The Park in Plano

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 3 residents (Resident #1) reviewed for right to receive written notification in that: The facility failed to follow their policy, which required a 5 day written notice of a room change, before Resident #1 was moved to a different room on 06/29/26. This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility's freezer and prep area were labeled and dated. These failures could affect residents by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observations, interviews, and record reviews 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 #42) of five residents, reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene during incontinence care for Resident #42. This failure placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 15 residents (Resident #1) reviewed for abuse. The facility failed to keep Resident #1 free from physical abuse by the Private Sitter on 01/30/2026. This failure could place residents at risk of abuse, harm, pain, mental anguish and emotional distress.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and time frames to meet the resident's medical, nursing, and psychosocial needs identified in the comprehensive assessment for 1 (Resident #1) of 4 residents reviewed for care plan review and revision. The facility failed to review and revise Resident #1's care plan after a fall on 05/06/2025 and a fall with major injury on 05/13/2025. This failure could affect all residents and contribute to residents not receiving the care and services they needed to prevent falls.

Inspectors wroteBased on interview, observations, 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 for two (Resident #1 and Resident #2) of three residents reviewed for pharmacy services. The Charge Nurse failed to administer Resident #1 and Resident #2 medications within one hour before or after the scheduled medication time in the morning of 04/29/2025. 1. The facility failed to administer on time Resident #1's Ascorbic Acid Tablet 500 MG , Oral tablet two times a day as ordered on 03/24/2025. 2. The facility failed to administer on time Resident #1 Carvedilol Tablet 3.125 MG, 1 tablet by mouth two times a day for Hypertension on 04/29/25. 3. [...]

Inspectors wroteBased on 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 1 (Resident #3) of 3 residents reviewed for infection control. 1. The Charge Nurse failed to sanitize the blood pressure cuff and the pulse oximeter between Resident #2 and Resident #3 on 04/29/25. This failure could put residents at risk of infection from cross contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 5 of 12 resident rooms (room [ROOM NUMBER], #2, #3, #4, and #5) reviewed for environment. The facility failed to ensure Resident Rooms #1, #2, #3, #4, and #5 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 20 residents (Resident #11, #27, and Resident #29) reviewed for ADL care provided to dependent residents. 1. The facility failed to ensure Resident #11 received proper podiatry care to treat feet. 2. The facility failed to provide fingernail care for Residents #27 and #29. These failures could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Include: 1. Record review of Resident #11's face sheet, dated 01/28/25, reflected an [AGE] year-old male who was originally admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to store, prepare, distributed, and serve in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the date the product was received from the vendor or date the product was stored after being used. 2. The facility failed to ensure the food stored in the freezer was properly sealed from air-borne contaminants. 3. The facility failed to ensure the ice machine in the dining area was cleaned. 4. The facility failed to cover a large trash can stored in the kitchen area. These failures could place residents at risk for cross contamination and other air-borne illnesses.

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 nine (Resident #5, Resident #6, Resident #18, Resident #26, Resident #27, Resident #33, Resident #39, Resident #43 and Resident #52) of eighteen residents reviewed for Infection Control. 1. The facility failed to ensure CNA G performed hand hygiene before checking on Resident #27 on 01/28/2025. 2. The facility failed to ensure LVN A did not bring the whole container of test strips used for checking blood sugar inside Resident #33's room on 01/28/2025. 3. [...]

Inspectors wroteBased on , interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to attain or maintain the resident's highest practicable mental nad psychosocial well-being for 1 of 5 residents (Resident #53) reviewed for care plans. The facility failed to ensure Resident #53 was care planned for the weekly psychological services being received based on physician orders dated 11/24/2024. This failure could place residents at risk of not receiving the necessary care and services needed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for one of three residents (Resident #5) reviewed for Incontinent Care. The facility failed to ensure CNA D used proper technique to clean Resident 5's perineal area (area between the legs) on 01/29/2025. This failure could place residents at risk of cross-contamination and development of urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #52) of two residents reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure LVN A cleaned the syringe and flushed the g-tube during Resident #52's medication administration through gastrostomy tube (G-tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) on 01/28/2025. These failures could place residents with G-tubes were at risk for infection, dehydration, and drug-to-drug interaction.

