Inspection Report Summary
The most recent inspection on June 5, 2025, found deficiencies related to incomplete care planning, specifically failing to update a resident’s care plan after recent falls. Earlier inspections showed a pattern of issues with care planning, infection control, medication administration, and environmental cleanliness. Complaint investigations substantiated problems with late medication administration and inadequate infection control practices, and a prior complaint found the facility failed to prevent a resident elopement, prompting corrective actions. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring challenges in care planning and infection control, with some corrective steps taken but deficiencies persisting over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
257% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with care plan requirements, specifically focusing on the development and implementation of comprehensive person-centered care plans for residents.
Findings
The facility failed to develop and implement a comprehensive care plan for Resident #1 that included measurable objectives and time frames, particularly failing to update the care plan after two recent falls. This deficiency could affect all residents by contributing to inadequate care and fall prevention.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, specifically failing to update Resident #1's care plan after falls on 05/06/2025 and 05/13/2025.
Report Facts
Residents reviewed for care plan revision: 4
Resident #1 BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim MDS Coordinator | Interviewed regarding care plan updates and fall risk interventions | |
| DON | Director of Nursing | Interviewed about care plan update practices and Resident #1's care plan |
| Administrator | Interviewed about care plan interventions and facility policy |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 29, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide timely pharmaceutical services and failure to maintain infection prevention and control procedures.
Complaint Details
The complaint investigation found substantiated issues with late medication administration and inadequate infection control practices, specifically failure to sanitize equipment between residents.
Findings
The facility failed to administer medications on time for two residents, resulting in potential risks of delayed treatment or worsening conditions. Additionally, the Charge Nurse failed to sanitize medical equipment between residents, risking cross-contamination and infection.
Deficiencies (2)
Failure to administer medications within one hour before or after the scheduled time for Resident #1 and Resident #2.
Failure to sanitize the blood pressure cuff and pulse oximeter between Resident #2 and Resident #3.
Report Facts
Residents affected: 2
Residents affected: 1
Medication administration time: 1
Number of nurses on 04/29/25: 4
Residents per nurse on 04/29/25: 23
Normal residents per nurse: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charge Nurse | Observed administering medications late and failing to sanitize equipment | |
| Assistant Director of Nursing | Interviewed regarding medication administration and infection control practices | |
| Director of Nursing | Interviewed regarding staffing and medication administration protocols | |
| Administrator | Interviewed regarding awareness of late medication administration and infection control |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, infection control, and facility environment at The Park IN Plano nursing home.
Findings
The facility was found deficient in multiple areas including maintaining a clean and safe environment in resident rooms, proper incontinent care techniques, appropriate feeding tube medication administration, respiratory care practices, and infection prevention protocols. Several staff failed to follow proper hand hygiene, equipment sanitization, and care procedures, potentially placing residents at risk of infections and decreased quality of life.
Deficiencies (5)
Failure to ensure resident rooms were thoroughly cleaned and sanitized, with air conditioning vents and walls observed with dirt and stains.
Failure to ensure proper perineal care technique by CNA D, cleaning from back to front instead of front to back, risking urinary tract infections.
Failure to clean syringe and flush gastrostomy tube properly during medication administration by LVN A, risking infection and drug interactions.
Failure to properly store nasal cannula when not in use, increasing risk of respiratory infection.
Multiple failures in infection prevention including lack of hand hygiene before care, bringing whole container of test strips into resident room, failure to sanitize stethoscope diaphragm and blood pressure cuff, and failure to change gloves before touching clean briefs.
