The Plaza at Richardson

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for one (Resident #1) of three residents reviewed for abuse and neglect. 1. The facility failed to report an allegation of abuse involving Resident #1 to the local police department immediately but no later than 24 hours on 07/21/2026. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of three residents (Resident #1) reviewed for pharmacy services. Med Aide B failed to ensure Resident #2's 8 AM medications were given on time on 01/07/26 according to facility policy. Med Aide B failed to document Resident #2's 8 AM medications were given late on 01/07/26. These failures placed residents at risk of not receiving medications timely and as ordered by physician.

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 1 of 2 residents (Resident #1) reviewed for infection control. 1. The facility failed to ensure Med Aide B performed hand hygiene while administering medication to Resident #1 on 01/07/26. 2. Med Aid B failed to sanitize the wrist blood pressure cuff prior to checking Resident #2's blood pressure and prior to putting it in the medication cart. These failures could place residents at risk for infection and cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident bedside was adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 1 of 3 residents (Resident #2) reviewed for residents' call system. The facility failed to ensure Resident #2's call light was not accessible to the resident and within reach. This failure could place residents at risk of a delay in getting assistance and of not having a means of directly contacting staff in an emergency.

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 safety in the facility's only kitchen. 1. The facility failed on 06/24/2025 to ensure the stand-by refrigerator opened food items were dated. 2. The facility failed to ensure the walk-in refrigerator food items were dated, labeled and securely stored. 3. The facility failed to ensure the walk-in freezer food items were dated and labeled. 4. The facility failed to ensure the dry storage food items were dated and labeled. 5. The facility failed to ensure that canned good food items were free of dents. 6. The facility failed to ensure that dishwashing protocol was followed. 7. The facility failed to ensure that prepared foods were held correctly and maintained safe temperatures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for two of the three hallways reviewed for pest control and the facility's only kitchen. The facility failed to ensure Hall 200 and 400 were free of gnat flies. The facility failed to ensure the facility's only kitchen was free of gnat flies. This failure could lead infestation of pests and compromise resident health

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to one medication cart of four medication carts observed for medication security, and for one medication in one of two common areas observed for medication security. 1. The facility failed to keep a dialysis medication cart locked in Resident #40's room. On 6/24/25 at 4:00 pm an unlocked dialysis medication cart containing intravenous medications was observed in Resident #40's room and unlocked dialysis fluids were observed in the room. 2. The facility failed to keep one medication (Advair Diskus) secured in a common area near the nurse's station . [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for 1 of 20 residents (Resident #52) reviewed for environment. The facility failed to ensure Resident #52's bedroom floor was clean of regurgitated food, on 6/24/2025, after it had been on the floor from 11:50 AM to 2:40 PM. 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 and interview, the facility failed to must ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for one (the only medication room) of one medication rooms reviewed for pharmacy services. The facility failed to ensure expired gentle female intermittent catheters were removed from the facility's only medication room on [DATE]. These failures could place residents at risk for infection and possible adverse effects.

Inspectors wroteBased on observation and interview, the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for one (the only medication room) of one medication rooms reviewed for pharmacy services. The facility failed to ensure expired IV/PICC supplies were removed from the facility's only medication room on [DATE]. These failures could place residents at risk for infection and possible adverse effects.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for (Resident #65) one of one resident reviewed for infection control. The facility failed to ensure CNA A performed hand hygiene while feeding lunch to Resident #65 on 06/24/25. This deficient practice could place residents at risk for infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately for 1 of 4 residents (Resident #1) reviewed for reporting, in that: The facility failed to report the allegation of neglect for Resident #1 to the State Agency within required reporting timeframes. This failure could place residents at risk ongoing abuse or neglect.

