Mustang Park Therapy And Living Center
Mustang Park Therapy and Living Center in Carrollton, TX — inspection on April 1, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The facility failed to ensure call lights were answered
and dignity.
Findings included: During confidential interviews with 5 residents, reported call light response time was greater than 30 minutes.
Record review of Resident Council Meeting Minutes indicated the following: - 12/30/25 complaints were made regarding call light response times,- 1/30/26 complaints were made regarding call light response from nursing staff, and that staff would come into the room to turn the call light off and not assist with their needs,- 2/26/2026 call light response was poor at times, and- 03/27/2026 call light response was poor at times.
During confidential interview resident stated that it takes up to an hour to respond to her call bell.
During confidential interview resident stated that the staff are slow at responding to call lights.
Resident stated that she had waited up to an hour before someone had come on but could not state a date.
Resident stated that she had not reported this to anyone, just figured they would get to me when they could.
During an interview on 03/31/2026 at 2:34 PM, LVN B stated that she had not received any call light response time complaints. LVN B stated that all staff were able to answer call lights.
She stated that the facility expectation of call light response time was to answer immediately. LVN B stated they had in-service in March on call light response time.
During an interview on 04/01/2026 at 3:00 PM, the DON stated he expected his staff to answer call lights timely.
The DON said that all his staff were to answer call lights and if they could not take care of the problem, they needed to get someone who could.
The DON said the call light should never stay on longer than five minutes and anything over that time was too long.
The DON said there was no reason that the staff should not answer the call lights or go in and turn the light off without fulfilling the residents request.
The DON stated that if a facility staff member could not fulfill resident request the resident light should remain on and that staff member was to go get someone who could assist.
During interview on 04/01/2026 at 3:32 PM, the ADM stated that his expectation of his staff was that they answered residents call lights as soon as possible.
The ADM stated that the risk to the resident if staff did not answer call light would be dependent on the need of the residents, but safety concerns for falls and injuries to residents.
Record review of facility in-service on Rounding and Answering call lights 03/24/2026 revealed the importance of responding promptly to call lights to ensure resident safety, satisfaction and quality of care.
Record review of facility policy titled Answering the Call Light undated revealed the following:The purpose of this procedure is to ensure timely responses to the residents' requests and needs.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
676363 04/01/2026
Mustang Park Therapy and Living Center 4501 Plano Parkway Carrollton, TX 75010
another nursing care facility.Regulation S483.15(c)(3) states Notice before transfer.
Before a facility
language and manner they understand.
The facility must send a copy of the notice to a representative
discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and(iii) Include in the notice the items described in paragraph (c)(5) of this section.S483.15(c)(5) Contents of the notice.
The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge;(ii) The effective date of transfer or discharge;(iii) The location to which the resident is transferred or discharged ;(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.
676363 04/01/2026
Mustang Park Therapy and Living Center 4501 Plano Parkway Carrollton, TX 75010
The facility failed to ensure Resident #37 was positioned correctly to provide care and services that promote the highest practical well-being while being fed.
This failure could place residents at risk for choking and aspiration.
Findings included: Record Review of Resident #37's annual MDS assessment, dated 02/06/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE].
The BIMs score was blank, but cognitive skills for daily decision-making were severely impaired.
The resident was dependent on staff for eating and was on a mechanically altered diet.
His diagnoses included heart failure, end-stage renal disease, Alzheimer's disease, seizure disorder, malnutrition, respiratory failure, and dysphagia (difficulty swallowing).
Record review of Resident #37's Order Summary report, dated 08/20/25, reflected:Pureed texture, nectar consistency liquids.
Record review of Resident #37's Care Plans, revised 03/06/26, reflected the risk for nutritional complications related to dysphagia.
Diet: pureed texture, nectar consistency.Facility interventions reflected: Resident in chair at 90 degrees for all food and fluid intake.
Record review of an in-service for Resident #37, dated 03/24/26, reflected:Proper Positioning when Feeding Resident #37.Resident needed to be positioned upright at a 90-degree angle.
Pillows could be used to support positioning.Signed by LVN C and CNA/MA D. An observation and interview on 03/30/26 at 1:05 PM, revealed Resident #37 was being fed by LVN C.
The resident was being fed a puree diet. He was seated in a geri-chair that was leaning back, he was not at a 90-degree angle. He was not coughing or choking. LVN C said the resident was supposed to sit upright to eat, but it required two staff to sit him up. LVN C stood up and adjusted the geri-chair and the resident was able to sit upright. LVN C said the resident was at risk for choking due to being laid back to eat. LVN C said the resident was supposed to be at a 90-degree angle to eat. An observation and interview on 03/31/26 at 12:42 PM revealed CNA/MA D fed Resident #37 a bite of pureed food while he was leaning back in his geri-chair. CNA/MA D said she could not sit him up because he would slide out of the chair.
