Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Victoria Gardens Of Frisco during CMS and state inspections, most recent first.
A resident with left-sided hemiplegia, serious mental illness, severe pain, and total dependence for mobility and most ADLs was observed in bed with the call light and bed remote hanging off the side of the bed, out of reach. The resident reported difficulty getting staff to respond, stated she yelled for help because she could not find the call light, and sometimes called family to contact staff. Staff, including a MA, CNA, ADON, DON, and Administrator, acknowledged that call lights must be within reach and that clips or alternative devices were available and had been used previously, but these were not consistently in place for this resident. Facility policy required ensuring the call light was easily reachable, yet at the time of observation this requirement was not met.
Surveyors found that drugs and biologicals were not consistently stored in locked compartments, with several residents having medications such as anti-fungal powder, eyedrops, and nasal spray accessible in their rooms without proper assessments or physician orders for self-administration. Staff confirmed that medications should be kept in medication carts and not in resident rooms unless a self-administration assessment is completed, and facility policy requires all medications to be securely stored.
A resident with severe cognitive impairment and multiple diagnoses did not receive a timely and accurate PASRR DME request for a low air loss mattress following an IDT meeting. The MDS nurse, new to the role, encountered repeated submission issues, including missing required documentation, resulting in a delay in providing the recommended equipment.
A resident requiring a two-person Hoyer lift transfer was dropped by a CNA who attempted the transfer alone, contrary to the resident's care plan and facility policy. The resident, with multiple diagnoses and total dependence on staff, was at risk due to this inadequate supervision.
A resident with dementia and other medical conditions was improperly restrained by an occupational therapist during a therapy session. The therapist used physical force to restrict the resident's head and mouth after the resident became agitated and spat at the therapist. This action violated the facility's policy and the resident's rights, as the restraint was not required for medical treatment.
A resident with dysphasia was served a fish sandwich containing small bones, despite requiring a mechanically altered diet. The facility had ordered boneless cod patties, but the presence of bones posed a choking risk. The resident reported the issue to the administrator, who confirmed the bones' presence. The dietary manager noted the importance of checking for bones in therapeutic diets, highlighting a deficiency in ensuring food safety.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, leading to improperly labeled and stored food items, moldy produce, and dirty equipment. This was observed in the kitchen, refrigerator, freezer, and dry storage areas, posing potential risks for food-borne illness and cross-contamination.
The facility failed to ensure resident safety by leaving a central supply closet containing hazardous materials open and accessible, and by not maintaining wheelchairs in a safe condition. A confused resident was found near the open closet, and three residents had wheelchairs with cracked armrests. The facility lacked a maintenance person and did not use its computerized maintenance system, leading to unaddressed equipment issues.
The facility failed to maintain an effective pest control program, resulting in the presence of live flies in various areas, including the nurse's station, Halls 100 and 400, and the main dining room. Observations and interviews indicated that flies were a recurring issue, although not consistently reported or documented in the pest control log. The pest control service visited regularly, but the logbook had not been updated since November 2023.
