Inspection Reports for The Collinwood Care Center
3100 S Rigsbee Dr, Plano, TX 75074, TX, 75074
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 7, 2025, identified deficiencies related to failure to provide scheduled showers and incomplete documentation for a resident requiring extensive assistance. Earlier inspections showed a pattern of issues including inadequate infection control practices, incomplete or outdated care plans, environmental cleanliness concerns, and lapses in behavioral health services and abuse investigations. Complaint investigations substantiated failures in abuse prevention, timely reporting, and thorough investigations, with one immediate jeopardy finding later resolved; enforcement actions or fines were not listed in the available reports. Most complaints were substantiated, particularly involving abuse allegations and inadequate behavioral health care. The inspection history indicates ongoing challenges with resident care and infection control, with no clear improvement trend over time.
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
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding care and assistance for residents unable to perform activities of daily living, specifically focusing on hygiene and shower provision.
Findings
The facility failed to ensure that Resident #7, who required extensive assistance with activities of daily living, received scheduled showers during July 2025. Documentation was incomplete, and staff did not consistently notify nursing or responsible parties of shower refusals, potentially risking skin integrity and resident well-being.
Deficiencies (1)
Failure to provide scheduled showers and proper documentation for Resident #7, including lack of notification to nursing staff and responsible parties regarding shower refusals.
Report Facts
Scheduled showers missed: 8
Length of CNA employment: 9
Length of LVN employment: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Provided bed baths to Resident #7 but failed to complete shower sheets and document refusals. |
| LVN D | Licensed Vocational Nurse | Responsible nurse for 500-hall; stated CNAs were required to complete shower sheets and notify him of refusals. |
| DON | Director of Nursing | Newly started; emphasized expectations for shower provision and documentation; conducted in-service training on showers. |
| ADON | Assistant Director of Nursing | Provided information on shower sheet procedures and expectations for notification and documentation. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, and infection control at Collinwood Nursing and Rehabilitation.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, developing and implementing comprehensive care plans, providing necessary assistance with activities of daily living, and implementing an effective infection prevention and control program. Deficiencies included unclean resident rooms, failure to update care plans after resident falls, inadequate shower provision for dependent residents, and improper hand hygiene during incontinence care.
Deficiencies (4)
Failure to ensure resident rooms were thoroughly cleaned and sanitized, including air condition vents, bathroom floors, faucets, and toilets.
Failure to develop and implement a comprehensive person-centered care plan with measurable objectives and timely updates after resident falls.
Failure to provide care and assistance for activities of daily living, including failure to provide scheduled showers for a dependent resident.
Failure to establish and maintain an infection prevention and control program, including failure of staff to change gloves and perform hand hygiene during incontinence care.
Report Facts
Resident rooms affected: 10
Residents reviewed for care plan: 4
Residents reviewed for ADL care: 4
BIMS score: 8
Fall risk score: 16
Scheduled showers missed: 0
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping P | Housekeeping Staff | Responsible for cleaning rooms on the 500-hall; acknowledged difficulty cleaning faucets and soap scum. |
| Housekeeping Director | Housekeeping Director | Supervised cleaning staff; acknowledged cleaning deficiencies and potential respiratory risks. |
| Administrator | Facility Administrator | Set expectations for housekeeping and care plan updates; acknowledged risks related to cleaning and care plan deficiencies. |
| ADON | Assistant Director of Nursing | Acknowledged failure to update care plan interventions after resident falls and shower documentation issues. |
| DON | Director of Nursing | Acknowledged importance of care plan updates and shower provision; recently started at facility. |
| CNA B | Certified Nursing Assistant | Observed failing to change gloves and perform hand hygiene during incontinence care. |
| RN A | Registered Nurse | Discussed importance of hand hygiene and infection control with CNA B. |
| LVN D | Licensed Vocational Nurse | Responsible nurse for 500-hall; acknowledged shower documentation deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 22, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and failure to provide appropriate behavioral health services at Collinwood Nursing and Rehabilitation.