Report Facts
Residents reviewed for Infection Control: 18
Residents affected by infection control deficiencies: 9
Resident rooms reviewed for environment: 12
Resident rooms with deficiencies: 5
Residents reviewed for incontinent care: 3
Residents reviewed for feeding tube care: 2
Residents reviewed for respiratory care: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in incontinent care deficiency for improper perineal care technique and failure to change gloves before touching clean brief |
| LVN A | Licensed Vocational Nurse | Named in feeding tube medication administration deficiency for failure to clean syringe and flush g-tube; also named in infection control deficiencies for failure to sanitize stethoscope diaphragm and bringing whole container of test strips into resident room |
| LVN B | Licensed Vocational Nurse | Named in infection control deficiencies for failure to sanitize blood pressure cuff and hands before medication administration |
| CNA G | Certified Nursing Assistant | Named in infection control deficiency for failure to perform hand hygiene before resident care |
| LVN H | Licensed Vocational Nurse | Interviewed regarding proper storage of nasal cannula |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding cleaning deficiencies in resident rooms |
| Administrator | Facility Administrator | Interviewed regarding multiple deficiencies and plans for in-service training |
| DON | Director of Nursing | Interviewed regarding proper care procedures and infection control expectations |
| Director Of Rehabilitation | Director of Rehabilitation | Interviewed regarding sanitizer provision to LVN B for blood pressure cuff sanitization |
Inspection Report
Routine
Deficiencies: 8
Date: Jan 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, infection control, and food safety at The Park IN Plano nursing facility.
Findings
The facility was found deficient in multiple areas including cleanliness of resident rooms, incomplete care planning for psychological services, inadequate assistance with activities of daily living, improper incontinent care, failure to properly administer medications via feeding tubes, improper respiratory care, food safety violations in the kitchen, and lapses in infection prevention and control practices.
Deficiencies (8)
Failed to ensure resident rooms were thoroughly cleaned and sanitized, including air conditioning vents and mini fridges.
Failed to develop and implement a comprehensive care plan for psychological services for Resident #53.
Failed to provide necessary assistance with activities of daily living including podiatry care and fingernail care for multiple residents.
Failed to provide appropriate incontinent care, including improper cleaning technique and failure to change gloves before touching new brief.
Failed to properly clean syringe and flush gastrostomy tube during medication administration for Resident #52.
Failed to properly store nasal cannula when not in use for Resident #18, risking respiratory infection.
Failed to ensure food in kitchen was properly labeled, sealed, and stored; ice machine was unclean; trash can uncovered.
Failed to implement infection prevention and control practices including hand hygiene, sanitizing equipment, and glove use for multiple residents.
Report Facts
Residents affected: 5
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 9
Residents affected: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Named in feeding tube medication administration and infection control deficiencies | |
| LVN B | Named in infection control deficiencies related to hand hygiene and equipment sanitizing | |
| CNA D | Named in incontinent care and infection control deficiencies | |
| CNA G | Named in infection control deficiency for failure to perform hand hygiene | |
| Housekeeping Supervisor | Mentioned regarding cleaning deficiencies | |
| Housekeeping/Laundry Aid D | Mentioned regarding cleaning deficiencies | |
| Administrator | Mentioned regarding responses to deficiencies and expectations | |
| DON | Director of Nursing | Named in multiple interviews regarding care planning, infection control, and staff expectations |
| Social Worker | Mentioned regarding podiatry appointment scheduling | |
| LVN H | Named in respiratory care deficiency | |
| DM | Dietary Manager | Named in food service deficiencies |
| DOR | Director of Rehabilitation | Named in infection control deficiency |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 18, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to determine if residents had comprehensive, person-centered care plans that included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs.
Findings
The facility failed to develop and implement comprehensive care plans for two residents (Resident #1 and Resident #20) regarding oxygen therapy and droplet precautions, which could place residents at risk of not receiving necessary care. The care plans lacked documentation for oxygen administration and infection control measures despite physician orders and observed use of oxygen therapy.
Deficiencies (2)
Failed to develop and implement a comprehensive person-centered care plan for Resident #1 that included oxygen administration.
Failed to develop and implement a comprehensive person-centered care plan for Resident #20 that included oxygen therapy and droplet precautions.
Report Facts
Oxygen flow rate: 3
Oxygen flow rate: 2
Residents reviewed for care plans: 8
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) A | Interviewed regarding Resident #1's oxygen therapy and care plan | |
| Director of Nursing (DON) | Interviewed regarding care plan requirements and responsibility for oversight | |
| Administrator | Interviewed regarding expectations for care plans and staff responsibilities |
Inspection Report
Routine
Deficiencies: 6
Date: Nov 6, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, infection control, medication administration, respiratory care, and environmental hazards at The Park IN Plano nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, inadequate assistance with activities of daily living such as scheduled showers, unsecured hot coffee station posing burn risks, improper respiratory care including improper storage of nasal cannula and missing humidifier bottle, medication administration errors such as leaving medications unattended with residents, and lapses in infection prevention practices including failure to perform hand hygiene and change gloves appropriately during incontinent care.
