Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation and record review, the facility failed to ensure residents had the right to formulate an
advanced directive for 3 (Resident #1, Resident #2 and Resident #3) of 8 residents reviewed for Advanced
Directives.The facility failed to ensure that Resident #1, Resident #2 and Resident #3's OOH-DNR (Out of
Hospital-Do Not Resuscitate) were completed correctly with both signatures of the resident/family and that
it was signed by a physician making the forms invalid.This failure could affect all residents who have
implemented an Advanced Directive and established their choice not to be resuscitated at the risk of
receiving CPR (Cardiopulmonary Resuscitation) against their wishes.Findings included:Record review of
Resident #1's face sheet dated [DATE] revealed he was admitted to the facility on [DATE] and was [AGE]
years old. His diagnosis included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right
Side, (paralysis to one side of the body caused by a stroke), Type 2 Diabetes and Hypertension (high blood
pressure). Resident #1's electronic face sheet reflected he was a Code Status: DNR.Record review of
Resident #1's MDS (Minimum Data Set) dated [DATE] reflected he scored a 15 on his BIMS (Brief Interview
of Mental Status) indicating no cognitive impairment. Resident #1's needed extensive assistance with bed
mobility, transfers and limited assistance with eating and toileting. Record review of Resident #1's undated
care plan revealed, Focus: he had an order for Do Not Resuscitate (DNR), Date initiated: [DATE], Revision
on [DATE] Goal: Resident/Responsible party's decision for DNR will be honored through the next review
date. Date Initiated: [DATE], Revised on: [DATE].Interventions: All aspects of DNR will be explained to
resident or responsible party, Date Initiated: [DATE] In absence of b/p, pulse, respiration, CPR will not be
initiated, Date Initiated: [DATE] Notify MD of change of condition, Date Initiated: [DATE] Resident will be
maintained at a level of comfort as ordered by physician, Date Initiated: [DATE] Social Services to consult
with resident and RP regarding their decision to continue DNR, Date Initiated: [DATE] Record review of
Resident #1's DNR dated [DATE] revealed it had been signed by the resident at the top of the form but did
not have his second signature at the bottom of the form where all who signed must sign twice to make the
document valid. In an interview on [DATE] at 3:10 pm. Resident # 1 stated he did not want CPR if his heart
stopped and that he had a DNR in place already.Record review of the Code Status list that was generated
from PCC provided by the facility revealed that Resident #1 was not listed on the document. Record review
of Resident #2's face sheet dated [DATE] revealed she was admitted to the facility on [DATE] and was
[AGE] years old. Her diagnosis included Unspecified Dementia, Unspecified Atrial Fibrillation (a condition in
which the heart beats irregularly and often too fast), Hypertension (high blood pressure) and Muscle
Wasting. Resident #2's electronic face sheet revealed she was a Code Status: DNR.Record review of
Resident #2's Quarterly MDS dated [DATE] reflected that she scored a 3 on her BIMS indicating severe
cognitive impairment. Resident # 2 needed supervision with toileting and
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
455861
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455861
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Plano Rehabilitation and Nursing Cente
1621 Coit Rd
Plano, TX 75075
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
dressing, moderate assistance with bathing and set up only for eating. Record review of Resident #2's
undated care plan revealed, Focus: she had an order for Do Not Resuscitate (DNR), Date initiated: [DATE],
Revision on [DATE] Goal: Resident/Responsible party's decision for DNR will be honored through the next
review date. Date Initiated: [DATE], Revised on: [DATE].Interventions: All aspects of DNR will be explained
to resident or responsible party, Date Initiated: [DATE] In absence of b/p, pulse, respiration, CPR will not be
initiated, Date Initiated: [DATE] Notify MD of change of condition, Date Initiated: [DATE] Resident will be
maintained at a level of comfort as ordered by physician, Date Initiated: [DATE] Social Services to consult
with resident and RP regarding their decision to continue DNR. Date Initiated: [DATE] Record review of
Resident #2's DNR dated [DATE] revealed it had been signed only once by the resident's representative at
the top of the form and is missing the second signature and the physician at the bottom of the form to make
it a valid document. Record review of Resident #3's face sheet dated [DATE] revealed she was admitted to
the facility on [DATE] and was [AGE] years old. Her diagnosis included Alzheimer's, Type 2 Diabetes and
Hypertension (high blood pressure). Record review Resident #3's Quarterly MDS dated [DATE] reflected
that she scored a 00 on her BIMS, indicating she was unable to participate. The staff interview was
conducted and indicated she did not know the current season, location of her room, staff names/faces or
that she was in a nursing home. Her cognitive skill for making daily decisions was severely impaired.
