The Healthcare Resort of Plano

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 4 residents reviewed for pressure ulcers. CNA A and CNA B failed to reposition Resident #1 as required by her orders and care plan on 10/15/25. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life. Record Review of Resident 1's admission MDS assessment, dated 09/19/25, revealed she was a [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four (Residents #1, #17, #30, and #156) of eighteen residents reviewed for respiratory care. 1. The facility failed to ensure Resident #1's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) at the back of the wheelchair was properly stored on 06/24/2024. 2. The facility failed to ensure Resident #17's nasal cannula was properly stored on 06/25/2025. 3. The facility failed to ensure Resident #30 had water on her humidifier bottle (a medical device designed to increase the moisture level in supplemental oxygen) and had an order for oxygen administration. 4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored properly in locked compartments for one (Resident #107) of fifteen residents and for two (Resident #107, Resident #`60) residents and one (Crash Cart #1) of four carts reviewed for storage of drugs and biologicals. 1. The facility failed to ensure that LVN B did not leave Resident #155's medications unsecured inside the resident's room on 06/24/2025. 2. The facility failed to ensure Resident #160's eyedrops were not left inside the resident's room on 06/24/2025. 3. The facility failed to ensure Resident 107's Lantus was not left on top of the nurse's cart on 06/25/2024. 4. The facility failed to ensure Crash Cart #1 was locked on 6/25/2025. [...]

Inspectors wroteBased observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (Residents #4, #39, #105, #107, #158, and #159) of twenty one residents reviewed for infection control. 1. The facility failed to ensure CNA H changed her gloves while providing incontinent care to Resident #4 on 06/25/2025. 2. The facility failed to ensure Resident #39's catheter bag (collects urine from the urinary bladder) was off the floor on 06/24/2025. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the personal privacy during medical treatment and personal care for two (Resident #106 and Resident #158) of twenty-one residents reviewed for privacy. 1. The facility failed to ensure CNA F and CNA G closed the door while transferring Resident #106 from wheelchair to bed using a mechanical lift (a mechanical lift used to transfer an individual with limited mobility) on 06/25/2025. 2. The facility failed to ensure RN J closed door while administering Resident 158's IV (administration of fluids or medications through a tube inserted in the vein) antibiotics on 06/25/2025. These failures could place the residents at risk of not having their personal privacy maintained during transfer and medical treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #43) of eight residents reviewed for care plans. The facility failed to ensure that Resident #43 had a care plan for her external catheter (non-invasive device used for urine collection that fits outside the body). This failure could place the residents at risk of not receiving the necessary care and services needed.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #43) three residents reviewed for catheter care. The facility failed to ensure that Resident #43's external catheter had an order on 06/24/2025. This failure could place residents with catheter at risk of not receiving continuity of catheter care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 (Resident #12) of 5 residents reviewed for pharmacy services. 1. The facility failed to accurately transcribe the pharmacist medication change order for Resident #12's Losartan/HCTZ Tab 100-12.5 on 08/14/2024. The order was transcribed as Losartan/Tab 300 and Hydrochlorothiazide (HCTZ) 12.5 mg. 2. LVN A, LVN B, RN C, and LVN D incorrectly documented they administered Losartan 300mg and Hydrochlorothiazide (HCTZ) 12.5 mg when they actually administered the resident's home medication of Irbesar/HCTZ Tab 300-12.5 mg from 09/08/24 to 09/15/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent accidents, for one Resident (Resident #1) of one resident reviewed for elopement risk. The facility staff failed to ensure that a contractor working in the facility did not let Resident #1 exit out of the facility, through a side door, unsupervised on 05/24/24. After exiting, Resident #1 was found unsupervised across a major roadway by facility staff. The noncompliance was identified as PNC. The IJ began on 05/24/24 and ended on 05/31/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injuries.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 1 (Resident #27) of 1 resident reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #27 after return from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (West Hall) and 6 of 6 (Resident #1, #2, #3, #16, #27, #32, #37, and #143) reviewed for pharmacy services. 1. LVN D failed to document the administration of narcotic medications in a timely manner for Residents #1, #2, and #27. 2. The facility failed to ensure the [NAME] Hall nurses medication cart contained accurate narcotic logs for Residents #3, #32, and #143. 3. The facility failed to ensure Residents #1, #16 and #27 lidocaine patches and #37's intravenous bottle and tubing were labeled with the date, time, and the initials. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and were labeled in accordance with currently accepted professional principles for 2 (Residents #143 and #146) of 10 residents reviewed for pharmacy services and one (West Hall cart) of two medication carts reviewed for storage of medications. 1. The facility failed to ensure Residents #143 and #146's Fluticasone Propionate (Nasal spray), Potassium tablet, Brimonidine eye drop solution 02.2% and Restasis (cyclosporins opth 0.05% eye drops were not stored at the resident's bedside table and not secured in the medication cart or medication room. 2. The facility failed to ensure the nurse medication cart for the [NAME] Side Hall was locked when unattended on 05/16/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 8 residents (Resident #1, #2, and #27) reviewed for infection control. LVN D failed to perform hand hygiene, disinfect the blood pressure cuff between residents while monitoring blood pressure to Resident #1, #2, and #27 and disinfecting the insulin pens tips while administering insulin to Residents #2. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #194) of five residents reviewed for care plans. The facility failed to create a care plan addressing Resident #194's hearing deficit. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstratesf that they were unavoidable for 1 (Resident #1) of 1 resident reviewed for an in-house acquired pressure ulcer. The facility failed to prevent Resident #1 from developing a pressure ulcer. The facility's failure could affect the prevention of pressure ulcers and affect residents with pressure ulcers and put them at risk for worsening of the wound, infection, and inappropriate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice based on the comprehensive assessment of a resident for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure that Resident #1 received timely orders for wound care for wounds present on admission to the facility. The failure could place residents at risk of infection and wound deterioration.