Deficiencies (6)
Failure to ensure call lights were within reach and accessible for residents #1 and #5.
Failure to provide scheduled bed baths to Resident #4 as planned.
Failure to secure a coffee station allowing residents to self-serve hot coffee, risking skin burns.
Failure to ensure proper respiratory care for Residents #2 and #6, including improper storage of nasal cannula and missing humidifier bottle on oxygen concentrator.
Failure to ensure medications were not left unattended with Resident #3.
Failure to maintain infection prevention and control practices, including failure of CNA D to change gloves and perform hand hygiene during incontinent care for Resident #4.
Report Facts
Residents reviewed for Reasonable Accommodation of Needs: 20
Residents reviewed for ADL care: 4
Residents reviewed for Respiratory Care: 12
Residents reviewed for Infection Control: 8
Medications left unattended: 1
BIMS score Resident #1: 0
BIMS score Resident #5: 10
BIMS score Resident #4: 12
BIMS score Resident #2: 9
BIMS score Resident #6: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in medication administration deficiency for leaving medications unattended with Resident #3 and in respiratory care deficiency for handling nasal cannula. |
| CNA C | Certified Nursing Assistant | Interviewed regarding call light accessibility issues for Resident #1 and Resident #5. |
| LVN B | Licensed Vocational Nurse | Interviewed regarding call light accessibility and respiratory care deficiencies. |
| Interim Administrator | Interviewed regarding call light, respiratory care, medication administration, infection control deficiencies and plans for staff education. | |
| DON | Director of Nursing | Interviewed regarding call light accessibility, respiratory care, medication administration, infection control deficiencies and plans for staff education. |
| CNA D | Certified Nursing Assistant | Observed and interviewed regarding failure to perform hand hygiene and change gloves during incontinent care for Resident #4. |
| CNA R | Staffing Coordinator/Certified Nursing Assistant | Interviewed regarding unsecured coffee station. |
| LVN C | Licensed Vocational Nurse | Interviewed regarding shower schedule and care for Resident #4. |
| CNA S | Certified Nursing Assistant | Interviewed regarding shower schedule and care for Resident #4. |
Inspection Report
Routine
Deficiencies: 2
Date: Aug 21, 2024
Visit Reason
The inspection was conducted to evaluate compliance with resident dignity and medication administration standards following observations and complaints regarding staff behavior and medication errors.
Findings
The facility failed to ensure staff treated residents with dignity by standing over a resident while assisting with feeding, and failed to administer blood pressure medications according to physician orders, resulting in medication given outside of prescribed parameters.
Deficiencies (2)
Facility failed to ensure staff did not stand over Resident #2 while assisting with feeding, violating resident dignity.
Facility failed to ensure residents were free from significant medication errors by administering Resident #1's blood pressure medications outside of physician-ordered parameters.
Report Facts
Medication administration errors: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Observed standing over Resident #2 while assisting with feeding | |
| LVN B | Administered blood pressure medication outside of parameters on multiple occasions | |
| LVN C | Administered blood pressure medication outside of parameters on multiple occasions and interviewed regarding medication administration | |
| Director of Nursing | Director of Nursing | Interviewed regarding staff standing over residents during meals and medication administration oversight |
| Administrator | Administrator | Interviewed regarding staff standing over residents during meals |
Inspection Report
Routine
Deficiencies: 8
Date: Dec 14, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, reasonable accommodation, environment safety, restraint use, activities of daily living, feeding tube care, respiratory care, and infection prevention and control.
Findings
The facility was found deficient in several areas including failure to ensure resident privacy, call light accessibility, cleanliness of resident rooms, proper use and documentation of physical restraints, timely incontinence care, appropriate feeding tube care, provision of humidifiers for oxygen concentrators, and adherence to infection control practices such as hand hygiene.
Deficiencies (8)
Failed to treat resident with respect and dignity by not providing privacy while transporting Resident #42 to the shower room.
Failed to ensure call light system was accessible to Residents #70 and #46, placing them at risk of not obtaining assistance.
Failed to provide a safe, clean, comfortable, and homelike environment in 8 resident rooms due to stains, dirt, and maintenance issues.