Record review of Resident #3's undated care plan revealed, Focus: she had an order for Do Not
Resuscitate (DNR), Date initiated: [DATE], Revision on [DATE] Goal: Resident/Responsible party's decision
for DNR will be honored through the next review date. Date Initiated: [DATE], Revised on:
[DATE].Interventions: All aspects of DNR will be explained to resident or responsible party, Date Initiated:
[DATE] In absence of b/p, pulse, respiration, CPR will not be initiated, Date Initiated: [DATE] Notify MD of
change of condition, Date Initiated: [DATE] Resident will be maintained at a level of comfort as ordered by
physician, Date Initiated: [DATE] Social Services to consult with resident and RP regarding their decision to
continue DNR. Date Initiated: [DATE] Record review of Resident #3's DNR dated [DATE] revealed it was
missing the first witness signature and it was signed by a Family Nurse Practitioner, and not the attending
physician which the form indicates, to make it a valid document. Record review of the Code Status list that
was generated from PCC provided by the facility revealed that Resident #1 was not listed on the document.
In an interview on [DATE] at 3:35 PM, LVN A stated he has been at the facility for 2 months. When he needs
to know the code status of a resident, he checks the system (PCC) to see what the code status is. He
stated the risk to the residents for not following their wishes about their code status is it would affect their
health.In an interview on [DATE] at 4:02 PM, ADON B stated that the social worker normally looks at the
DNR's but since they don't have one at present, she does it. She stated she was unaware that 3 of the
DNR's had not been filled out correctly. She stated the risk to the residents would be negligent on the part
of the facility.In an interview on [DATE] at 4:25 PM, the DON stated he was not aware the DNR's had not
been completed correctly and that he and the ADON check the documents for accuracy. He did not know
why Resident #1's name was missing from the Code Status list since there was an order in the chart. He
stated the risk to the residents was the facility would not fulfill their wishes. Record Review of the facility's
Advanced Directive undated policy, Do Not Resuscitate Order revealed in part, Procedure: Texas Out of
Hospital DNR Form 1. Any resident may initiate an Out of Hospital DNR Order.2. If the resident is capable
of providing informed consent for the order, he/she will sign and date the DNR order on the front of the
official DNR form from the state of Texas.5. In all cases the form must be signed and dated by two
witnesses. Record review of the OOH DNR Order instructions for issuing and OOH-DNR Order revealed
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455861
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455861
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Landmark of Plano Rehabilitation and Nursing Cente
1621 Coit Rd
Plano, TX 75075
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
the following: Purpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side
complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized
representatives to direct health care professionals to forgo resuscitation attempts and to permit the person
to have a natural death with peace and dignity. Applicability: This OOH-DNR Order applies to health care
professions in out-of-hospital settings, including physicians' offices, hospital clinics and emergency
departments. Implementation: A competent adult person at least [AGE] years of age, or the person's
authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's
attending physician will document existence of the Order in the person's permanent medical record. The
OOH-DNR Order may be executed as follows: . In addition: the OOH-DNR Order must be signed and dated
by two competent adult witnesses, who have witnessed either the competent adult person making his/her
signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if
applicable, have witnessed a competent adult person making and OOH-DNR Order by nonwritten
communication to the attending physician, who must sign in Section D and also the physician's statement
section.
Event ID:
Facility ID:
455861
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
FAQ · About this visit
Common questions about this visit
What happened during the November 13, 2025 survey of Landmark of Plano Rehabilitation and Nursing Cente?
This was a inspection survey of Landmark of Plano Rehabilitation and Nursing Cente on November 13, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Landmark of Plano Rehabilitation and Nursing Cente on November 13, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.