Deficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
The inspection was conducted as an annual survey of Park Manor of McKinney to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide timely written notification to a resident and the resident's representative about a transfer or discharge, including the reasons and appeal rights.
Complaint Details
The complaint investigation focused on Resident #1, who was discharged without written notification to him, his power of attorney, or the Ombudsman. Interviews and record reviews revealed the resident was admitted on 02/16/25, exhibited exit-seeking behaviors, and was discharged the same day without proper documentation or notification. The family was not provided discharge rights or appeal information. The resident was later admitted to a locked behavioral health unit at another facility.
Findings
The facility failed to notify Resident #1 and the resident's representative in writing about the transfer/discharge, the reasons for the move, the right to appeal, and failed to send a copy of the notice to the Office of the State Long-Term Care Ombudsman. This failure could place residents at risk of being transferred or discharged without access to advocacy services or appeal processes.
Deficiencies (1)
Failure to provide timely notification to the resident, resident representative, and ombudsman before transfer or discharge, including appeal rights.
Report Facts
Dates of Neuropsychological Evaluation Services: 10/22/24, 11/01/24, 11/04/24, and 11/05/24
Admission Date: 02/16/25
Date of Survey Completion: 03/19/2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Provided nurse's notes and described resident's admission and discharge events. |
| Administrator | Initiated tour and admission process, communicated with family, and acknowledged failures in admission and discharge procedures. | |
| DON | Director of Nursing | Provided interview regarding admission and discharge procedures and staff actions. |
| NP C | Nurse Practitioner | Provided admission orders and medication review. |
Inspection Report
Routine
Deficiencies: 11
Date: Apr 25, 2024
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, reasonable accommodation of needs, safe and homelike environment, accuracy of assessments, care planning, activities of daily living assistance, nutritional status, respiratory care, pharmaceutical services, infection prevention and control, and notification of abnormal test results.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to communication, reasonable accommodation of needs, clean environment, accurate assessments, comprehensive care plans, adequate ADL assistance, nutritional monitoring, respiratory care, timely medication reordering, infection control practices, and prompt notification of abnormal lab results. An Immediate Jeopardy was identified related to delayed notification and isolation for a resident with C. difficile infection and failure to follow infection control protocols.
Deficiencies (11)
Failure to ensure residents' right to communication with kitchen staff who primarily spoke Spanish, affecting nutritional and dietary needs.
Failure to ensure call light systems were accessible to residents, risking inability to obtain assistance.
Failure to provide clean privacy curtains for residents, risking unsanitary and hazardous living conditions.
Failure to ensure accurate resident assessments, specifically for Resident #12's functional impairments.
Failure to develop and implement comprehensive care plans for catheter care and blood thinner medication.
Failure to provide necessary ADL services, including nail care, risking infection and loss of dignity.
Failure to provide appropriate respiratory care including proper storage of nebulizer mask and labeling of oxygen equipment.
Failure to ensure timely reordering of medications, risking residents not receiving prescribed medications.
Failure to promptly notify physician of abnormal lab results and delay in placing resident with C. difficile infection on isolation, resulting in Immediate Jeopardy.
Failure to maintain infection prevention and control program, including failure to use appropriate PPE and isolation precautions, contributing to Immediate Jeopardy.
Failure to maintain accurate and complete medical records for Resident #51, including documentation of weights.