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 3 residents (Resident #1, Resident #2, and Resident #3) of 4 residents reviewed for discharge planning. -The facility failed to provide or document sufficient preparation for an orderly discharge of Resident #1 to a private residence and Resident #2 and Resident #3 to a nursing facility. This failure could place residents at risk of not receiving care and services to meet their needs upon discharge, which could cause physical and emotional harm.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an effective discharge planning process that focused on a resident's discharge goals and allowed the resident to be an active partner in the transition and development of a discharge plan for 3 residents (Resident #1, Resident #2, and Resident #3) of 4 residents reviewed for discharge planning. - The facility failed to prepare and involve Residents #1, #2, and #3 and responsible parties in an effective discharge planning process. This failure could place all residents at risk of not being an active part in their goals and discharge planning process, which could result in an unsafe discharge, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify a Grievance Official who was responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions, and leading any necessary investigations by the facility for 1 of (Resident #1) of 3 residents reviewed for grievances. 1. The facility failed to ensure the Grievance Official was aware of a grievance for Resident #1. The Grievance Official failed to investigate a grievance for Resident #1. The facility's failure could place the residents at risk for concerns not being reported and addressed.

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 for 1 (Resident #35) of 8 residents reviewed for pharmacy services. The facility failed to obtain the routine scheduled pain medication for Resident #35, who was to receive it every 4 hours, from her hospice company. Resident #35 missed 7 doses of her scheduled pain medication placing her at risk for unnecessary pain. The medications were received after surveyor inquiry. This failure could place residents who require pain medication at risk of suffering pain due to lack of medication availability.

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 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure foods in the refrigerator, freezer, and dry storage were properly stored, labeled, and dated. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (Resident #42) of six residents reviewed for accidents and hazards. The facility failed to ensure Resident #42 did not have access to a disposable razor. This failure could place residents at risk of injury or harm, as well as contribute to avoidable accidents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of five residents (Resident #32) reviewed for infection control. CNA C failed to perform hand hygiene while providing incontinence care to Resident #32 and between resident rooms. This failure could place the residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two (Residents #25 and #218) of eighteen residents reviewed for resident rights and dignity. 1. The facility failed to treat Resident #218 with dignity and respect during the discharge process from the facility to the resident's home. 2. The ADON failed to ensure Resident #25 was provided with a dignified dining experience, when she stood over him as she was assisting him in eating a lunch meal service. This failure could place residents at risk for a loss of dignity, decreased self-worth, and decreased self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for one of one resident (Resident #1) reviewed for abuse. The facility failed to report an allegation of sexual abuse of Resident #1 that occurred on 03/23/24 by CNA A, to the State Survey Agency within 2 hours of being notified. This failure could place residents at risk of abuse.

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 measurableobjectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect the resident's diagnosis of prostate cancer. This failure could place the residents at risk of not receiving adequate care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure menus were followed for 10 of 10 residents (Resident #5, #17, #24 #27, #34, #42, #46, #43, #45, and #48) reviewed for menus meeting resident needs. 1. The facility failed to ensure the menu was followed and residents (Resident #5, #17, #24 #27, #34, #42, #46, #43, #45, and #48) were served pork sausage, scrambled eggs and waffles for breakfast instead of a choice of cereal, bacon, scrambled eggs and toast as indicated on the breakfast menu . 2. The facility failed to ensure the menu was followed and residents (Resident #5, #17, #24 #27, #34, #42, #46, #43, #45, and #48) were served turkey with gravy, green beans, cornbread and frosted orange cake, instead of red beans and sausage, steamed rice, mixed greens, cornbread and frosted orange cake as indicated on the lunch menu . [...]

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 safety in the facility's only (1 of 1) kitchen where all facility food was prepared. The facility failed to ensure food was dated and not expired in their kitchen. This failure could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan, and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 08 of 10 residents (Residents #5, #17, #27, #34, #42, #43, #45, and #46 ) reviewed for activities. 1. The facility failed to provide activities to residents who resided in the facility. 2. The facility failed to provide activities to residents who resided on the facility's secured unit. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for one (the Activity Director) of one Activity Director reviewed for qualifications. The facility failed to ensure the Activity Director was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for a reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.

Inspectors wroteBased on interview and record review the facility failed to ensure, except when waived, they used the services of a registered nurse for at least eight consecutive hours a day, 7 days a week (for 26 days out of 90 days reviewed) and designate a registered nurse to serve as the director of nursing on a full-time basis (from 12/11/22 to 1/4/23 and 2/6/23 to 3/8/23). 1. The facility failed to designate a Registered Nurse to serve as the Director of Nursing on a full-time basis from 12/11/22 to 1/4/23 and 2/6/23 to 3/8/23. 2. The facility failed to employ a Registered Nurse to provide eight consecutive hours of RN coverage, seven days a week for 26 days between 12/01/22 to 03/19/23. These deficient practices could place residents at risk of leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.