The facility failed to ensure that the call lights for three residents were within reach, which could result in unmet needs and potential harm. One resident with severe cognitive and visual impairments had her call light tangled and placed on top of a refrigerator. Another resident with severe cognitive impairment and a history of falls had her call light placed out of reach behind her refrigerator. A third resident with severe cognitive impairment and a history of falls had his call light placed on a dresser out of reach.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and resident rights to reasonable accommodation of needs and preferences. The resident was an adult female with multiple significant diagnoses, including muscle wasting and atrophy, bipolar disorder, depression, history of stroke with left-sided hemiplegia/hemiparesis, seizures, reduced mobility, anxiety disorder, and cognitive, speech, and language deficits. Her MDS showed serious mental illness, intact memory (BIMS 14), fluctuating inattention, disorganized thinking, altered level of consciousness, and daily behavioral symptoms that interfered with activities and social interactions. Functionally, she was dependent for mobility, transfers, toileting, and most ADLs, always incontinent, and reported almost constant pain at a level of nine out of ten. During observation and interview, the resident was found in bed with the call light and bed remote hanging off the left side of the bed, out of her reach, despite her inability to use her left side. She reported that it was hard to get staff to come, that she yelled because she needed help, and that she often could not find the call button because it always fell. When informed the call light was hanging on her right side, she attempted to reach for it but was unable to pull the cord within reach. She stated she sometimes called family members to contact the facility on her behalf and did not recall ever having a clip on the call light or using a touchpad-type call button. Staff interviews confirmed that the call light was expected to be within reach and that alternative devices or clips were available, but these measures were not consistently implemented for this resident. A medication aide stated she typically placed the call light and remote on the resident’s upper abdomen and acknowledged they could slide off due to the resident’s body not being a flat surface, agreeing another solution was needed. The ADON, DON, CNA, and Administrator all stated that call lights should be within reach and that clips or tying the call light to the bed could be used, and several indicated the resident had previously had a clip or pad-type button that was no longer in place. The Administrator also reported multiple instances of responding to the resident yelling and finding the call light on her chest, while the resident claimed she did not have one. The facility’s written policy required ensuring the call light is easily reachable by the resident, but at the time of surveyor observation, this requirement was not met for this resident.
Failure to Secure Medications in Locked Storage
Penalty
Summary
Surveyors identified that drugs and biologicals were not consistently stored in locked compartments as required by professional standards. Multiple residents were found with medications in their rooms, in plain view and accessible, without documented assessments for self-administration or physician orders permitting them to manage their own medications. For example, one resident with severe cognitive impairment and dementia had an anti-fungal powder on her overbed table, despite no assessment indicating she was competent to self-administer medications. Another resident, who was cognitively intact but had no physician order for Systane eyedrops, had three bottles of the eyedrops on her overbed table. A third resident with severe cognitive impairment had a nasal spray on her dresser, also without a physician order or self-administration assessment. Staff interviews confirmed that medications should not be kept in residents' rooms unless there is a documented assessment supporting self-administration. Nursing staff and administration acknowledged that the presence of medications in resident rooms was not in accordance with facility policy or professional standards. Staff also noted that medications left in resident rooms could be accessed by other residents, particularly those who are confused, and that there was no monitoring of medication use in these instances. Record reviews further revealed that there were no assessments for self-administration, no clear instructions for residents to self-administer, and no documentation of resident competency to manage their own medications. Facility policy required all drugs and biologicals to be stored in locked compartments and for nursing staff to be responsible for medication storage. The observed practices were inconsistent with these requirements, leading to the identified deficiency.
Failure to Timely Submit PASRR DME Request for Low Air Loss Mattress
Penalty
Summary
The facility failed to submit and complete an accurate request and recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report for a low air loss mattress within 20 days after the Interdisciplinary Team (IDT) meeting for one resident. The resident, who had diagnoses including dementia, major depressive disorder, mild intellectual disabilities, and pervasive developmental disorder, was identified as PASRR Level 2 with serious mental and intellectual disability. The MDS assessment indicated severe cognitive impairment, and the resident required limited assistance with activities of daily living. The PASRR record showed the resident was assessed for durable medical equipment (DME) on a specific date, but the facility did not submit a complete and accurate request for the recommended low air loss mattress within the required timeframe after the IDT meeting. Interviews revealed that the MDS nurse, who was new to the position, encountered repeated issues submitting the DME request, including missing a required signature page, which led to the request being denied. Despite these issues, the facility eventually provided the resident with the recommended mattress, but not within the required timeframe. The Director of Nursing stated she was not involved in the PASRR process, and the responsibility was assigned to the MDS nurse. Observations confirmed the resident was eventually provided with the low air loss mattress, but the delay in submission and completion of the PASRR request constituted the deficiency.