Complaint Details
The complaint investigation was triggered by allegations of abuse including physical assault by Resident #1 on Resident #2, threats of stabbing by Resident #1 towards Resident #3, and failure to investigate and report these allegations properly. Additionally, concerns about inadequate behavioral health services and care planning were investigated.
Findings
The facility failed to protect residents from abuse, failed to thoroughly investigate abuse allegations, failed to develop and implement comprehensive care plans addressing verbal abuse and suicidal ideations, failed to provide appropriate behavioral health services, and failed to secure treatment carts. Immediate Jeopardy was identified but later removed after corrective actions were implemented.
Deficiencies (5)
Failed to protect residents from physical and verbal abuse, including threats and actual physical harm.
Failed to thoroughly investigate and report abuse allegations within 5 working days.
Failed to develop and implement comprehensive person-centered care plans addressing verbal abuse and suicidal ideations.
Failed to provide appropriate treatment and services to a resident with mental disorder and psychosocial adjustment difficulty, including timely behavioral health interventions after suicidal ideations.
Failed to ensure treatment cart was locked when unattended.
Report Facts
Residents reviewed for abuse: 3
Residents reviewed for care plans: 6
Residents reviewed for behavioral health services: 6
Date Immediate Jeopardy identified: May 21, 2025
Date Immediate Jeopardy removed: May 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Documented witnessing Resident #1 hitting Resident #2 and attempted to intervene. |
| LPN B | Licensed Practical Nurse | Documented investigation of abuse allegations and denial by Resident #1. |
| Administrator | Facility Administrator | Responsible for abuse investigation and reporting; provided statements regarding incidents and corrective actions. |
| ADON | Assistant Director of Nursing | Participated in abuse investigations, staff education, and corrective action implementation. |
| Nurse Aide C | Nurse Aide | Provided statements about Resident #1 and Resident #2 behaviors and staff challenges. |
| RN D | Registered Nurse | Received in-services on abuse, neglect, resident rights, and behavioral health. |
| RN E | Registered Nurse | Received in-services on abuse, neglect, resident rights, and behavioral health. |
| LVN F | Licensed Vocational Nurse | Received in-services on abuse, neglect, resident rights, and behavioral health. |
| Nurse Aide G | Nurse Aide | Received in-services on abuse, neglect, resident rights, and behavioral health. |
| Nurse Aide H | Nurse Aide | Received in-services on abuse, neglect, resident rights, and behavioral health. |
| Housekeeper | Received in-services on abuse and neglect, resident rights, and reporting procedures. | |
| Dietary Manager | Dietary Manager | Received in-services on abuse, neglect, resident rights, and behavioral health. |
| Receptionist | Receptionist | Received in-services on abuse, neglect, resident rights, and behavioral health. |
| VP of Clinical Services | Vice President of Clinical Services | Provided in-services to Administrator, ADON, and DON on abuse, neglect, resident rights, and behavioral health. |
| Social Worker | Social Worker | Conducted audits and participated in behavioral health in-services and care plan reviews. |
| MDS Nurse | MDS Nurse | Conducted audits of MDS assessments and care plans; participated in behavioral health in-services. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement policies and procedures to prevent abuse, neglect, and theft, specifically related to Resident #12's report of self-harm behavior on 12/10/24.
Complaint Details
The complaint investigation focused on Resident #12 who reported self-harm by pulling the call light cord around her neck on 12/10/24. The facility failed to report this to the State Agency and did not conduct a timely investigation. Resident #12 was monitored one-on-one and transferred to a behavioral unit on 12/11/24. Interviews with the Social Worker and VP of Clinical Services confirmed the failures in reporting and investigation.