Failed to ensure Residents #2, #26, #35, and #43 had physician orders for bolster side rails used as physical restraints.
Failed to provide timely incontinent care to Resident #43, resulting in soiled brief and mattress.
Failed to ensure LVN H capped the tip of Resident #45's gastrostomy tube when disconnected, risking infection.
Failed to ensure Resident #67's oxygen concentrator had a humidifier to prevent nasal dryness and irritation.
Failed to ensure ADON and Wound Care Nurse performed hand hygiene during incontinence and wound care for Residents #43 and #55 respectively.
Report Facts
Residents reviewed for resident rights: 8
Residents reviewed for reasonable accommodation: 8
Resident rooms observed for environment: 27
Residents reviewed for restraints: 8
Residents reviewed for quality of life: 8
Residents reviewed for feeding tube care: 3
Residents reviewed for respiratory care: 2
Residents reviewed for infection control: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in privacy violation while transporting Resident #42. | |
| CNA M | Interviewed regarding call light importance and placement. | |
| CNA Y | Interviewed regarding call light placement for Resident #46. | |
| LVN H | Licensed Vocational Nurse | Acknowledged feeding tube tip care and oxygen humidifier issues. |
| DON | Director of Nursing | Provided multiple interviews regarding deficiencies and corrective actions. |
| Administrator | Interviewed regarding expectations for resident care and oversight. | |
| Housekeeping Manager | Interviewed regarding cleaning practices and room maintenance. | |
| WCN | Wound Care Nurse | Observed failing to perform hand hygiene during wound care. |
| CNA B | Named in delayed incontinent care for Resident #43. | |
| LVN K | Licensed Vocational Nurse | Interviewed regarding feeding tube and oxygen care. |
| LVN D | Licensed Vocational Nurse | Provided physician orders for bed bolsters for Residents #2 and #26. |
Inspection Report
Routine
Deficiencies: 12
Date: Dec 12, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights, reasonable accommodation of resident needs, safety and cleanliness of the environment, restraint use, care planning, activities of daily living assistance, feeding tube care, respiratory care, infection control, food safety, and RN coverage.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy, call lights accessibility, cleanliness of resident rooms and kitchen, proper restraint orders, timely care for incontinent residents, appropriate feeding tube care, respiratory care with humidifiers, infection control hand hygiene, and maintaining required RN coverage on weekends. Several residents' care plans were not updated quarterly. Food storage and kitchen sanitation were inadequate.
Deficiencies (12)
Failed to ensure CNA provided privacy to Resident #42 while transporting her to the shower room.
Failed to ensure call light system was accessible to Residents #70 and #46.
Failed to maintain safe, clean, comfortable, and homelike environment in 8 resident rooms.
Failed to ensure Residents #2, #26, #35, and #43 had physician orders for bolster side rails.
Failed to ensure comprehensive care plans were reviewed and revised quarterly for Residents #2, #38, and #59.
Failed to provide timely incontinent care to Resident #43.
Failed to ensure LVN capped the tip of Resident #45's gastrostomy tube when not in use.
Failed to ensure Resident #67's oxygen concentrator had a humidifier.
Failed to maintain RN coverage of at least 8 consecutive hours on weekends for 21 days during review period.
Failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards; food was unlabeled and undated; kitchen was unclean.
Failed to ensure ADON performed hand hygiene during incontinence care for Resident #43.
Failed to ensure wound care nurse performed hand hygiene during wound care for Resident #55.
Report Facts
RN coverage hours: 6.2
RN coverage hours: 2
RN coverage hours: 2
RN coverage hours: 2
RN coverage hours: 6.3
RN coverage hours: 2
RN coverage hours: 2
RN coverage hours: 0
RN coverage hours: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in privacy violation finding for Resident #42 | |
| CNA B | Named in incontinent care delay finding for Resident #43 | |
| LVN H | Licensed Vocational Nurse | Named in feeding tube care and respiratory care findings |
| DON | Director of Nursing | Named in multiple findings including feeding tube care, respiratory care, RN coverage, and infection control |
| CNA M | Named in call light accessibility finding | |
| CNA Y | Named in call light accessibility finding | |
| LVN K | Licensed Vocational Nurse | Named in respiratory care and call light accessibility findings |
| Administrator | Named in multiple findings including call light accessibility, feeding tube care, respiratory care, RN coverage, and kitchen sanitation | |
| Housekeeping Manager | Named in cleanliness and environment findings | |
| Dietary Manager | Named in kitchen sanitation and food storage findings | |
| WCN | Wound Care Nurse | Named in infection control hand hygiene finding for Resident #55 |
| ADON | Assistant Director of Nursing | Named in infection control hand hygiene finding for Resident #43 |
| LVN D | Licensed Vocational Nurse | Named in restraint orders finding for Residents #2 and #26 |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of respiratory care for residents, specifically focusing on the care and maintenance of oxygen concentrators for residents requiring respiratory support.