Inspectors wroteBased on observation, interview, 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 one (Resident #18) of twelve residents reviewed for Respiratory Care. The facility failed to ensure Resident #18's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 01/28/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

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 two (Resident #1 and Resident #20) of eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #1 was care planned for oxygen administration. 2. The facility failed to ensure Resident #20 was care planned for oxygen therapy (oxygen delivered through a flexible tube to the nose through two prongs) and droplet precautions (prevent infection with germs that can be spread by speaking, sneezing, or coughing). [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #1 and Resident #5) of twenty residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Resident #1 and Resident #5 on 11/05/2024. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #4) of 4 residents reviewed for (ADLs) care provided to dependent residents. The facility failed to ensure Resident #4 received scheduled bed baths reviewed from October 1, 2024 - October 31, 2024. This failure placed the resident at risk of not receiving necessary services to maintain good personal hygiene, skin breakdown, and decreased self- esteem.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 ( unknown Resident) of 68 residents at the facility reviewed for accident prevention . The facility failed to secure a coffee station on 11/06/24 that allowed for residents to self-serve coffee, which could result in skin burns. This failure could prevent residents from having an environment that was free and clear of accidents and hazards.

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 two (Resident #2 and Resident #6) of twelve residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #2's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored on 11/05/2024. 2. The facility failed to ensure that Resident #6's oxygen concentrator (machine that produces oxygen) had a humidification bottle (adds moisture to reduce nasal irritation) connected to it on 11/05/2024. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one (Resident #3) of five residents were provided medications and/or biologicals and pharmaceutical services to meet their needs. The facility failed to ensure LVN A did not leave Resident #3's medications inside the resident's room on 11/05/2024. This failure could place the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased observations, interviews, 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 #4) of eight residents reviewed for Infection Control. The facility failed to ensure that CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #4 on 11/06/2024. This failure could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of three residents reviewed for medication errors in that: The facility failed to administer Resident #1's blood pressure medications as ordered by the physician. This failure could place residents at risk of medical complications and a decrease in therapeutic dosages of their medications as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity for 1 of five (Resident #2) residents reviewed for dignity in that: The facility failed to ensure staff did not stand over Resident #2 while assisting the resident with her meal in the dining area on 08/21/2024 This failure could affect residents who require assistance with activities of daily living and placed them at risk for psychosocial harm due to a diminished quality of life.

Inspectors wroteBased interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 21 days of the 4-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the services of a registered nurse for at least 8 consecutive hours a day on Saturdays and Sundays for 21 days of the four months (July 20023 - December 2023) reviewed. This failure placed residents at risk of receiving higher levels of patient care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #70 and Resident #46) of eight residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #70 and #46's rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 8 (Resident #'s 2, 10, 12, 31, 36, 38, 50, and 51's) of 27 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Resident #'s 2, 10, 12, 31, 36, 38, 50, and 51's rooms were cleaned, sanitized, and maintained, based on observations made on 12/12/23. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 4 of 8 (Resident #2, #26, #35 and #43) residents reviewed for restraints. The facility failed to ensure Residents #2, #26, #35 and #43 had physician orders as of 12/12/2023 for the bolster side rails on their mattress . These failures could unnecessarily inhibit the residents' freedom of movement or activity.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 3 of 6 residents (Resident #2, #38, and #59) reviewed for Care Plans. The facility failed to ensure Resident #2, #38, and #59's Care Plan was reviewed and updated quarterly, based on record reviews made on 12/13/23. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerators, and freezer were labeled and dated according to guidelines and in a sanitary manner in the facility's only kitchen. The facility failed to ensure the kitchen was clean and sanitized. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased 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 2 (Resident #43 and Resident #55 ([NAME]) of 8 residents reviewed for infection control. 1. The facility failed to ensure the ADON performed hand hygiene while providing incontinence care to Resident #43. 2. The facility failed to ensure the WCN performed hand hygiene while providing wound care to Resident #55. This failure could place residents at risk of cross-contamination resulting in infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity for 1 of 8 residents (Resident #42) reviewed for resident rights. 1. The facility failed to ensure CNA A provided privacy to Resident #42 while transporting her to the shower room. This failure placed the residents at risk of not having their privacy respected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carryout activities of daily living received services to maintain grooming and personal hygiene for 1 of 8 residents (Resident #43) reviewed for quality of life. The facility failed to ensure CNA B provided Resident #43 with timely incontinent care. These failures could place residents at risk for a decreased quality of life and pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #45) of three residents reviewed for feeding tube. The facility failed to ensure LVN H would cap the tip of Resident #45's gastrostomy tube (G-tube-a tube inserted through the abdomen that delivers nutrition directly to the stomach) when not in use. This failure could place residents with G-tubes at risk of infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #67) of two residents reviewed for respiratory care. The facility failed to ensure Resident #67's oxygen concentrator had a humidifier.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1 had oxygen concentrator filters free of sediment and debris. This failure could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Findings Included: Review of Resident #1's face sheet on 10/19/2023 revealed she was an [AGE] year-old female re-admitted to the facility on [DATE]. [...]