Inadequate Supervision During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents, specifically for one resident who required a two-person transfer with a Hoyer lift. On the date of the incident, a Certified Nurse Aide (CNA) attempted to perform a one-person transfer using a Hoyer lift, despite the resident's care plan and facility policy requiring two-person assistance. This resulted in the resident being dropped to the floor during the transfer process. The resident involved in the incident was an elderly female with multiple diagnoses, including Dysphagia, Lymphedema, Alzheimer's Disease, and others, which rendered her totally dependent on staff for activities of daily living, including transfers. The resident's care plan and Minimum Data Set (MDS) clearly documented the need for a two-person assist with a Hoyer lift due to her impaired physical mobility. Despite this, the CNA proceeded with the transfer alone, leading to the resident sliding out of the Hoyer sling and being dropped to the floor. The incident was documented in the resident's progress notes, and it was noted that the CNA had been trained to use the Hoyer lift with at least two people present. The facility's policy and the manufacturer's user manual also specified the requirement for a second caregiver during such transfers. The CNA's actions were contrary to her training and the established protocols, resulting in a situation that placed the resident at risk of serious injury.
Inappropriate Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were not required for medical treatment. On the specified date, an occupational therapist (OT A) applied physical force to restrict the movement of a resident's head and mouth. This action was not in line with the resident's care plan or medical needs and was identified as a past noncompliance issue. The incident was reported to have occurred when the resident became agitated during a therapy session and spat at the therapist, leading to the inappropriate use of physical restraint. The resident involved was an elderly male with a history of dementia, hypertension, stroke, Parkinson's disease, and other medical conditions. His care plan indicated that he was resistive to care and had potential for physical aggression. The care plan included interventions such as allowing the resident to make decisions about treatment, providing clear explanations, and using de-escalation techniques. Despite these guidelines, the therapist's response to the resident's behavior was to physically restrain him, which was against the facility's policy and the resident's rights. Interviews with staff and witnesses revealed that the therapist's actions were not consistent with the facility's training on handling difficult behaviors. The therapist admitted to covering the resident's mouth to block spitting, acknowledging that it was an inappropriate reflex action. The facility's policies clearly state that residents have the right to be free from physical restraints unless necessary for medical treatment, and the incident was a violation of these policies.
Failure to Provide Mechanically Altered Diet Free of Bones
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet individual needs for a resident who required a mechanically altered therapeutic diet. The resident, a female with a history of dementia, diverticulitis, type II diabetes, and dysphasia, was served a fish sandwich that contained small bones, posing a risk of aspiration or choking. The resident, who had intact cognition and could eat independently, discovered the bones while eating and reported the incident to the facility's administrator. The administrator confirmed the presence of bones in the fish and acknowledged the potential risk to residents, especially those with swallowing difficulties. The facility had ordered boneless cod patties from their supplier, and the dietary manager, who had recently assumed her role, stated that the kitchen staff was aware of the importance of checking for bones in food prepared for therapeutic diets. Despite the supplier's error, the facility's failure to ensure the fish was free of bones led to the deficiency, as the presence of bones in the mechanically altered diet could have resulted in choking hazards for residents.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that the ice machine filter and vent were covered in dirt and dust, and the ice machine chute guard had a light pink stain. Additionally, food items in the refrigerator, freezer, and dry storage room were not labeled or stored according to professional standards. Items were found without proper labels, received by dates, or consume by dates, and some items were past their expiration dates. This included various dairy products, sandwiches, cheeses, and produce, some of which were moldy or spoiled. The facility also failed to ensure that multiple food items stored in bins or containers were clearly identifiable. For example, a sheet pan with peanut butter and jelly sandwiches and a metal pan with cheese sandwiches were not properly labeled with item descriptions or consume by dates. In the walk-in refrigerator, several items such as provolone cheese, cheddar cheese, broccoli salad, and seedless green grapes were found without proper labeling. Moldy strawberries were also found in the refrigerator, indicating a failure to inspect produce inventory and monitor for spoilage. Interviews with the Dietary Manager revealed that there were inconsistencies in how inventory was managed and labeled. The Dietary Manager admitted that she did not always have time to label items properly and that the cooks and dietary aides were responsible for inventory in her absence. The facility's Nutrition Services Food Storage Policy and the U.S. FDA Food Code were not followed, leading to potential risks for food-borne illness and cross-contamination among residents.