Report Facts
Residents reviewed for rights: 5
Residents reviewed for reasonable accommodation: 12
Residents reviewed for safe, clean environment: 5
Residents reviewed for assessment accuracy: 3
Residents reviewed for care plans: 8
Residents reviewed for ADL assistance: 4
Residents reviewed for respiratory care: 3
Residents reviewed for pharmaceutical services: 10
Residents reviewed for infection control: 4
Weight loss percentage: 3.59
Length of Immediate Jeopardy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA B | Medication Aide | Named in medication reordering deficiencies for Residents #3 and #46 |
| LVN A | Licensed Vocational Nurse | Named in medication reordering and respiratory care deficiencies |
| LVN K | Licensed Vocational Nurse | Named in infection control and notification deficiencies |
| LVN O | Licensed Vocational Nurse | Named in infection control PPE violation and suspension |
| ADON | Assistant Director of Nursing | Named in infection control and notification deficiencies |
| DON | Director of Nursing | Named in infection control, notification, and care planning deficiencies |
| Administrator | Facility Administrator | Named in infection control and notification deficiencies |
| MDS Coordinator | Named in assessment and care planning deficiencies | |
| CNA X | Certified Nursing Assistant | Named in infection control training and PPE use |
| CNA Y | Certified Nursing Assistant | Named in infection control training and PPE use |
| CNA C | Certified Nursing Assistant | Named in infection control training and PPE use |
| LVN L | Licensed Vocational Nurse | Named in infection control and notification deficiencies |
| LVN M | Licensed Vocational Nurse | Named in infection control and notification deficiencies |
| LVN N | Licensed Vocational Nurse | Named in infection control and notification deficiencies |
| LVN R | Licensed Vocational Nurse | Named in infection control training and notification deficiencies |
| LVN S | Licensed Vocational Nurse | Named in infection control training and notification deficiencies |
| LVN T | Licensed Vocational Nurse | Named in infection control training and notification deficiencies |
| Medical Director | Named in infection control and notification deficiencies | |
| Infectious Disease NP | Nurse Practitioner | Named in infection control and notification deficiencies |
| Housekeeping Supervisor | Named in privacy curtain cleanliness deficiencies | |
| Housekeeper F | Named in privacy curtain cleanliness deficiencies | |
| Housekeeper G | Named in privacy curtain cleanliness deficiencies | |
| Housekeeper J | Named in privacy curtain cleanliness deficiencies |
Inspection Report
Routine
Deficiencies: 9
Date: Apr 23, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident care, infection control, medication management, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, failure to maintain clean privacy curtains, inaccurate resident assessments, incomplete care plans, inadequate assistance with activities of daily living, failure to provide appropriate respiratory care, failure to maintain accurate medical records, failure to provide timely medication reordering, and failure to maintain an effective infection prevention and control program.
Deficiencies (9)
Failure to ensure call light system was accessible to residents #3 and #46.
Failure to provide clean privacy curtains for Residents #18, #35, and #52.
Failure to ensure accurate assessment for Resident #12, specifically regarding impairments to extremities.
Failure to develop and implement a comprehensive care plan for Residents #12 and #117.
Failure to provide necessary assistance with activities of daily living, including nail care for Resident #20.
Failure to provide appropriate respiratory care including proper storage of nebulizer mask for Resident #15 and labeling/dating of oxygen equipment for Residents #20 and #40.
Failure to ensure timely medication reordering for Residents #3 and #46.
Failure to maintain accurate and complete medical records for Resident #51.
Failure to maintain an effective infection prevention and control program, including delayed isolation of Resident #1 with C. Diff and failure of staff to wear appropriate PPE for Residents #1 and #6.
Report Facts
Weight loss percentage: -3.59
BIMS score: 7
BIMS score: 7
BIMS score: 11
BIMS score: 15
BIMS score: 12
BIMS score: 15
BIMS score: 13
Medication dosage: 2.5
Medication dosage: 300
Medication dosage: 1.5
Oxygen flow rate: 3
Oxygen flow rate: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA B | Medication Aide | Failed to timely reorder medications for Residents #3 and #46 |
| LVN A | Licensed Vocational Nurse | Acknowledged medication reordering responsibilities and assisted with medication administration |
| ADON | Assistant Director of Nursing | Provided statements on call light accessibility, medication reordering, and infection control |
| DON | Director of Nursing | Provided statements on call light accessibility, medication reordering, infection control, and care planning |
| Administrator | Facility Administrator | Provided statements on call light accessibility, medication reordering, infection control, and care planning |
| CNA C | Certified Nursing Assistant | Provided statements on call light importance and infection control |
| Respiratory Therapist | Provided statements on call light importance and respiratory care | |
| Housekeeping Supervisor | Provided statements on privacy curtain cleaning and replacement | |
| Housekeeper F | Provided statements on privacy curtain cleaning and replacement | |
| Housekeeper G | Responsible for replacing stained or dirty privacy curtains | |
| LVN K | Licensed Vocational Nurse | Provided statements on nail care and respiratory care |
| LVN O | Licensed Vocational Nurse | Failed to wear appropriate PPE and was suspended pending investigation |
| NA P | Nurse Aide | Failed to wear appropriate PPE while caring for residents on isolation |
| MDS Coordinator | Provided statements on assessment accuracy and care planning | |
| PT D | Physical Therapist | Provided statements on importance of accurate assessments |
| LVN Z | Licensed Vocational Nurse | Failed to obtain resident weight as ordered |
| CNA X | Certified Nursing Assistant | Provided statements on nail care and infection control |
| CNA Y | Certified Nursing Assistant | Provided statements on infection control |
| CNA AA | Certified Nursing Assistant | Provided statements on infection control |
| CNA BB | Certified Nursing Assistant | Provided statements on infection control |
| LVN R | Licensed Vocational Nurse | Provided statements on infection control |
| Medical Director | Provided statements on infection control expectations | |
| Clinical Resource RN | Registered Nurse | Provided statements on infection control training and expectations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 16, 2023
Visit Reason
The inspection was conducted due to a complaint regarding failure to implement a resident's care plan, specifically related to non-weight bearing status and adequate supervision during transfers.