Findings
The facility failed to ensure that Resident #1's oxygen concentrator filters were free of sediment and debris, which could compromise oxygen delivery and increase risk of infection. Interviews revealed unclear responsibilities for cleaning and maintaining oxygen concentrator filters, and observations confirmed significant filter contamination.
Deficiencies (1)
Failure to ensure Resident #1 had oxygen concentrator filters free of sediment and debris.
Report Facts
Oxygen flow rate: 2
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Staff Nurse | Interviewed regarding Resident #1's oxygen concentrator filter maintenance |
| ADON | Assistant Director of Nursing | Interviewed about cleaning Resident #1's oxygen concentrator filters and leadership rounding |
| DON | Director of Nursing | Interviewed about expectations for oxygen concentrator filter maintenance and infection control |
| Administrator | Interviewed about nursing staff responsibilities for oxygen concentrator maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident elopement incident that occurred on 07/17/2023, where Resident #1 left the facility unsupervised.
Complaint Details
The complaint investigation found that Resident #1 eloped from the facility on 07/17/2023. The resident was found in a car repair shop parking lot after being allowed out through a door with a code accessed by another resident. The wander guard was not active at the time. The facility conducted interviews and investigations, implemented one-on-one monitoring, changed door codes, re-educated staff, and obtained new physician orders for wander guard use. The resident was transferred to a secured Memory Care Unit.
Findings
The facility failed to prevent Resident #1 from eloping on 07/17/2023 despite the resident being identified as an elopement risk. The resident was found outside the facility in a nearby parking lot. The wander guard device was not in use at the time, and the facility identified lapses in supervision and security protocols, including door code management. The facility implemented corrective actions including one-on-one monitoring, changing door codes, staff re-education, and increased elopement prevention measures.
Deficiencies (1)
Failed to provide an environment free from accident hazards and adequate supervision to prevent Resident #1 from eloping on 07/17/2023.
Report Facts
Elopement Risk Score: 11
Residents assessed as high risk for elopement: 3
Minutes resident was gone during elopement: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Interviewed regarding observations on day of elopement and elopement protocol |
| CNA J | Certified Nursing Assistant | Interviewed as present during elopement and involved in resident assessment |
| Administrator | Interviewed regarding investigation, corrective actions, and policy changes | |
| DON | Director of Nursing | Interviewed regarding investigation, corrective actions, and policy changes |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 16, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 2
Date: Oct 13, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards related to food service safety and infection prevention and control.
Findings
The facility failed to ensure kitchen staff wore proper head coverings while preparing and serving food, risking food contamination. Additionally, the facility failed to ensure proper sanitization of pulse oximetry and blood pressure devices between residents, risking cross contamination and infection.
Deficiencies (2)
Facility failed to ensure kitchen staff wore proper head coverings when preparing, distributing, and serving food in the kitchen area.
Facility failed to ensure LVN L sanitized pulse oximetry device and blood pressure device between Resident #18 and Resident #50's care.
Report Facts
Residents Affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN L | Licensed Vocational Nurse | Named in infection control deficiency for failing to sanitize equipment between residents |
| Dietary Manager | Named in food service deficiency for not wearing hair restraint and advising staff | |
| Dietary Staff T | Named in food service deficiency for not wearing hair restraint while preparing food | |
| LPN N | Infection Control Preventionist | Interviewed regarding facility policy and expectations on head coverings and sanitization |
| DON | Director of Nursing | Interviewed regarding expectations for sanitizing equipment and head coverings |
| Administrator | Interviewed regarding facility policy and expectations on head coverings and sanitization |
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