Landmark of Plano: DNR Documentation Failures - TX
Federal inspectors who visited Landmark of Plano Rehabilitation and Nursing Center on November 13, 2025, found problems with exactly that paperwork. The facility was cited for failures related to the proper execution of out-of-hospital do-not-resuscitate orders, a deficiency that affected some residents. The violation was tagged under F0578 and assessed at a level of minimal harm or potential for actual harm.
The inspection focused on whether the facility was correctly handling a specific and legally precise document: the Out-of-Hospital Do-Not-Resuscitate Order, governed by Texas Health and Safety Code Chapter 166. That law sets out a careful process for how these orders are supposed to work. They are not hospital documents. They are designed to follow a person into any setting outside a hospital, including a nursing home, a physician's office, a clinic, or an emergency department, and to instruct health care professionals in any of those places to forgo resuscitation.
The requirements are not vague. Under Texas law, an out-of-hospital DNR order must be signed and dated by two competent adult witnesses. Those witnesses must have actually observed the signing, whether the person executing the order is a competent adult doing so themselves, an authorized representative signing on their behalf, or a qualified relative acting in that capacity. If a person cannot sign at all and communicates their wishes to their attending physician through nonwritten means, the physician must sign both the order itself and a separate physician's statement section. The attending physician is also required to document the existence of the order in the person's permanent medical record.
Inspectors found that Landmark of Plano was not meeting these requirements for some of its residents.
The specific failures the inspection identified point to a breakdown in a process that facilities are supposed to have mastered. Executing an out-of-hospital DNR correctly is not a complicated medical procedure. It is administrative work, the kind of careful documentation that a nursing facility handles every day. When it goes wrong, the consequences are not always immediately visible. A resident does not feel the error. A family member may not know it happened. The order sits in a chart, looking complete, and nobody knows it wouldn't survive scrutiny until the moment it matters most.
That moment tends to arrive fast. Emergency medical personnel responding to a cardiac event in a nursing home are trained to resuscitate unless they are presented with a valid, properly executed order. If the paperwork has a flaw, if the witnesses didn't sign correctly, if the physician's documentation is missing, if the form wasn't completed according to the requirements of Chapter 166, the order may not be honored. A resident who clearly communicated that they did not want to be resuscitated could find themselves receiving exactly the intervention they spent their final months making sure would never happen.
Texas built its out-of-hospital DNR statute around this problem. The law is specific about witnesses precisely because a document like this needs to be bulletproof. It needs to be something that a paramedic, an emergency room physician, or a nursing home staffer at three in the morning can look at and immediately know is valid. Every missing signature, every undated line, every omitted section is a point of failure.
For nursing home residents, the stakes of this particular kind of failure are different from almost any other paperwork error a facility can make. A billing mistake can be corrected. A care plan can be updated. An improperly executed DNR order may be encountered only once, and by then there is no time to fix it.
The residents affected at Landmark of Plano were not identified by name in the inspection report, as is standard practice. The report noted that some residents were affected, a designation that means more than one but does not specify how many. The harm level was assessed as minimal harm or potential for actual harm, which under CMS definitions means inspectors did not find evidence that a resident had already been harmed by the deficiency, but found the conditions were such that harm was possible.
That framing can create a misleading sense of reassurance. A deficiency classified as potential harm is still a deficiency that involves residents whose end-of-life wishes may not be legally protected. The classification reflects what inspectors could document at the time of the visit, not a judgment about whether the situation mattered.
Landmark of Plano Rehabilitation and Nursing Center is a long-term care and rehabilitation facility operating in Plano, a city of roughly 290,000 people in Collin County, north of Dallas. The November inspection was a complaint inspection, meaning it was triggered by a specific complaint rather than a routine survey cycle.
The inspection report does not describe what prompted the complaint, who filed it, or whether it came from a resident, a family member, or a staff member. Complaint inspections at nursing facilities are initiated when CMS or a state survey agency receives information suggesting a potential violation and determines the allegation warrants an on-site visit. The fact that this inspection was complaint-driven means someone believed something was wrong and reported it.
What inspectors found when they arrived was a documentation problem that cut directly to the question of whether residents at this facility could trust that their most fundamental health care directive would be honored.
The out-of-hospital DNR order is, at its core, a promise. A resident fills it out, signs it, has it witnessed, has their physician document it, and hands it over to the facility. They are trusting that the facility will maintain that document correctly, that it will be findable when needed, and that it will be legally valid when the moment comes. The residents at Landmark of Plano who were affected by this deficiency made that decision. The facility did not hold up its end of it.
The inspection report does not say whether the facility was notified of the deficiency and given an opportunity to correct the records before the survey concluded, which is a standard part of the inspection process. It does not say whether the affected residents or their families were told. It does not say what the facility's response was.
What it says is that some residents had out-of-hospital do-not-resuscitate orders that did not meet the requirements of Texas law, and that federal inspectors found it.
For a resident who has spent time making peace with the end of their life, deciding who should be with them, deciding what interventions they do and do not want, signing a document that is supposed to make those wishes legally enforceable, the idea that a clerical failure at their nursing home could undo all of that is not a minor concern. It is the concern. It is the whole point of the document they signed.
The paperwork existed. It just wasn't done right.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Landmark of Plano Rehabilitation and Nursing Cente from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 2, 2026 · Our methodology
Landmark of Plano Rehabilitation and Nursing Cente in Plano, TX was cited for violations during a health inspection on November 13, 2025.
Federal inspectors who visited Landmark of Plano Rehabilitation and Nursing Center on November 13, 2025, found problems with exactly that paperwork.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.