Findings
The facility failed to report and investigate an incident where Resident #12 reported pulling the call light cord around her neck to kill herself. The facility did not follow policy to notify the State Agency or conduct a timely investigation. Resident #12 was monitored one-on-one until transferred to a behavioral unit. The facility's policies require reporting and thorough investigation of such incidents, which were not properly followed.
Deficiencies (3)
Failed to implement written policies and procedures to prevent neglect and abuse related to Resident #12's self-harm report.
Failed to report the incident to the State Agency and initiate an investigation within required timeframes.
Failed to conduct a thorough investigation and report findings to the State Survey Agency within 5 working days.
Report Facts
Residents Affected: 1
Days to report to State Agency: 24
Days to report investigation findings: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding failure to report and investigate Resident #12's self-harm incident | |
| VP of Clinical Services | Interviewed regarding reporting policies and failure to investigate incident |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, assessment accuracy, care planning, food safety, and infection control at Collinwood Nursing and Rehabilitation.
Findings
The facility was found deficient in ensuring call lights were accessible to residents, maintaining a clean and homelike environment, providing accurate resident assessments, developing comprehensive care plans, proper food storage and labeling, and adherence to infection prevention and control practices including hand hygiene during incontinent care.
Deficiencies (6)
Failed to ensure call light systems were accessible to residents #2, #21, #51, and #54, risking inability to obtain assistance.
Failed to provide a safe, clean, comfortable, and homelike environment in 6 resident rooms due to dirt, grime, and calcium buildup.
Failed to ensure accurate assessments reflecting impairments for residents #35, #40, and #46, risking inadequate care.
Failed to develop and implement a comprehensive care plan for Resident #50's Parkinson's disease diagnosis.
Failed to ensure food was stored, labeled, dated, and discarded properly in the kitchen, including expired and dented items.
Failed to maintain infection prevention and control program; CNA D did not perform hand hygiene or change gloves properly during incontinent care for Residents #21 and #46.
Report Facts
Residents reviewed for reasonable accommodation: 16
Residents affected by call light deficiency: 4
Rooms observed for environment: 10
Rooms with environmental deficiencies: 6
Residents reviewed for assessment accuracy: 6
Residents affected by inaccurate assessments: 3
Residents reviewed for care plans: 6
Residents affected by incomplete care plan: 1
Residents observed for infection control: 8
Residents affected by infection control deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in infection control deficiency for failing to perform hand hygiene and change gloves properly during incontinent care for Residents #21 and #46. |
| LVN B | Licensed Vocational Nurse | Interviewed regarding call light accessibility and infection control practices. |
| ADON | Assistant Director of Nursing | Interviewed regarding call light accessibility, infection control, and assessment accuracy. |
| DON | Director of Nursing | Interviewed regarding call light accessibility, infection control, assessment accuracy, and care planning. |
| Administrator | Facility Administrator | Interviewed regarding call light accessibility, environmental cleanliness, food safety, and infection control. |
| LVN C | Licensed Vocational Nurse | Interviewed regarding resident #35's impairments and assessment. |
| RN A | Registered Nurse | Interviewed regarding resident #40's contracture and care needs. |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding assessment accuracy and documentation. |
| PT E | Physical Therapist | Interviewed regarding importance of accurate assessments. |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and safety in the kitchen. |
| Dietician | Dietician | Interviewed regarding food storage and safety in the kitchen. |
| Director of Environmental Services | Director of Environmental Services | Interviewed regarding environmental cleanliness and housekeeping practices. |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, and accurate resident assessments at Collinwood Nursing and Rehabilitation.
Findings
The facility failed to ensure call lights were accessible to residents, resulting in potential risk of harm. Additionally, the facility did not maintain accurate resident assessments for impairments and failed to implement proper infection prevention and control practices, including hand hygiene during incontinent care.
Deficiencies (3)
Failed to ensure call light systems were accessible to residents #2, #21, #51, and #54.
Failed to ensure accurate assessments reflective of residents' impairments for residents #35, #40, and #46.
