Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Reserve At Richardson during CMS and state inspections, most recent first.
A resident's confidential medical information, including diagnosis and medication details, was left exposed and unattended on the nurse's station countertop by an ADON. The document was visible to anyone passing by, in violation of facility policy and HIPAA regulations. Facility leadership confirmed that such information should be protected and not accessible to unauthorized individuals.
A nurse medication cart containing drugs and biologicals was left unlocked and unattended in a hallway, with a resident nearby. Staff interviews confirmed the cart should have been locked when not in use, and the responsible LVN admitted to leaving it unsecured while stepping away. Facility policy requires all medication storage compartments to be locked when unattended.
Three residents with severe cognitive impairment and high dependence on staff were found to have call lights that were not accessible, with devices either out of reach or on the floor. Staff interviews confirmed the expectation that call lights should always be within reach, and care plans for these residents included this intervention due to their fall risk and need for assistance. Facility policy also required call lights to be accessible, but this was not followed, resulting in a deficiency.
A resident with asthma and severe cognitive impairment did not have her nebulizer breathing mask properly stored in a bag when not in use, as required by facility policy and professional standards. Staff interviews confirmed the expectation for bagging the mask to prevent infection, but the mask was observed left unbagged after treatment.
Two residents were found with medications in their rooms, including nasal spray, eye drops, and antifungal powder, without physician orders or assessments for self-administration. Staff confirmed these medications should not have been accessible to residents and were not stored in locked compartments as required.
During incontinent care for a resident with diarrhea and ADL deficits, two CNAs failed to change gloves and perform hand hygiene after cleaning soiled areas and before handling a clean brief, contrary to facility infection control policy. Both staff and administration acknowledged the lapse in proper infection prevention procedures.
The facility failed to create comprehensive care plans for three residents, including one with emphysema using oxygen therapy, another with a catheter and on hospice care, and a third unable to use a call light due to physical and cognitive limitations. These omissions in care planning could lead to inconsistent care delivery and unmet needs.
The facility failed to provide appropriate respiratory care for several residents, leading to deficiencies in their care. A resident with emphysema used oxygen therapy without a physician's order, while another with sleep apnea had a CPAP mask improperly stored. Additionally, a resident with a PRN order for oxygen had unbagged tubing, and another lacked a physician's order for a CPAP machine, with the mask also unbagged. These issues reflect non-compliance with professional standards and facility policies.
The facility's kitchen failed to meet professional standards for food safety, with an ice scoop stored improperly, uncovered trash and tea dispenser, and unclean equipment. These deficiencies were observed during a survey, and staff acknowledged the risk of cross-contamination.
A resident with a moderate cognitive impairment and an indwelling catheter was observed in the dining area with a visible catheter bag, despite having a privacy bag that was not fully pulled down. The facility's policy requires catheter bags to be covered to maintain dignity, but the CNA responsible for transferring the resident did not ensure this. The ADON and DON acknowledged the oversight and confirmed the expectation for staff to properly use privacy bags.
A facility failed to update a comprehensive care plan timely for a resident with obstructive sleep apnea and severe cognitive impairment. The last care plan update was in June 2024, despite a physician's order for CPAP use in October 2023. Staff interviews revealed a lack of adherence to the policy requiring quarterly updates, leading to potential confusion in care provision.
A resident with severe cognitive impairment and a history of falls was found with bolster pads on her bed without physician orders. The DON confirmed the absence of orders, which is against the facility's policy requiring physician approval for such equipment.
A facility failed to have a physician's order for a resident's external catheter, used to aid in the healing of a pressure ulcer. The resident, who was cognitively intact, had been using the catheter since January without a documented order. Staff, including the LVN, ADON, and DON, acknowledged the oversight, which could lead to staff being unaware of necessary care interventions.
The facility failed to store probiotics for two residents according to the manufacturer's instructions, which required refrigeration after opening. Both a medication aide and an LVN administered probiotics that were improperly stored in a medication cart drawer instead of being refrigerated, as observed during a survey. The ADON and DON confirmed the oversight, which could affect the potency of the probiotics.
A facility failed to maintain an effective infection control program when a CNA did not change gloves after touching a resident's Foley catheter tubing during care. The resident, who had an indwelling catheter due to uropathy, was cognitively intact. The CNA initially followed proper hygiene protocols but failed to change gloves after handling the potentially contaminated tubing, contrary to facility policy. This oversight was acknowledged by the CNA and confirmed by the DON and ADON.
