did not receive ordered wound care over the weekend. The treatment nurse said weekday wound care was completed by her, while the weekend RN admitted he forgot to do the care on one day and did not return to complete it on another when the resident was out on pass. The ADON and DON confirmed the ordered wound care was not completed.
Failure to perform hand hygiene and change gloves during incontinent care. A resident with bowel/bladder incontinence, impaired mobility, and a sacral pressure ulcer was observed soiled with urine and feces while a CNA cleaned her. After cleaning, the CNA did not perform hand hygiene or change gloves and used the same dirty gloves to apply a clean brief. The CNA stated she was unsure about the requirement, while the IP and DON stated hand hygiene and glove changes were expected and that glove use does not replace hand hygiene.
Surveyors found that sharps containers mounted by the doors in nine occupied rooms were filled past the designated fill line, preventing the security flaps from operating. Facility policy required designated individuals to seal and replace sharps containers when they were 75–80% full. An LVN and the ADON stated that nurses were responsible for changing the containers, with all staff expected to monitor and report when containers needed replacement, and both acknowledged the risk of bloodborne pathogen exposure from overfilled containers. The DON stated she was unaware the containers were overfilled and reported that both nursing and housekeeping staff had keys and could change full boxes.
A resident with emphysema, lung cancer, end-stage kidney disease on dialysis, and diabetes developed a persistent cough, and an LVN documented administration of cough syrup for this symptom. The LVN reported obtaining a verbal order from a nurse practitioner for PRN guaifenesin and administering it immediately but failed to enter the order into the EHR or physician order sheet. Review of the record showed no cough syrup order, and the DON confirmed that facility policy required immediate documentation of verbal orders with full prescriber details. This omission resulted in an incomplete and inaccurate medical record for the resident.
Two residents with chronic respiratory failure were observed with improperly stored respiratory equipment, risking contamination. A nebulizer mask and a nasal cannula were not bagged after use, contrary to facility expectations. Staff interviews confirmed the oversight, but the facility's policy on equipment storage was not provided.
A facility failed to maintain an effective Infection Prevention and Control Program when a CNA did not perform hand hygiene between glove changes during incontinent care for a resident with muscle weakness. The CNA acknowledged the omission, which could lead to cross-contamination, despite having received training on infection control. The facility's policy emphasizes hand hygiene as a primary means to prevent infections.
A resident with paraplegia and incontinence was not provided timely incontinence care during a shift, leading to a delay of an hour and forty-five minutes. The resident's call light was answered by an LVN who did not ensure follow-up care, and CNA A, who was assigned to another hall, did not attend to the resident until later. The facility's policy on perineal care was not followed, risking skin breakdown and infection.
A resident with a pressure ulcer did not receive necessary wound care on two consecutive days, despite requesting assistance multiple times. The Charge Nurse claimed to have completed the care, but there was no documentation to support this, and the resident's wound dressing condition suggested otherwise. The facility's wound care policy was not followed, leading to a deficiency in care.
Failure to Honor Resident Dignity and Toileting Rights
Penalty
Summary
The deficiency involves a failure to honor residents’ rights to a dignified existence, self-determination, and communication, specifically related to toileting needs for two cognitively intact residents. Resident #1, an older female with a history of cerebral infarction, dementia, depression, lack of coordination, and urinary retention, was totally dependent for toileting per her care plan. Her discharge MDS showed a BIMS score of 14, indicating no cognitive impairment. Resident #2, an older male with dementia and depression, also had no cognitive impairment with a BIMS score of 15. Video footage reviewed on 04/14/26 at 8:00 AM showed CNA A entering the shared room when Resident #2 stated she needed to go to the bathroom. CNA A responded that she could not take the resident because she could not pick her up alone, and that the nurse, who had previously been in the room, could not assist because she was passing medications. CNA A told the resident she had a diaper and stated there was nothing they could do at that moment, adding that if she had to go, she should go in her pants and they would clean it up later, emphasizing that it took multiple people to safely pick her up. During this interaction, Resident #1 was heard crying, and CNA A reiterated that the resident would have to wait and, if necessary, use her brief. CNA A then left the room, returned with a meal tray, and stated she was new and needed to ask others for help. Resident #1 stated she had wet the bed, and CNA A verbally confirmed this. Resident #2 apologized to Resident #1 and reported that she had spoken to two or three people who said they would return but did not. The video showed Resident #2 walking out of the room afterward. Multiple CNAs interviewed later stated that residents should never be told to have a bowel movement or urinate in their brief and that residents should be assisted to the bathroom and changed as soon as possible. The DON and ADONs, after viewing the footage, identified the staff member as an agency CNA and acknowledged that telling residents to use their brief and not changing them when requested was a resident rights and dignity concern. The facility’s admission agreement stated that assistance and/or supervision with ADLs, including toileting, would be provided when required.