Failed to maintain an infection prevention and control program; CNA did not perform proper hand hygiene or glove changes during incontinent care for residents #21 and #46.
Report Facts
Residents reviewed for reasonable accommodation: 16
Residents affected by call light deficiency: 4
Residents reviewed for assessment accuracy: 6
Residents affected by inaccurate assessments: 3
Residents observed for infection control: 8
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene and glove changes during incontinent care |
| LVN B | Licensed Vocational Nurse | Interviewed regarding call light accessibility and infection control practices |
| ADON | Assistant Director of Nursing | Interviewed regarding call light importance, infection control, and assessment accuracy |
| DON | Director of Nursing | Interviewed regarding call light expectations, infection control, and assessment accuracy |
| Administrator | Facility Administrator | Interviewed regarding call light expectations and infection control |
| LVN C | Licensed Vocational Nurse | Interviewed regarding resident #35's impairments and assessments |
| RN A | Registered Nurse | Interviewed regarding resident #40's contracture and care needs |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding accuracy of resident assessments |
| PT E | Physical Therapist | Interviewed regarding importance of accurate resident assessments |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 4, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident care, specifically focusing on reasonable accommodation of resident needs and preferences, and the development and implementation of comprehensive care plans.
Findings
The facility failed to ensure call light systems were accessible to five residents, potentially placing them at risk of harm. Additionally, the facility failed to develop and implement comprehensive person-centered care plans for hospice care for two residents, which could result in inadequate care and services.
Deficiencies (2)
Facility failed to ensure the call light system in residents' rooms was accessible to residents #1, #2, #3, #4, and #5.
Facility failed to develop and implement a comprehensive person-centered care plan for hospice care for residents #3 and #6.
Report Facts
Residents reviewed for reasonable accommodation: 12
Residents affected by call light deficiency: 5
Residents reviewed for care plans: 4
Residents affected by care plan deficiency: 2
BIMS score for Resident #1: 7
BIMS score for Resident #2: 3
BIMS score for Resident #4: 0
BIMS score for Resident #5: 3
BIMS score for Resident #6: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nursing Assistant | Interviewed regarding importance and placement of call lights |
| LVN S | Licensed Vocational Nurse | Interviewed regarding call light policies and education of CNAs |
| LVN E | Licensed Vocational Nurse | Interviewed regarding call light placement and rounds |
| CNA A | Certified Nursing Assistant | Interviewed regarding call light importance and rounds |
| DON | Director of Nursing | Interviewed regarding call light policy and care planning responsibilities |
| Administrator | Facility Administrator | Interviewed regarding call light importance and care plan expectations |
| MDS Nurse | Minimum Data Set Nurse | Interviewed regarding care plan importance and hospice care planning |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding physical restraints, food safety and sanitation, and infection prevention and control at Collinwood Nursing and Rehabilitation.
Findings
The facility failed to ensure proper physician orders for a scoop mattress used as a restraint, failed to maintain proper food storage and staff hygiene in the kitchen, and failed to ensure proper sanitization of medical equipment between resident uses, placing residents at risk of injury, contamination, and infection.
Deficiencies (3)
Failure to ensure resident had physician orders for a scoop mattress used as a physical restraint.
Failure to ensure food was properly sealed and staff properly covered their hair during dietary duties.
Failure to ensure medical assistant sanitized blood pressure machine and cuff between resident uses.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA S | Medical Assistant | Named in infection control deficiency for failing to sanitize blood pressure equipment between residents |
| LVN A | Licensed Vocational Nurse | Interviewed regarding scoop mattress orders for Resident #58 |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
The document is an annual inspection report for Collinwood Nursing and Rehabilitation conducted as part of regulatory oversight.
Findings
No health deficiencies were found during the inspection. The level of harm and residents affected are both listed as unknown.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
The inspection was conducted as a routine annual survey of Collinwood Nursing and Rehabilitation 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.
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