Complaint Details
The complaint involved Resident #50 reporting that a Certified Nurse Aide (CNA B) encouraged her to bear weight on her fractured ankle despite physician orders for non-weight bearing status. The resident reported delayed assistance, inadequate help during transfers, and inappropriate physical contact by the aide. The facility staff and administration acknowledged the failure to follow the care plan and the risk of reinjury.
Findings
The facility failed to ensure that Resident #50's care plan for non-weight bearing status was implemented, resulting in the resident bearing weight on her fractured ankle during transfers. Staff did not provide the appropriate level of assistance, and the resident was encouraged to self-transfer, risking reinjury. Interviews with the resident, staff, and administration confirmed these failures.
Deficiencies (2)
Failure to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, specifically related to non-weight bearing status.
Failure to ensure adequate supervision and assistance devices to prevent accidents, resulting in resident bearing weight on fractured ankle during transfers.
Report Facts
Residents reviewed for care plans: 8
Weeks non-weight bearing order: 8
Weeks elapsed in NWB order: 6
Weeks remaining in NWB order: 2
Years CNA experience: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nurse Aide | Named in findings related to failure to follow care plan and encouraging resident to bear weight |
| LVN E | Licensed Vocational Nurse | Named in findings related to awareness of resident's non-weight bearing orders and response to complaint |
| Director of Rehabilitation | Provided expert opinion on appropriate assistance level for non-weight bearing resident | |
| DON | Director of Nursing | Interviewed regarding incident and facility policies on care plans and assistance |
| Administrator | Interviewed regarding complaint and facility expectations for staff compliance with care plans |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 13, 2023
Visit Reason
The inspection was conducted based on complaints and observations regarding the facility's failure to provide a safe, clean, comfortable, and homelike environment, and concerns about care plan implementation and resident supervision.
Complaint Details
The complaint investigation focused on poor housekeeping and maintenance issues in resident rooms, failure to follow care plans for non-weight bearing residents, inadequate supervision leading to potential injury, and food safety concerns in the kitchen.
Findings
The facility failed to maintain a safe, clean, and homelike environment in resident rooms, specifically room #404, with damaged walls and poor housekeeping. Additionally, the facility failed to implement the care plan for Resident #50 related to non-weight bearing status, resulting in inadequate assistance and potential risk of injury. Food safety issues were also noted with an uncovered iced tea dispenser in the kitchen.
Deficiencies (4)
Failed to provide residents with a safe, clean, comfortable, and homelike environment in room #404, including damaged walls, debris accumulation, and inadequate housekeeping.
Failed to ensure Resident #50's care plan related to non-weight bearing status was implemented, resulting in inadequate assistance during transfers and risk of reinjury.
Failed to ensure adequate supervision and assistance devices to prevent accidents for Resident #50, risking re-injury or falls.
Failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards; iced tea dispenser was uncovered for over 2 hours.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 8
Time uncovered: 2
Years CNA experience: 22
Weeks NWB order duration: 8
Weeks elapsed NWB: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nurse Aide | Named in Resident #50 care plan non-compliance and transfer incident |
| LVN E | Licensed Vocational Nurse | Mentioned in Resident #50 incident and response |
| HK A | Housekeeping Staff | Observed and interviewed regarding inadequate cleaning of room #404 |
| HK Supervisor | Housekeeping Supervisor | Interviewed about housekeeping expectations and cleaning logs |
| MT Supervisor | Maintenance Supervisor | Interviewed about maintenance issues in room #404 |
| DON | Director of Nursing | Interviewed regarding care plan expectations and Resident #50 incident |
| Administrator | Facility Administrator | Interviewed regarding facility expectations and Resident #50 incident |
| [NAME] A | Dietary Staff | Prepared iced tea and failed to cover dispenser |
| Director of Rehabilitation | Interviewed about Resident #50 transfer needs and care plan |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
The document is an annual inspection report for Park Manor of McKinney conducted to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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