A resident with dementia and a history of falls eloped through an unsecured door in the dining area, leading to a fall down a stairwell and multiple serious injuries. The resident's care plan included frequent monitoring and fall precautions, but the door was not identified as a hazard, and the alarm was not responded to in time. Staff were aware of the resident's needs, but the facility failed to secure the door, resulting in the incident.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. A container of Beef Bullion paste past its expiration date was found in the refrigerated storage area, which could have exposed residents to foodborne illnesses. The facility's policy and FDA guidelines were not followed.
Resident Medical Information Left Unattended and Exposed at Nurse's Station
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's personal and medical records when the Assistant Director of Nursing (ADON) left a piece of paper containing sensitive medical information exposed and unattended on top of the nurse's station countertop. The document included the resident's name, medical record number, physician's name, proposed course of therapy, medication name, and the condition being treated, which was psychotic behavior. The paper was left facing the hallway with no staff present at the nurse's station, making the information visible to anyone passing by. The resident involved was an elderly female diagnosed with depression and unable to complete a cognitive assessment interview. Her care plan included medication management for depression, and her physician's order specified the use of Quetiapine Fumarate. The ADON acknowledged leaving the document exposed and recognized that this action constituted a violation of confidentiality and HIPAA regulations. Both the Director of Nursing (DON) and the Administrator confirmed that resident health information should not be exposed or accessible to unauthorized individuals, as per facility policy.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A nurse medication cart was observed parked outside the nurse's station, unlocked and unattended, with drawers containing medications accessible and facing the hallway. A resident in a wheelchair was sitting approximately ten steps from the open cart. Multiple staff interviews confirmed that the cart should have been locked when not in use, and that it was not clear who was responsible for the cart at the time it was left unattended. The facility's policy requires all drugs and biologicals to be stored in locked compartments when not in use, and for carts to not be left unattended if open or accessible. Further interviews revealed that the LVN responsible for the cart left it unlocked while going to the restroom, acknowledging that the cart should have been secured before leaving it unattended. Staff, including the ADON, DON, and Administrator, all stated that the expectation is for all medication carts to be locked when not in use to prevent unauthorized access. The facility's policy, dated December 2024, reiterates the requirement for all compartments containing drugs and biologicals to be locked when not in use.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of three residents were accessible, as required by their care plans and facility policy. Observations on the specified date revealed that one resident's call light was hanging on the bed railing and not within reach, another resident's call light was found on the floor and out of reach, and a third resident's call light was also on the floor behind a side table. All three residents had severe cognitive impairments and required significant assistance with daily activities, including personal hygiene, transfers, and mobility. Their care plans specifically included interventions to keep call lights within reach due to their risk for falls and dependence on staff for assistance. Interviews with staff, including a CNA, LVN, and two ADONs, confirmed that call lights should always be within reach of residents, especially those who are dependent or have limited mobility. Staff acknowledged that they had not noticed the call lights were inaccessible during their rounds and recognized the importance of ensuring accessibility to address residents' needs and prevent incidents such as falls. The facility's policy also required that call lights be within easy reach of residents who are in bed or confined to a chair. Record reviews for each resident showed that their care plans included the intervention to keep call lights within reach, and there was no documentation indicating any refusal by the residents to have their call lights accessible. The deficiency was identified through direct observation, interviews, and review of care plans and facility policy, demonstrating a failure to reasonably accommodate the needs and preferences of the residents as required.
Improper Storage of Nebulizer Mask for Resident Requiring Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with asthma and severe cognitive impairment, who required respiratory care including nebulizer treatments, was not provided with safe and appropriate storage of her respiratory equipment. During observation, the resident's nebulizer breathing mask was found connected to the machine and not stored in a bag when not in use, contrary to professional standards and the facility's own infection prevention policy. The resident was unable to state where the mask was kept after treatments, indicating a lack of awareness or involvement in the storage process. Interviews with nursing staff and facility leadership confirmed that the expectation was for the breathing mask to be bagged after each use to prevent infection and cross-contamination, regardless of whether the treatment was administered daily or as needed. The facility's policy specifically required respiratory therapy equipment, such as nebulizer circuits, to be stored in a plastic bag when not in use. The failure to follow this protocol was observed and acknowledged by staff, resulting in a deficiency related to the safe and appropriate provision of respiratory care.
Failure to Secure Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as required, for two residents. Both residents were found to have medications in their rooms without proper authorization or assessment for self-administration. Specifically, one resident had a nasal spray and a cup with powder on her side table, and the other had Systane eye drops and antifungal powder at her bedside. Neither resident had a physician's order or care plan indicating they were permitted to self-administer these medications, nor was there an assessment documenting their ability to do so. Record reviews showed that both residents were cognitively intact, with BIMS scores of 15, and had various medical diagnoses including asthma, bipolar disorder, allergic rhinitis, and depression. However, their care plans did not include interventions or permissions for self-administration of medications. Additionally, there were no physician orders for the nasal spray or eye drops found in the residents' rooms, and no assessments had been completed to determine their capability for self-administration. During interviews, staff members acknowledged that medications should not be left in residents' rooms due to the risk of accidental overdose or misuse. Staff also confirmed that the medications observed should have been administered by nursing staff and not left accessible to the residents. The facility's policy requires all drugs and biologicals to be stored securely and separately from other substances, which was not followed in these instances.
Failure to Follow Hand Hygiene and Glove Change Protocol During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinent care for one resident diagnosed with diarrhea and requiring assistance for toileting due to an ADL self-care performance deficit. During the observed care, two CNAs initially performed hand hygiene and donned gloves. However, when one CNA needed new gloves, the other CNA removed her gloves, retrieved new gloves from a box without sanitizing her hands, and then continued care. After cleaning the resident's bottom, the CNA did not change her gloves or perform hand hygiene before handling a clean brief and placing it under the resident. Both CNAs acknowledged during interviews that gloves should have been changed and hand hygiene performed after contact with soiled areas and before touching clean items. The ADON and Administrator confirmed that the staff did not follow facility policy, which requires hand hygiene before donning gloves and after removing them, as well as changing gloves when moving from dirty to clean tasks. The failure to follow these procedures was directly observed and confirmed through staff interviews and record review.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which could potentially place them at risk of not receiving necessary care. Resident #2, a cognitively intact female with emphysema and respiratory failure, was observed using oxygen therapy without a corresponding care plan or physician order. Despite her regular use of oxygen, her care plan did not reflect this need, indicating a lack of documentation and planning for her respiratory support. Resident #74, a cognitively intact male with an unstageable pressure ulcer and AIDS, was using a condom catheter and receiving hospice care, yet his care plan did not include these critical aspects of his care. Observations confirmed the presence of a catheter, and interviews with staff revealed an oversight in care planning, as the resident's catheter use and hospice admission were not documented in his care plan. This lack of documentation could lead to inconsistencies in care delivery. Resident #182, a male with Alzheimer's disease, quadriplegia, and contractures, was unable to use the call light due to his physical and cognitive limitations. However, his care plan did not address this inability, which could result in staff not conducting more frequent checks. The DON acknowledged the oversight, noting that the resident's inability to use the call light should have been care planned to ensure staff awareness and timely response to his needs.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for several residents, leading to deficiencies in their care. Resident #2, diagnosed with emphysema and respiratory failure, was using oxygen therapy without a physician's order. Despite the resident's regular use of oxygen, there was no care plan or physician order documented for this therapy, which was observed during an interview and record review. Resident #19, who suffers from obstructive sleep apnea, had a CPAP mask that was not stored properly. The mask was found unbagged on a table, contrary to the facility's policy that requires such equipment to be bagged when not in use to prevent contamination. This oversight was noted during an observation and confirmed through interviews with staff, who acknowledged the risk of respiratory infection due to improper storage. Resident #39, who had a PRN order for oxygen due to shortness of breath, had oxygen tubing left unbagged in his room. The tubing was not stored in a plastic bag as required when not in use, posing a risk of infection. Similarly, Resident #67, who required a CPAP machine for sleep apnea, did not have a physician's order for the machine, and the CPAP mask was found unbagged. These deficiencies highlight a lack of adherence to professional standards and facility policies regarding respiratory care and equipment management.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. The ice scoop was improperly stored inside the ice machine, and it had brownish stains, indicating it was not cleaned. Additionally, a large trash can in the kitchen area was left uncovered, and a tea dispenser was not covered, exposing its contents to potential airborne contaminants. These observations suggest a lack of proper sanitation practices in the kitchen. Further inspection revealed that kitchen equipment was not adequately cleaned. A microwave had brownish stains along its inner walls, and a deep fryer had thick, dried-up grease on its inner walls. Interviews with the Dietary Manager in Training and the Dietician confirmed awareness of these issues, and they acknowledged the risk of cross-contamination due to these deficiencies. The facility's policy on Food Safety and Sanitation mandates compliance with local, state, and federal standards, which were not met in this instance.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that the privacy bag on the resident's catheter was properly positioned to cover the catheter bag and its contents. During lunchtime, the resident was observed in the dining area with the catheter bag visibly hanging from the back of the wheelchair, despite having a privacy bag that was not fully pulled down. This oversight was noted by the Assistant Director of Nursing (ADON), who acknowledged the issue and indicated that the staff responsible for transferring the resident should have ensured the catheter bag was fully covered. The resident involved was a male with a moderate cognitive impairment and an indwelling catheter due to obstructive and reflux uropathy. The facility's policy on dignity and quality of life mandates that urinary catheter bags be covered to maintain resident dignity. Interviews with the Certified Nursing Assistant (CNA) who transferred the resident and the Director of Nursing (DON) confirmed that the catheter bag should not have been visible, and the expectation was for staff to ensure privacy bags are properly used when residents are outside their rooms.
Failure to Update Comprehensive Care Plan Timely
Penalty
Summary
The facility failed to ensure the timeliness of a comprehensive care plan for a resident diagnosed with obstructive sleep apnea, who required significant assistance and support in daily life due to severe cognitive impairment. The resident's last quarterly care plan was completed on 06/12/2024, and no updates were made until 03/11/2025, despite the resident's ongoing need for a CPAP machine as indicated by a physician's order dated 10/26/2023. This oversight in updating the care plan was acknowledged by the Assistant Director of Nursing (ADON) and the MDS Nurse, who admitted that the care plans were supposed to be reviewed quarterly to ensure residents' needs were met. Interviews with facility staff, including the ADON, MDS Nurse, Director of Nursing (DON), and the Administrator, revealed a lack of adherence to the facility's policy requiring quarterly updates to comprehensive care plans. The staff recognized that without timely care plans, there could be confusion regarding the care provided to residents, as the care plans guide staff on the latest goals and interventions. The deficiency was attributed to an oversight, and the staff responsible for auditing care plans acknowledged the need for improvement in ensuring that care plans are completed and updated as required.
Lack of Physician Orders for Fall Prevention Equipment
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards by not obtaining physician orders for bolster pads used for fall prevention. The resident in question, a female with severe cognitive impairment and a history of falls, was observed with bolster pads on her bed. However, a review of her records revealed no physician orders for these pads, which were intended as an intervention for her fall risk. During an interview, the Director of Nursing (DON) acknowledged the absence of physician orders for the bolster pads, despite initially believing they were in place. The facility's policy on restraints specifies that such equipment should only be used for the safety and wellbeing of residents and requires physician orders. The lack of orders for the bolster pads could potentially result in injury if the resident attempted to get out of bed.
Lack of Physician Order for External Catheter
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence. Specifically, the facility did not have a physician's order for the use of an external catheter (condom catheter) for a resident diagnosed with an unstageable pressure ulcer to the sacrum. The resident, who was cognitively intact, had been using the catheter since January, but there was no documented order for its use as of March. Observations and interviews revealed that the resident had a catheter bag hanging at the side of the bed, and staff members, including the LVN, ADON, and DON, acknowledged the absence of a physician's order for the catheter. The facility's policy requires that all treatments, including catheter use, have a written order from a licensed prescriber. The lack of an order could lead to staff being unaware of the necessary interventions for the resident's care, potentially compromising the resident's health and safety.
Improper Storage of Probiotics
Penalty
Summary
The facility failed to ensure that probiotics for two residents were stored according to the manufacturer's instructions, which required refrigeration after opening. This deficiency was observed during medication administration for two residents, both of whom were receiving probiotics as part of their treatment plans. The probiotics were stored in a medication cart drawer instead of being refrigerated, as indicated on the product label. For the first resident, a female with a history of constipation and nausea, the medication aide did not notice the refrigeration requirement on the probiotic bottle. The aide admitted to not reading the instructions on the medication label, which led to the improper storage of the probiotics. Similarly, for the second resident, a male with severe cognitive impairment and diagnosed with diarrhea and flatulence, the LVN also failed to store the probiotics in the refrigerator as required. The LVN acknowledged the oversight after reading the label during the surveyor's observation. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were informed of the issue and confirmed that probiotics requiring refrigeration were not stored properly, which could affect their potency. The facility's policy on medication storage, which mandates refrigeration for medications requiring it, was not followed in these instances, leading to the deficiency.
Infection Control Deficiency Due to Improper Glove Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not change gloves after touching the drainage tubing of a resident's Foley catheter during incontinent care. This oversight was observed during care provided to a resident who had an indwelling catheter due to obstructive and reflux uropathy. The resident was cognitively intact and capable of normal cognition, as indicated by a BIMS score of 15. During the care process, the CNA initially followed proper hand hygiene and glove use protocols by washing hands, donning gloves, and sanitizing hands after removing gloves. However, after touching the catheter tubing, which is considered potentially contaminated, the CNA failed to change gloves before continuing with the care. This lapse in protocol was acknowledged by the CNA, who admitted that the tubing is presumed dirty and that gloves should have been changed to prevent cross-contamination. The facility's policy on infection control guidelines clearly states that gloves should be changed when moving from a dirty site to a clean one to prevent cross-contamination. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both confirmed the expectation for staff to change gloves and sanitize hands when transitioning from handling potentially contaminated materials to clean tasks. The failure to adhere to these guidelines during the care of the resident with a Foley catheter represents a deficiency in the facility's infection control practices.
Resident Elopement and Fall Due to Unsecured Door
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident, leading to an elopement incident. The resident, who had a history of dementia, repeated falls, and cognitive impairment, was able to exit through an unsecured door in the dining area. This door led to a corridor and a fire exit door, which connected to a stairwell. The resident experienced an unwitnessed fall down the stairs, resulting in multiple serious injuries, including fractures to the wrist, face, and nasal area. The resident's care plan identified her as at risk for falls and wandering, with interventions such as frequent monitoring, re-direction, and fall precautions. However, on the day of the incident, the resident was able to leave the dining area unsupervised. Staff were aware of her care needs, but the door she exited through was not secured, and the alarm was not responded to in time to prevent the fall. Interviews with staff revealed that the resident was at her baseline behavior on the day of the incident, and no unusual behaviors were noted. The facility had not previously identified the door as a potential hazard, as no residents had attempted to exit through it before. The incident highlighted a lapse in the facility's safety protocols, as the resident was able to access an area that should have been secured to prevent such accidents.
Failure to Discard Expired Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. During an observation and interview with the Dietician, a 16-ounce container of Beef Bullion paste was found in the refrigerated storage area with a date reading 11/07/23. The container had been opened on an unknown date, and the Dietician explained that the date on the container was the date the facility received the Beef Bullion paste. The Dietician immediately discarded the container in front of the investigator. The Dietician later revealed that if the Beef Bullion paste was past its expiration date and had gone bad, it could have exposed vulnerable residents to foodborne illnesses and potentially caused harm if residents became ill. In an interview with the DON, it was emphasized that it is important to discard any foods past their expiration date in the kitchen to prevent exposing residents to illness. The facility's policy on Frozen and Refrigerated Foods Storage, revised in November 2017, requires items stored in the refrigerator to be dated upon receipt unless they contain a manufacturer use-by, sell-by, or best-by date. The FDA Food Code also mandates that refrigerated, ready-to-eat time/temperature control for safety food must be clearly marked to indicate the date by which the food shall be consumed, sold, or discarded. The facility failed to adhere to these guidelines, leading to the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Richardson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Plaza At Richardson | 0.4 mi | — | 3 | 0 |
| Richardson Nursing And Rehabilitation | 0.8 mi | — | 7 | 0 |
| Cottonwood Creek Healthcare Community | 1.3 mi | — | 0 | 0 |
| Lindan Park Care Center Lp | 1.7 mi | — | 0 | 0 |
| Remington Transitional Care Of Richardson | 1.8 mi | — | 0 | 0 |
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