Inspectors wroteBased on observation and interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #3) of four residents reviewed for infection control. WCN failed to utilize appropriate infection control practices during wound care to Resident #3. This deficient practice could place residents at risk of infection, slow wound healing, and or a decline in health.

Inspectors wroteBased on record review, interviews, and observation the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered are plan, and the resident's goals and preferences for 2 (Resident #10, Resident 40) of 3 residents reviewed for physician order for PICC line. The facility failed to ensure there was an order prior to placing a PICC line The facility failed to ensure proper date of dressing changes were written on the dressing for residents #10 and #40 This failure could affect all residents at the facility by placing them at risk placing a PICC line in the wrong resident, other staff including the physician not being aware of the PICC line therefore and staff including the physician not being aware of the dressing change dates, and not providing care as required.

Inspectors wroteBased on interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for four (Residents #23, #45, #1, and #107) of ten residents reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature to residents who complained the food was cold or not hot during the breakfast service on 02/22/23. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that each resident received, and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community for one (breakfast on 02/22/23) of one meal observed. The facility failed to serve the 02/22/23 breakfast meal on time at the scheduled time. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medications given without food, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for all 8 of 8 reviewed for proper food storage in that: The facility failed to ensure foods were properly stored, labeled, and expired foods were discarded This failure could affect all residents at the facility by placing them at risk for food exposed to adulteration or potential contaminants

Inspectors wroteBased on interview and record review, the facility failed to ensure, based on a comprehensive assessment, that PRN orders for psychotropic drugs were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication for 1(#45) of 8 residents reviewed for psychoactive medications, in that: The facility failed to ensure that Resident #45 had orders for psychotropic medications (Clonazepam) that did not contain PRN orders beyond 14 days without a stop date and reassessment. This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions.

Inspectors wroteBased on observations, interview, and record review, the facility failed to, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs, to meet the needs of each resident, for one (Resident #00) of five residents reviewed for medication storage. The facility failed to ensure Resident #00 did not have prescription and unsecured medication in his room on 2/21/23. This failure could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #00) of five residents observed for infection control in that: 1. CNA F failed to perform hand hygiene during incontinent care for Resident #00.

Inspectors wroteBased on observation and interview the facility failed to ensure that the daily nurse staffing was posted as required. The facility failed to update the daily staffing information posting between 02/16/23 and 02/22/23. This failure could place the residents, families, and visitors at risk of not having access to information regarding the daily nurse staffing data and facility census.