Inspectors wroteBased on interviews and record reviews, the facility failed to act upon the recommendations of the pharmacist report of irregularities for three residents (Residents #40, #37 and #26) of five residents reviewed for (DRR) Drug Regimen Review. 1. The facility failed to follow-up on a recommendation from the pharmacist regarding Resident #40's PRN psychotropic medications (Haldol [Haloperidol] and Lorazepam). 2. The facility failed to follow-up on a recommendation from the pharmacist regarding Resident #40's medications (lactobacillus, hyoscyamine, and baclofen) that were listed to be given orally although the resident was NPO. 3. The facility failed to follow-up on a recommendation from the pharmacist regarding Resident #37's Depakote and Risperidone when the diagnoses were not approved indications. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary drugs for three (Residents #40, #37 and #2) of five residents whose records were reviewed for psychotropic drugs, in that: 1. Resident #40 had an order for the antianxiety medication lorazepam as needed on 08/10/22 and the order did not include an end date after 14 days. 2. Resident #40 had an order for the antipsychotic medication haloperidol as needed on 11/08/22 and the order did not include an end date after 14 days. 3. Resident #37 had an order for the antipsychotic medication Risperdal for a diagnosis of unspecified psychosis, which was not an appropriate indication for use. 4. Resident #37 had an order for the anticonvulsant medication Depakote for a diagnosis of unspecified dementia, which was not an appropriate indication for use. 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 27%, based on 18 errors of 66 opportunities, which involved two of six residents (Residents #12 and #14) and 1 of 2 staff observed during medication administration for medication errors. The facility failed to ensure the medications were administered per the physician orders for Residents #12 and #14. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for three (Residents #36,#34, and #40) of five residents reviewed for clinical records. 1. The facility failed to document on Resident #36's MAR/NAR that he had received his prescribed medications. 2. The facility failed to document on Resident #34's MAR/NAR that he had received his prescribed medications. 3. The facility failed to ensure that Resident #40's physician's orders for lactobacillus, hyoscyamine, and baclofen were written to be given NPO and not orally. This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided.

Inspectors wroteBased on record review and interview, the facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis for one of one Social Worker reviewed employment , in that: The facility, licensed for 124 beds, did not employ a full-time, qualified social worker since 02/28/23. This deficient practice could result in residents' social service needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two (Residents #36 and #16) of eight residents observed for infection control. 1. The facility failed to ensure CNA B completed hand hygiene while performing incontinent care for Resident #16. 2. The facility failed to ensure LVN U performed hand hygiene while performing wound care for Resident #36. These failures could place the residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for one (Resident #34) of three residents reviewed for dignity in that: The facility failed to ensure Resident #34's urinary catheter drainage bag had a dignity/privacy cover. This deficient practice affected residents who had indwelling urinary catheters and placed them at risk for dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 5 residents (Resident #40) reviewed for medication administration in that: The facility failed to ensure medications via feeding tube were not crushed and mixed together when being administered to Resident #40. This deficient practice could affect residents and place them at risk of not receiving the therapeutic dosage and drug diversion.

Inspectors wroteBased on observation and interviews, the facility failed to assure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, for one (Resident #40) of five residents reviewed for labeling and storage, in that: The facility failed to ensure Resident #40's tube feeding formula was labeled with the correct resident's name on it. This deficient practice could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications.

Inspectors wroteBased on observation , interview and record review the facility failed to provide 2 of 10 residents (Resident #45 and #43) reviewed with food prepared in a form designed to meet individual needs a physician ordered therapeutic diet. 1. The facility failed to follow Resident #43 physician ordered for no pork. 2. The facility failed to follow Resident #45 dietician ordered mechanical soft texture as ordered by the dietician. These deficient practices could place residents at risk of weight loss or other medical problems.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the daily nurse staffing was posted as required. The facility failed to post the daily staffing information posting from 03/20/23 to 03/22/23. 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.