Failure to Ensure Resident Safety and Proper Maintenance of Equipment
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible. The central supply closet, which contained direct care products such as mouthwash, razors, and toothpaste, was found open and accessible to residents. A confused resident was observed in close proximity to the supply closet with no staff within line of sight. The closet did not have a lock, and staff were unaware of the potential hazard until it was pointed out by a surveyor. The Director of Nursing (DON) and the Administrator were both unaware that the closet lacked a lock and acknowledged the risk of residents ingesting harmful products. Additionally, the facility failed to properly maintain wheelchairs for three residents. Observations revealed that the wheelchairs had cracked armrests with jagged edges and exposed foam, posing a risk of skin tears and other injuries. Interviews with staff indicated that there was no maintenance personnel available to address these issues, and the computerized maintenance system was not in use. Staff were supposed to report equipment issues to the DON or Administrator, but there was no effective system in place to ensure timely repairs. The facility's policies on the receipt and storage of supplies and maintenance services were not followed. Hazardous materials were not properly stored or secured, and equipment was not maintained in a safe and operable manner. The lack of a maintenance person and the failure to use the computerized maintenance system contributed to the oversight in addressing the wheelchair repairs. The DON and Administrator were not aware of the deficiencies until they were brought to their attention during the survey.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live flies in various areas, including the nurse's station, Halls 100 and 400, and the main dining room. Observations on multiple occasions revealed flies crawling on tables, open boxes of formula, and even on a resident's feeding pump. Interviews with staff and family members indicated that flies were a recurring issue, although not consistently reported or documented in the pest control log. The pest control service was noted to visit regularly, but the logbook at the nurse's station had not been updated since November 2023, and there were no current entries for 2024. The facility's policy, revised in September 2023, stated that an ongoing pest control program should be maintained, but the lack of documentation and reporting indicated a failure to adhere to this policy. Despite the presence of flies being observed and reported by family members, staff did not consistently document these sightings or take appropriate action to address the issue. This deficiency could potentially lead to the spread of infection, cross-contamination, and a decreased quality of life for the residents.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that the call lights for three residents were within reach, which could result in unmet needs and potential harm. Resident #1, a [AGE] year-old female with severe cognitive and visual impairments, was observed without her call light within reach. Her call light was found tangled and placed on top of a refrigerator, making it inaccessible. Despite her severe dependency on staff for all activities of daily living, her call light was not positioned correctly, which could prevent her from contacting staff when needed. Resident #20, an [AGE] year-old female with severe cognitive impairment and a history of falls, also had her call light placed out of reach behind her refrigerator. During observations, it was noted that she could not reach the call light and would have to call out for help instead. This placement contradicts her care plan, which specifies that the call light should always be within reach to prevent falls. Resident #21, a [AGE] year-old male with severe cognitive impairment and a history of falls, was found with his call light placed on a dresser out of reach. Although he stated that he could use the call light when it was placed on his bedrail, he was unable to reach it due to his physical limitations. This improper placement of the call light could prevent him from getting timely assistance, increasing the risk of falls and other complications.
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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 Frisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonemere Rehabilitation Center | 1.7 mi | ★★★★★ | 3 | 0 |
| Baybrooke Village Care And Rehab Center | 2.8 mi | ★★★★★ | 20 | 0 |
| The Legacy At Willow Bend | 4.4 mi | ★★★★★ | 4 | 0 |
| Prairie Estates | 5.5 mi | ★★★★★ | 12 | 0 |
| The Belmont At Twin Creeks | 6.5 mi | ★★★★★ | 6 | 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.