Unlocked Medication and Treatment Carts with Accessible Drugs and Biologicals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored in locked compartments and accessible only to authorized personnel, as required by State and Federal laws. On the morning of 04/14/26 at 6:45 AM, a surveyor observed Medication Cart #1 left unlocked with its drawer facing outward at the nursing station, with no staff present at or within view of the nursing station or the cart. Treatment Cart #2 was also observed unlocked, positioned adjacent to the nursing station with its drawers facing the hallway. Later that morning at 9:40 AM, the surveyor inspected the inside of Treatment Cart #2 and found multiple biologicals and treatment supplies, including sterile water USP 500 mL, TheraHoney gel, zinc oxide paste, hydrophilic wound dressings, Skin Integrity hydrogel, and hydrogen peroxide topical solution USP. During an interview at 7:00 AM, an LVN stated he had an emergency and stepped away from the medication cart, leaving it unsecured, and further stated that the treatment cart stayed unlocked for emergencies. The LVN acknowledged that residents with dementia could take medications from an unlocked medication cart and that it needed to be locked. In a separate interview at 7:10 AM, an RN stated that the medication cart needed to be locked at all times because residents or visitors could access and take medications, and that the nurse assigned to the cart was responsible for ensuring it was locked. In an interview at 4:00 PM, the DON stated each nurse was responsible for making sure their medication and treatment carts were locked, and that carts should be locked even when at the nursing station to prevent residents from taking medications and experiencing an adverse reaction. The surveyor exited without obtaining a written medication/treatment cart security policy.
PASRR Screening Not Accurate for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that all PASRR level 1 residents with mental illness received a PASRR level 2 evaluation for one resident reviewed. Resident #8’s PASRR level 1 screening did not reflect mental illness, and the resident did not have a PASRR level II evaluation. The resident’s quarterly MDS assessment dated 01/15/2026 identified her as a [AGE] year-old female admitted to the facility on [DATE], with a BIMs score of 15 indicating intact cognition. Resident #8’s diagnoses included Bipolar Disorder, Generalized Anxiety Disorder, PTSD, and Insomnia. Her care plan documented that she was receiving Behavioral Health services for PTSD, Anxiety, and Mood Disorder, and that she had behaviors including crying, excessive worry, irritability, and paranoia. The PASRR level 1 screening dated 09/06/2024 indicated the resident did not have a serious mental illness. During interview, MDS Nurse A stated she did not know why the PASRR level 1 screening was negative, explained that the PASRR had been completed by the hospital and not checked for accuracy on admission, and stated she was responsible for ensuring PASRRs were correct.
Missed wound care for resident with diabetic foot wounds
Penalty
Summary
The facility failed to ensure wound care was completed for one resident with a partial amputation of the left 3rd toe related to diabetes and a diabetic ulcer of the left plantar foot. The resident’s physician orders required daily wound care for both areas, including cleansing, dressing application, and wrapping. The resident had a BIMS score of 15 and was observed in a wheelchair with wound dressings to the left 3rd toe. During interview, the resident stated the wound care was not completed on the weekend, although it had been done that morning. The treatment nurse stated she provided wound care on weekdays and that charge nurses were responsible for wound care on Saturdays and Sundays. The weekend charge nurse, RN I, stated he did not complete the wound care on Saturday because it skipped his mind and did not complete it on Sunday because the resident was out on pass and he forgot to return to the room later. The ADON and DON confirmed that RN I was expected to complete the wound care per physician orders and that the wound care was not completed over the weekend.
