Victoria Gardens of Frisco

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for one (Resident #1) of four residents reviewed for call lights.The facility failed to ensure Resident #1's call light was within reach of the resident. This failure could place the residents at risk of falling, injury, and feelings of low self-worth due to not being able to call for help. Findings included:Review of Resident #1's face sheet, dated 01/14/26, reflected the resident was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included muscle wasting and atrophy (loss of muscle mass and strength), bi-polar disorder, depression, history of stroke (a blood clot in the brain, which damages the brain), seizures, reduced mobility, and anxiety disorder. She also had diagnoses of cognitive, speech and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Findings included: 1. Record review of Resident #1's Face Sheet, dated 10/23/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obesity (excessive accumulation of body fats) and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #1's Comprehensive MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 10/02/2025, reflected the resident had as severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 03. The Comprehensive MDS Assessment indicated the resident had dementia and obesity. Record review of Resident #1's Comprehensive Care Plan, dated 10/12/2025, reflected the resident had the potential for impaired skin integrity and one of the interventions was to provide proper skin care. Record review of Resident #1's Physician Order, dated 10/08/2025,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure all foods stored in the refrigerator or freezer was covered, labeled, and dated. 2. The facility failed to ensure wrappers of frozen food stayed intact until thawing. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the dining room on 5/27/2025 at 9:04 a.m., revealed the following: -1 large pitcher of drink not labeled or dated. Observation of the refrigerator on 5/27/2025 at 9:08 a.m., revealed the following: -4 trays of drinks not labeled or dated. Observation of the walk-in freezer on 5/27/2025 at 9:13 a.m., revealed the following: -1 29.7 lb box of biscuits dated 5/22/2025 exposed to the air. -1 20lb box of frozen vegetables dated 5/8/2025 exposed to the air. In an interview with [NAME] A on 05/27/2025 at 11:45 a.m., she stated all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to submit and complete accurate request and recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report for a low air loss mattress within 20 days after the IDT meeting for one (Resident #1) of three residents reviewed for PASRR services. The facility did not submit a complete and accurate request for a low air loss mattress for Resident #1 within 20 days after the Interdisciplinary Team (IDT) meeting held on 12/20/2024. The past noncompliance began on 12/20/2024 and ended on 03/17/2025. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's MDS assessment, dated 02/24/2025, revealed he was admitted to the facility on [DATE] with diagnoses of Dementia without behavioral disturbances,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for 1 (Resident #1) of 5 residents reviewed for meals. -The facility failed to ensure Resident #1's mechanical soft fish was free of small bones. This failure placed all residents, especially those with swallowing issues, at risk of aspirating or choking. Findings included: Record review of Resident #1's face sheet, dated 06/13/24, reflected a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: dementia (loss of memory and thinking), diverticulitis of intestine (small, inflamed pockets in intestine), type II diabetes, and dysphasia (difficulty swallowing). Record review of Resident #1's quarterly MDS assessment, dated 05/16/24, reflected her BIMS score was 14, which indicated cognition was intact. Further review reflected Resident #1 required a mechanically altered therapeutic diet . Record review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for four (Resident #12, #18, #44, and one unknown resident) of six residents reviewed for adequate supervision to prevent accidents. The facility failed to ensure resident safety, as evidenced by: The door of the central supply closet, that contained direct care products: mouth wash, razors, shaving cream, toothpaste, denture cleaner, conditioning shampoo, body lotion, and orange stick located on Hall 400 was open and accessible to residents. Resident #12, a confused resident, was in close proximity to the central supply, with no staff within line of sight of the supply closet. The facility failed to properly maintain wheelchairs for Residents #12, #18, and #44. These deficient practices could place residents at risk for ingesting direct care products, fall, and exposure to skin tears that could be detrimental to his or her health, resulting in illness or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine filter and vent were free from dirt and dust. 2. The facility failed to ensure the ice machine chute guard was clean. 3. The facility failed to ensure food items in the refrigerator (1 of 2), freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers and dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure multiple food items stored in a bin/container were clearly identifiable. 