Victoria Gardens of Frisco

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure the dry storage food items were dated, labeled and securely stored. The facility failed to ensure the refrigerator food items were dated, labeled and securely stored. The facility failed to ensure the freezer food items were dated, labeled and securely stored. The facility failed to ensure that canned good food items were free of dents. The facility failed to ensure that the kitchen equipment (steam tray table, floors, ovens, drain) was clean. The facility failed to ensure that dishwashing protocol was followed for the 3-compartment sink. The facility failed to ensure baked bread rolls were covered prior to serving. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meeting for 1 of 1 confidential resident reviewed for resident council during survey. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns, grievances not being addressed, and fear of retaliation. Findings Included:An interview on 07/07/2026 at 9:59 AM with Activity Director revealed resident council meetings were being held in the main dining room. She stated they were conducting the meetings in the activity office, but the area was no longer large enough for all who wanted to attend. An observation on 07/08/2026 at 2:30 PM with Resident Council revealed meeting was held in main dining room. [...]

Inspectors wroteBased on 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 2 residents (Resident #89 and Resident #2) of 21 residents reviewed for care plans. The facility failed to correctly care plan Resident #89 advance directive as DNR.The facility failed to care plan Resident #2's primary diagnosis of dementia and primary language of Vietnamese. These failures could affect residents by placing them at risk of not receiving care and services to meet their needs and could deny a resident's end-of-life directive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #1) of four residents reviewed for call lights. The facility failed to ensure Resident #1's call light was within reach of the resident. This failure could place the residents at risk of falling, injury, and feelings of low self-worth due to not being able to call for help.

Inspectors wroteFindings included: 1. Record review of Resident #1's Face Sheet, dated 10/23/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obesity (excessive accumulation of body fats) and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #1's Comprehensive MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 10/02/2025, reflected the resident had as severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 03. The Comprehensive MDS Assessment indicated the resident had dementia and obesity. [...]

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 in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure all foods stored in the refrigerator or freezer was covered, labeled, and dated. 2. The facility failed to ensure wrappers of frozen food stayed intact until thawing. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the dining room on 5/27/2025 at 9:04 a.m., revealed the following: -1 large pitcher of drink not labeled or dated. Observation of the refrigerator on 5/27/2025 at 9:08 a.m., revealed the following: -4 trays of drinks not labeled or dated. Observation of the walk-in freezer on 5/27/2025 at 9:13 a.m., revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to submit and complete 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 IDT meeting for one (Resident #1) of three residents reviewed for PASRR services. The facility did not submit a complete and accurate request for a low air loss mattress for Resident #1 within 20 days after the Interdisciplinary Team (IDT) meeting held on 12/20/2024. The past noncompliance began on 12/20/2024 and ended on 03/17/2025. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents. On 2/22/2025 Certified Nurse Aide (CNA) A attempted to perform a 1-person transfer, with a Hoyer lift, on Resident #1 who required a 2-person transfer with a Hoyer lift. CNA A was unable to complete the transfer and dropped Resident #1 on the floor. This was determined to be past non-compliance immediate jeopardy from 2/22/2025 to 2/22/2025 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of serious injury or death.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents the right to be free of any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (Resident #1) of five residents reviewed for restraints. The facility failed on 09/09/24 to ensure Resident #1 remained free of any physical restraint in that: the movement of Resident #1's head and mouth were restricted by physical force applied by the hands of OT A. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 09/09/24 and ended on 09/09/24. The facility had corrected the noncompliance before the state's investigation began. This failure could place residents at risk for associated risks of potential physical injury or psychological harm.

Inspectors wroteBased on interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for 1 (Resident #1) of 5 residents reviewed for meals. -The facility failed to ensure Resident #1's mechanical soft fish was free of small bones. This failure placed all residents, especially those with swallowing issues, at risk of aspirating or choking.

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 four (Resident #12, #18, #44, and one unknown resident) of six residents reviewed for adequate supervision to prevent accidents. The facility failed to ensure resident safety, as evidenced by: The door of the central supply closet, that contained direct care products: mouth wash, razors, shaving cream, toothpaste, denture cleaner, conditioning shampoo, body lotion, and orange stick located on Hall 400 was open and accessible to residents. Resident #12, a confused resident, was in close proximity to the central supply, with no staff within line of sight of the supply closet. The facility failed to properly maintain wheelchairs for Residents #12, #18, and #44. [...]

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 in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine filter and vent were free from dirt and dust. 2. The facility failed to ensure the ice machine chute guard was clean. 3. The facility failed to ensure food items in the refrigerator (1 of 2), freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers and dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure multiple food items stored in a bin/container were clearly identifiable. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for two (Halls 100, 400) of two halls, the facility's only nurse's station, and only dining room, observed for pest control program. The facility had live flies various in areas of the facility including the nurse's station, Halls 100, 400, and the dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Included: The facility had live flies in areas of the facility including the nurse's station, Halls 100, 400, and the main dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Include: Observation on 04/16/24 at 09:15 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 3 of 9 residents (Resident #1, #20 and #21) reviewed for accommodation of needs in that: The facility failed to ensure that Resident #1, #20 and #21's call lights were in reach. This failure could affect all residents who needed assistance and could result in needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for one (Resident #2) of one resident reviewed for foot care. The facility failed to provide foot care for Resident #2. This failure could affect residents by placing them at risk for poor foot health, decreased personal hygiene, and a decline in their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide special eating equipment and utensils for residents who need them for one (Resident #1) of two resident reviewed for meal service. The facility failed to provide Resident #1 a divided plate or plate guard at breakfast on 12/06/23 to assist her with eating independently. This failure could place residents at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss.