Inspection Report Summary
The most recent inspection on April 24, 2025, identified deficiencies related to resident supervision, medication management, and elopement prevention. Earlier inspections showed a pattern of issues with person-centered care planning, medication safety, infection control, and food service practices. Complaint investigations substantiated concerns about staff competency and resident safety, including an incident of improper repositioning and a resident elopement that posed immediate jeopardy but was corrected promptly. Enforcement actions such as staff suspension and in-service training were noted, while fines or license suspensions were not listed in the available reports. The facility’s deficiencies have persisted over time with similar themes, indicating ongoing challenges in care and safety practices.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
149% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident where Resident #329 was missing from the facility for approximately 1.5 hours without staff awareness.
Complaint Details
The complaint investigation was substantiated. Resident #329 eloped from the facility on 03/18/25 and was found at a nearby apartment complex. The facility failed to prevent the elopement and failed to provide adequate supervision. Staff were in-serviced after the incident. The noncompliance was identified as Past Noncompliance Immediate Jeopardy beginning 03/18/25 and ending 03/31/25, corrected before the survey.
Findings
The facility failed to ensure adequate supervision and safety measures to prevent Resident #329 from eloping, resulting in immediate jeopardy to resident health or safety. The resident was found at a nearby apartment complex, and the facility had not timely re-ordered medications for Resident #64, resulting in a missed dose and improper medication borrowing.
Deficiencies (3)
Failed to ensure adequate supervision and assistance devices to prevent accidents and elopements for Resident #329.
Failed to provide pharmaceutical services ensuring timely re-ordering of medications for Resident #64, resulting in a missed dose.
Failed to keep medications secure when LVN H borrowed medication from another resident to administer to Resident #64.
Report Facts
Residents reviewed for accidents and hazards: 5
Residents affected by elopement deficiency: 1
Residents reviewed for pharmacy services: 9
Missed medication dose: 1
Elopement drill dates: 4
In-service dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN M | Licensed Vocational Nurse | Documented Resident #329's elopement and provided one-on-one supervision; participated in in-services and elopement drills. |
| LVN G | Licensed Vocational Nurse | Filed incident report on Resident #329's elopement; conducted staff in-services on elopement and abuse and neglect. |
| Receptionist | Unlocked front door allowing Resident #329 to exit; received in-service on elopements and updated elopement book. | |
| CNA N | Certified Nursing Assistant | Reported no prior exit-seeking behavior for Resident #329; participated in elopement drills and in-services. |
| Administrator | Facility Administrator | Notified of elopement; oversaw staff in-services and corrective actions; stated importance of preventing elopements. |
| Maintenance Director | Maintenance Director | Retrieved Resident #329 from apartment complex; conducted elopement drills; checked exit doors. |
| RN G | Registered Nurse | Conducted elopement drills; assessed Resident #329 after elopement; notified physician and family; provided staff education. |
| LVN H | Licensed Vocational Nurse | Borrowed medication from another resident to administer to Resident #64; failed to timely reorder medication. |
| LVN E | Licensed Vocational Nurse | Charge nurse who stated responsibility for medication reordering and shift change counts. |
| Unit Manager F | Unit Manager | Verified no Levothyroxine was pulled from pharmacy on 04/09/25. |
| DON | Director of Nursing | Stated borrowing medication was unacceptable; explained medication reordering process and staff responsibilities. |
Inspection Report
Routine
Deficiencies: 9
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive person-centered care plans, inadequate assistance with activities of daily living, failure to prevent resident elopement, improper medication management, inadequate infection control practices, and food safety violations.
Deficiencies (9)
Failed to develop and implement a comprehensive person-centered care plan for residents #73, #4, and #14, including measurable objectives and timeframes.
Failed to provide necessary services for residents unable to perform activities of daily living, including failure to trim fingernails and shave facial hair for residents #4 and #289.
Failed to ensure adequate supervision to prevent accidents resulting in elopement of Resident #329 for approximately 1.5 hours.
Failed to provide appropriate care to prevent urinary tract infections for Resident #32 by not maintaining the foley catheter drainage bag below the bladder during mechanical transfers.
Failed to provide safe and appropriate respiratory care for Residents #32 and #289, including failure to maintain sterile technique during tracheostomy care and lack of physician orders for oxygen therapy.
Failed to provide pharmaceutical services ensuring timely medication re-ordering and secure medication storage, resulting in missed dose and unsecured medication for Resident #64.
Failed to ensure all drugs and biologicals were stored in locked compartments with proper temperature controls and restricted access for medication carts on Hall E.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including undated and unsealed food items, lack of thermometers in chest freezers, and improper hand hygiene and hair restraints by dietary staff.
Failed to establish and maintain an infection prevention and control program, including failures in hand hygiene during incontinence care, wound care, and glucose monitoring for residents #60, #32, and #179.
Report Facts
Residents reviewed for Care Plans: 10
Residents reviewed for ADLs: 8
Residents reviewed for accidents and hazards: 5
Residents reviewed for catheter and incontinence care: 3
Residents reviewed for respiratory care: 3
Residents reviewed for pharmacy services: 9
Medication missed dose: 1
Residents reviewed for medication storage: 4
Dietary staff observed: 4
Residents reviewed for infection control: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN H | Borrowed medication from another resident and left medication cart unlocked; missed medication re-order for Resident #64 | |
| LVN E | Performed tracheostomy care with poor hand hygiene and sterile technique; failed to sanitize glucometer properly; charge nurse during medication re-order incident | |
| CNA D | Failed hand hygiene during incontinence care and wound care; failed to maintain catheter drainage bag below bladder during transfer | |
| Treatment Nurse | Failed hand hygiene during wound care and incontinence care for Resident #32 | |
| LVN J | Failed hand hygiene after fingerstick blood sugar for Resident #179 | |
| Dietary Manager | Failed to wear facial hair restraint and proper hand hygiene during meal preparation | |
| Dietary [NAME] O | Failed to wear effective hair restraint during meal preparation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 8, 2024
Visit Reason
The inspection was conducted following a complaint alleging abuse by a Certified Nurse Aide (CNA A) who forcibly grabbed Resident #1's neck to reposition him in bed, which was reported on 9/5/2024.
Complaint Details
The complaint was substantiated as the facility self-reported the allegation of abuse on 9/5/2024. The investigation confirmed that CNA A grabbed Resident #1 by the neck to reposition him, causing discomfort but no injury. CNA A was suspended and received in-service training. Resident #1 was transferred to a new hall at the family's request.
Findings
The facility failed to ensure staff competency in providing care according to the care plan and facility policies. CNA A grabbed Resident #1 by the neck to reposition him, causing the resident to grimace in pain. The facility self-reported the incident, suspended CNA A, provided in-service training, and reassigned CNA A away from Resident #1's hall. No injuries were found on the resident.
Deficiencies (1)
Failure to ensure nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being, specifically related to improper repositioning technique causing potential harm to Resident #1.
Report Facts
Date of incident: Sep 5, 2024
Date of correction: Sep 9, 2024
Date of investigation start: Nov 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in abuse allegation and competency deficiency |
| Director of Nursing C | Director of Nursing | Provided interviews and conducted in-service training related to the incident |
| Administrator B | Administrator | Provided interview regarding facility response to the incident |
Inspection Report
Routine
Deficiencies: 3
Date: May 1, 2024
Visit Reason
The inspection was conducted to assess compliance with safety and sanitation standards, including fall prevention measures for residents and food service safety in the facility's kitchen.
Findings
The facility failed to ensure fall mats were properly placed for a high-risk resident, increasing risk of injury. Additionally, the kitchen was found to have grease buildup and food residue on the stove and grease trap, posing a risk of food contamination and food-borne illness.
Deficiencies (3)
Failure to ensure Resident #1's fall mats were placed on both sides of his bed as required by his care plan.
Failure to ensure the grease trap in the oven was free of grease buildup.
Failure to ensure the sides of the stove were clean from food residue and grease buildup.
Report Facts
Residents reviewed for accidents and hazards: 4
Residents affected by fall mat deficiency: 1
Residents affected by kitchen sanitation deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide A | Nurse Aide | Named in fall mat placement deficiency for Resident #1 |
| LVN B | Licensed Vocational Nurse | Provided statements regarding fall mat placement responsibility |
| DON | Director of Nursing | Provided statements on fall risk and staff responsibilities |
| Administrator | Administrator | Provided statements on staff responsibilities for fall mat placement |
| Food Services Director | Food Services Director | Provided statements and interviews regarding kitchen sanitation and cleaning responsibilities |
| [NAME] C | Cook | Interviewed regarding stove and grease trap cleaning |
| [NAME] D | Cook | Interviewed regarding stove cleaning responsibilities |
| [NAME] E | Cook | Interviewed regarding grease trap cleaning |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident activities, feeding tube care, and food service safety at Life Care Center of Plano.
Findings
The facility failed to provide a resident-centered activities program reflecting residents' interests, resulting in minimal harm risk. Additionally, the facility failed to ensure proper labeling and dating of enteral feeding bags for a resident with a feeding tube, and failed to store, label, and date food items properly in the kitchen, posing risks of infection and foodborne illness.
Deficiencies (3)
Failed to provide an ongoing resident-centered activities program that incorporated and met residents' interests, hobbies, and cultural preferences for 4 of 5 residents reviewed.
Failed to ensure Resident #40's feeding bag was labeled and dated.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including failure to label and date food items and improper food storage in the kitchen.
Report Facts
Residents reviewed for activities: 5
Residents affected by activities deficiency: 4
Residents reviewed for feeding tube: 3
Residents affected by feeding tube deficiency: 1
Enteral feeding rate: 65
Enteral feeding duration: 12
Flush volume: 120
Years Activities Director E worked at facility: 7
Activities Director E last day: 16
Activities Director F start date: 19
Activities Director F expected return date: 11
Date of facility activity policy: Sep 21, 2023
Date of facility Enteral Nutrition Therapy policy: Aug 8, 2023
Date of facility Food Safety policy: Apr 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director E | Activities Director | Worked about 7 years, resigned 3 weeks ago, responsible for scheduling activities and entertainers, reported budget cuts affecting activities |
| Activities Director F | Activities Director | Started 02/19/2024, on medical leave since 02/22/2024, certified Activities Director, responsible for assessing resident activity needs |
| Activities Assistant G | Activities Assistant | Implemented activities during Activities Director F's leave, not certified, unaware of resident concerns about activities |
| LVN A | Licensed Vocational Nurse | Responsible for starting and discontinuing tube feeds for Resident #40, stated feeding bags should be dated and labeled |
| LVN B | Licensed Vocational Nurse | Hung tube feed bag for Resident #40 on 3/4/24, forgot to label and date due to lack of marker |
| DON | Director of Nursing | Stated expectation that all nursing staff follow protocols for dating and labeling tube feed formula |
| Dietary Aide D | Dietary Aide | Responsible for dating and labeling foods in kitchen, had not received recent in-services on this topic |
| [NAME] C | Cook | Responsible for dating and labeling food items, unaware why cheese was on floor |
| Food Service Manager | Food Service Manager | Responsible for food storage and safety, found inconsistent labeling and dating, no planned in-services provided |
| Dietitian | Dietitian | Provided monthly in-services, last in-service on food storage was April 2023, expects all food to be labeled, dated, and covered |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident activities, feeding tube care, and food service safety.
Findings
The facility failed to provide a resident-centered activities program that met residents' interests and preferences, resulting in minimal harm or potential for harm to some residents. Additionally, the facility failed to ensure proper labeling and dating of feeding tube bags for one resident, and food items in the kitchen were not consistently labeled, dated, or stored properly, posing risks of infection and foodborne illness.
Deficiencies (3)
Failed to provide an ongoing resident-centered activities program that incorporated and met residents' interests, hobbies, and cultural preferences for 4 of 5 residents reviewed.
Failed to ensure Resident #40's feeding bag was labeled and dated.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including failure to label and date food items and improper food storage.
Report Facts
Residents reviewed for activities: 5
Residents affected by activities deficiency: 4
Residents reviewed for feeding tubes: 3
Residents affected by feeding tube deficiency: 1
Enteral feeding rate: 65
Enteral feeding duration: 12
Feeding flush volume: 120
Years Activities Director E worked at facility: 7
Activities Director E last day: 6
Activities Director F start date: 19
Activities Director F expected return date: 11
Date of facility activity policy: Sep 21, 2023
Date of facility Enteral Nutrition Therapy policy: Aug 8, 2023
Date of facility Food Safety policy: Apr 26, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director E | Activities Director | Worked about 7 years, resigned 3 weeks prior to inspection, responsible for scheduling activities and entertainers, reported budget cuts affecting activities. |
| Activities Director F | Activities Director | Started 02/19/2024, on medical leave due to emergency, certified Activities Director, responsible for assessing resident activity needs and creating activity calendar. |
| Activities Assistant G | Activities Assistant | Implemented activities during Activities Director F's leave, not certified, unaware of resident concerns about activities. |
| LVN A | Licensed Vocational Nurse | Responsible for starting tube feeds for Resident #40, stated feeding bags should be dated and labeled. |
| LVN B | Licensed Vocational Nurse | Hung tube feed bag for Resident #40 on 3/4/24, forgot to label and date due to lack of marker. |
| DON | Director of Nursing | Stated expectation that all nursing staff follow protocol to date and label tube feed formula. |
| Dietary Aide D | Dietary Aide | Responsible for dating and labeling foods in kitchen, had not received recent in-services on this topic. |
| [NAME] C | Cook | Responsible for dating and labeling food items, unaware why cheese was on floor. |
| Food Service Manager | Food Service Manager | Responsible for food storage and safety, found inconsistent labeling and dating, no planned in-services provided. |
| Dietitian | Dietitian | Provided monthly in-services, last in-service on food storage was April 2023, expects all food to be labeled, dated, and covered. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 7, 2023
Visit Reason
The inspection was conducted as an annual survey of the Life Care Center of Plano to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were unknown.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 19, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to comprehensive care planning, respiratory care, psychotropic medication use, and food safety in the nursing facility.
Findings
The facility failed to develop comprehensive person-centered care plans for residents, ensure oxygen was administered at physician-ordered levels, implement gradual dose reductions for psychotropic medications, and maintain proper food safety and hand hygiene practices in the kitchen.
Deficiencies (4)
Failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for residents, including addressing Resident #24's preference to wear pants below waist and Resident #6's oxygen use.
Failed to provide safe and appropriate respiratory care by not ensuring supplemental oxygen was provided at the physician ordered liter amount for Resident #6.
Failed to implement gradual dose reductions and behavioral interventions for psychotropic medications for Resident #32, including failure to attempt gradual dose reduction of Risperdal.
Failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including failure to label and date refrigerator food items, seal freezer food items, and perform hand hygiene during meal preparation.
Report Facts
Residents reviewed for comprehensive care plans: 24
Oxygen flow rate observed: 4
Risperidone dose: 0.25
Dates of medication administration records reviewed: 3
Date of last care plan revision for Resident #24: Dec 21, 2022
Date of last care plan revision for Resident #6: Nov 6, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Interviewed regarding oxygen administration errors for Resident #6 and psychotropic medication monitoring. |
| DON | Director of Nursing | Interviewed about care planning for Resident #24, oxygen administration policies, and psychotropic medication management. |
| Dietary Manager | Interviewed about food safety violations and hand hygiene issues in the kitchen. | |
| Dietary Aide F | Dietary Aide | Observed failing to perform hand hygiene during meal preparation. |
| Resident #32's MD | Physician | Interviewed about psychotropic medication management and gradual dose reduction attempts. |
| Social Worker | Interviewed regarding care planning and behavioral observations for Resident #24 and Resident #32. |
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