5. The facility failed to inspect produce inventory and monitor for spoilage or over ripening and to discard spoiled, moldy, or over ripened food items. These failures could place residents at risk for food-borne…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for two (Halls 100, 400) of two halls, the facility's only nurse's station, and only dining room, observed for pest control program. The facility had live flies various in areas of the facility including the nurse's station, Halls 100, 400, and the dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Included: The facility had live flies in areas of the facility including the nurse's station, Halls 100, 400, and the main dining room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Include: Observation on 04/16/24 at 09:15 a.m. a fly flew around the ceiling light in the conference room, then landing on the table. Observation on 04/16/24 at 9:25 a.m. there was a fly in the central supply room at the end of Hall 400, crawling on the open boxes that had formula…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 3 of 9 residents (Resident #1, #20 and #21) reviewed for accommodation of needs in that: The facility failed to ensure that Resident #1, #20 and #21's call lights were in reach. This failure could affect all residents who needed assistance and could result in needs not being met. Findings included: Record review of Resident #1's Face Sheet, dated 3-21-2024, indicated a [AGE] year-old-female admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of osteomyelitis (inflammation of bone or bone marrow, usually due to infection), multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), sepsis (a life-threatening complication of an infection), and glaucoma (a group of eye conditions that can cause blindness). Record review of Resident #1's MDS, dated [DATE], revealed a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and care to maintain good foot health for one (Resident #2) of one resident reviewed for foot care. The facility failed to provide foot care for Resident #2. This failure could affect residents by placing them at risk for poor foot health, decreased personal hygiene, and a decline in their quality of life. Findings included: Review of Resident #2's face sheet, dated 12/06/23, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia (lack of oxygen), schizoaffective disorder (mood disorder), vascular dementia (memory loss), bipolar disorder (mood swings), hypertension (high blood pressure). Review of Resident #2's MDS assessment, dated 11/21/23 revealed her cognition was severely impaired. The MDS reflected Resident #2 was dependent for personal hygiene. Review of Resident #2's care plan, dated 6/24/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide special eating equipment and utensils for residents who need them for one (Resident #1) of two resident reviewed for meal service. The facility failed to provide Resident #1 a divided plate or plate guard at breakfast on 12/06/23 to assist her with eating independently. This failure could place residents at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss. Findings included: Review of Resident #1's MDS assessment dated [DATE] revealed she was a [AGE] year-old female admitted to the facility on [DATE] Her diagnosis included encephalopathy (alter brain function), chronic obstructive pulmonary disease (difficulty breathing), hemiplegia (paralysis), and hemiparesis following cerebral infarction affecting left non-dominant side and vascular dementia (one sided muscle weakness). Her ADL functional status for eating revealed she required supervision for self-performance and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food located in the kitchen, dry food pantry, and prep areas were labeled and dated. 2. The facility failed to ensure that staff working in the kitchen had fingernails free of nail polish, dip polish, and artificial nails while conducting dietary duties. 3. The facility failed to ensure that the deep fryer grease was clean and free of buildup from dark (expresso-colored) brown oil, grime, crumbs from previously fried food. 4. The facility failed to cover the clean plates stacked and stored in the plate warmer. 5. The facility failed to cover the iced tea container at the top to prevent exposure. These failures placed residents at risk for cross contamination and other bacteria illnesses. Findings include: An observation on 02/28/2023 at 9:10 AM revealed the following food in the dry pantry:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #4) reviewed for Care Plans. The facility failed to ensure Resident #4's Care Plan included goals and interventions for her (high-risk) psychological medication, anticoagulant medication, and the correct information for advanced directives. This failure could place residents at risk of their needs not being met. Findings include: Review of Resident #4's Face Sheet, dated 03/01/23, revealed She was a [AGE] year-old female re-admitted on [DATE]. Relevant diagnoses included high blood pressure, heart beat dysfunction, type 2 diabetes (insulin resistance), anxiety (feelings of fear, dread,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.