Failure to Perform Hand Hygiene and Change Gloves During Incontinent Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one resident observed during incontinent care. Resident #75 was a [AGE]-year-old female admitted on 01/14/26 with diagnoses including hypertension, a sacral pressure ulcer, muscle weakness, neuromuscular dysfunction of the bladder, and muscle wasting and atrophy. Her care plan identified bowel and bladder incontinence related to disease process, impaired mobility, and neurogenic disorder, with a goal to remain free from skin breakdown due to incontinence and brief use. Her admission MDS dated 01/20/26 showed a BIMS score of 14 and that she required assistance with toileting. During an observation on 02/09/26, CNA D provided incontinent care to Resident #75 while she was soiled with urine and feces. After cleaning the resident, CNA D did not perform hand hygiene or change gloves, and used the same dirty gloves to apply a clean brief. In interview, CNA D stated she was not aware whether she was supposed to change gloves and complete hand hygiene after cleaning the resident and said she did not think she needed to wash her hands after changing the resident if she changed gloves. LVN E, the infection preventionist, stated CNA D was expected to complete hand hygiene and change gloves after cleaning the resident, and the DON stated the same expectation. The facility policy on hand washing/hand hygiene stated hand hygiene is the primary means to prevent the spread of infections and that glove use does not replace hand washing/hand hygiene.
Overfilled Sharps Containers in Multiple Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of sharps containers in resident rooms. During observations on 01/20/26 between 10:00 AM and 11:00 AM, all resident rooms were noted to have sharps containers mounted by the door. In nine occupied rooms (104, 105, 108, 209, 212, 306, 307, and 312), the sharps containers were filled past the marked fill line to the extent that the security flap could not operate. Record review of the facility’s “Sharps Disposal” policy dated January 2012 showed that designated individuals were responsible for sealing and replacing containers when they were 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container. In interviews, an LVN stated that nurses were responsible for replacing sharps containers when they reached the fill line and acknowledged that overfilling created a risk of exposure to bloodborne pathogens from used needles. The ADON stated that nurses were responsible for changing out sharps containers, and that all staff were responsible for monitoring the boxes and alerting a nurse when a change was needed; the ADON also stated that an overfilled container posed a risk of exposure to used needles that could cause infection from pathogens. The DON reported she was not aware that sharps containers were overfilled and stated that both nurses and housekeeping had keys and could change out a full box, and that the risk of an overfilled container was bloodborne pathogen exposure from a used needle.
Failure to Document Verbal Order for PRN Cough Medication
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for one resident when a nurse did not enter a physician’s verbal order for cough medication into the electronic health record (EHR). The resident was an elderly female with emphysema, lung cancer, end-stage kidney disease requiring dialysis, and diabetes, who had a care plan noting a self-care deficit, a lung tumor, and scheduled dialysis three times weekly. Progress notes documented that the resident had a persistent cough, and on a subsequent day, LVN B documented that cough syrup was administered for this cough. However, review of the resident’s physician orders showed no corresponding order for cough syrup. During interview, LVN B stated she had contacted the resident’s nurse practitioner and received a verbal order for guaifenesin 10 ml every 4 hours as needed for cough, and that she administered the medication immediately due to the severity of the resident’s cough but forgot to enter the verbal order into the physician orders. The DON confirmed that nurses were permitted to accept verbal or phone orders and were expected to write the order down, repeat it back to the prescriber, and enter it into the EMR, ideally immediately or at least before the end of the shift. The facility’s Medication and Treatment Orders policy required that drug orders be recorded on the physician’s order sheet and that verbal orders be recorded immediately in the resident’s chart with the prescriber’s last name, credentials, date, and time. These requirements were not followed in this instance, resulting in an incomplete and inaccurate medical record for the resident.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the storage and handling of respiratory equipment. Resident #1, a cognitively intact female with chronic respiratory failure and hypoxia, was observed with a nebulizer mask improperly stored on top of the machine without being bagged. The resident was unaware of the proper storage procedure and stated that it was not her responsibility to bag the mask. The nurse responsible for administering the treatment did not ensure the mask was stored correctly after use. Similarly, Resident #2, also cognitively intact and diagnosed with chronic respiratory failure and hypoxia, was observed with a nasal cannula connected to a portable oxygen tank hanging on the wheel of her wheelchair, not bagged and almost touching the wheel. A CNA acknowledged the improper storage and indicated the risk of contamination. The RN later confirmed the improper storage and replaced the equipment but had not noticed the issue initially. Interviews with the facility's Administrator and DON revealed an expectation for staff to bag respiratory equipment when not in use to prevent infection. However, the facility's policy on bagging the nasal cannula was not provided upon request, indicating a possible gap in policy communication or availability.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA B during the provision of incontinent care to Resident #2. Resident #2, a cognitively intact female with muscle weakness and atrophy, required maximal assistance for toileting. During the care, CNA B did not perform hand hygiene between glove changes, which is a critical step in preventing cross-contamination and infection. Specifically, after cleaning the resident's perineal area, CNA B changed gloves without sanitizing his hands and repeated this omission after touching the trash can before handling a new brief. The facility's policy on hand hygiene emphasizes the importance of using an alcohol-based hand rub before donning sterile gloves and after contact with contaminated items. Despite having received in-service training on hand hygiene and infection control, CNA B acknowledged his failure to apply these practices, which could lead to cross-contamination. The facility's Administrator and DON both recognized the importance of hand hygiene in preventing infections and acknowledged the need for staff to adhere to established policies and procedures.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to Resident #81, a male with a cognitive status intact, diagnosed with heart failure, cerebral palsy, and paraplegia, who was dependent on staff for toileting and always incontinent of bowel and bladder. On 11/17/24, during the 2:00 PM - 10:00 PM shift, there was no documentation of incontinence care provided to the resident. Resident #81 reported having to wait an hour and forty-five minutes for care, during which he sat in a wet brief. The resident's call light was answered by an LVN who informed him that CNA A would assist him after attending to other residents, but the LVN did not follow up to ensure the care was provided. CNA A, who was assigned to a different hall, did not reach Resident #81 until around 9:00 PM, stating he was unaware of the call light and had to prioritize other residents. The Director of Nursing (DON) was unaware of the staff's true names and the lack of documentation for the shift. The facility's policy on perineal care emphasizes the importance of timely care to prevent infections and skin irritation, but this was not adhered to, placing the resident at risk for skin breakdown and infection.
Failure to Provide Adequate Wound Care for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary wound care for a resident with pressure ulcers on two consecutive days, leading to a deficiency in care. The resident, who was cognitively intact, reported not receiving wound care on the specified dates despite requesting assistance multiple times. The resident's medical history included a pressure ulcer on the right buttock, among other conditions such as hypertension, cerebral infarction, and type 2 diabetes. The resident expressed dissatisfaction with the care received over the weekend, noting that the weekday staff provided better assistance. The Charge Nurse responsible for wound care over the weekend claimed to have completed the necessary treatment, but there was no documentation to support this. The Treatment Administration Record (TAR) was not completed for the dates in question, and the Director of Nursing (DON) was made aware of this issue. Despite the nurse's assertion that the care was provided, the resident and the condition of the wound dressing suggested otherwise. The resident's wound was observed to have a moderate amount of slough and skin excoriations, indicating a lack of proper care. Interviews with the nursing staff revealed inconsistencies in the documentation and communication regarding the resident's wound care. The Assistant Director of Nursing (ADON) and other staff members were unaware of the missed treatments until informed by the resident. The facility's wound care policy outlines specific procedures for documentation and care, which were not followed in this instance. The failure to provide adequate wound care and maintain accurate records could have serious implications for the resident's health and well-being.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Allen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Belmont At Twin Creeks | 1.5 mi | ★★★★★ | 6 | 0 |
| Mckinney Healthcare And Rehabilitation Center | 4.8 mi | ★★★★★ | 1 | 0 |
| The Park In Plano | 4.9 mi | ★★★★★ | 11 | 0 |
| Collinwood Nursing And Rehabilitation | 5.7 mi | ★★★★★ | 2 | 0 |
| Garnet Hill Rehabilitation And Skilled Care | 5.7 mi | ★★★★★ | 11 | 0 |
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