The DON walked over to the table and sat up the resident's geri-chair. CNA/MA D said the resident was not supposed to be lying down to eat. An interview on 03/31/26 at 12:50 PM revealed the DON said the staff received an in-service on how to feed Resident #37.
The DON said the resident was at risk for choking if he was left lying down in his geri-chair to eat. In an interview on 03/31/26 at 12:55 PM, CNA/MA D revealed the resident was supposed to be at a 90-degree angle to eat. CNA/MA D said she did not sit up the resident's geri-chair because she did not know the geri-chair could be positioned to an upright position. CNA/MA D said Resident #37 was at risk for choking if he was fed while laying down. An interview on 04/01/26 at 12:10 PM with the DON revealed Resident #37 had not suffered from aspiration.
The DON also said the facility was ordering the resident a new wheelchair to sit in to eat upright. A follow-up interview on 04/01/26 at 12:15 PM with LVN C revealed she received an in-service regarding Resident #37. LVN C said she did not sit up the geri-chair because she was afraid the resident would slide out of the geri-chair. LVN C said the resident had never slid out of the geri-chair.
Review of the facility policy, Positioning the Resident, not dated, reflected: .Positioning the Residentd.
Maintain natural spinal curves: Stabilize pelvis.
Chest up and forward.
Head erect.
The facility failed to provide palatable food served at an appetizing temperature to10 confidential residents and Residents #31 and #23.
This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction with the meals served and weight loss.The findings included:
Record review of Resident #31's Quarterly MDS Assessment, dated 01/01/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE].
Her BIMS score was 15.
Her cognitive skills were intact.
Her diagnoses included end-stage renal disease and schizophrenia.
Record review of Resident #23's Quarterly MDS Assessment, dated 01/02/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE].
Her BIMS score was 10.
Her cognitive skills were moderately impaired.
Her diagnoses included stroke, diabetes, and non-Alzheimer's dementia.
During an interview on 3/30/2026 at 1:14 PM, Resident #23 stated that the food is not good, it was always cold, on a rare occasion it was lukewarm. Resident #23 stated she did not feel if she told anyone that it would get fixed.
Stated she did not ask staff reheat her food.
During an interview on 3/30/2026 at 1:33 PM, Resident #31 stated that the food was always cold never hot, she stated that she told residents council.
Observation of food cart on 03/31/2026 at 12:25 PM, revealed a non-insulated food cart on hall 500 with 10 food trays.
Two staff members observed passing trays.
During a confidential interview on 03/31/2026 at 10:34 AM, 10 residents stated that they received cold food if they ate in their room.
Residents stated that it was not dietary fault as the dietary staff gets the food out, but the carts have sat on the hall for five to ten minutes before staff would pass the trays.
During an interview on 03/31/2026 at 2:07 PM, CNA F stated that she had received one or two cold food complaints. CNA F stated that when she received a cold food complaint that she would take the tray and rewarm the tray in the microwave.
During interview on 03/31/2026 at 2:34 PM, LVN B stated that she had received cold food complaints.
She stated that she reported it to the previous DON and put in grievances five months ago. LVN B stated that since then she had not received any complaints.
Record review of resident council meeting minutes dated 02/26/2026 revealed new meal cart is not insulated, which caused food to cool faster.
Record review of January, February and March 2026 grievance log and no complaints of cold food.
Record review of seven residents weights and no significant weight loss noted.
During interview on 04/01/2026 at 3:00 PM, the DON stated that he was not aware of any cold food complaints.
The DON stated that his expectation of his staff were that they needed to pass the food trays as soon as dietary department delivered them to the halls.
During interview on 04/01/2026 at 3:32 PM, the ADM stated that his expectation of his staff was that food be served to residents at a safe and appetizing temperature.
The ADM stated that the nursing staff was responsible for ensuring food trays were delivered as soon as the dietary staff brought the trays to the hall so that the residents who ate in their rooms received meals at appetizing temperatures.
The ADM stated if food was not served at an appetizing temperature, it could have caused residents to not want to eat their food which could have led to weight loss.
Record review of meal trays in-service dated 3/24/2026, revealed staff are to ensure that all residents have meal trays offered, regardless of whether residents eat or not.
Unless resident is nothing by mouth.
Staff are to feed residents as needed and ensure food order matches what's on the tray and trays are passed in a timely manner.
Record review of facility policy Nutritional Management undated revealed, The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.
Requested meal service policy via email on 04/01/2026 at 1:25 PM.
Did not receive it prior to exit.
676363 04/01/2026
Mustang Park Therapy and Living Center 4501 Plano Parkway Carrollton, TX 75010
census of 55 residents.
Record review of the posted Meal Service Times in the dining room revealed
review of the Facility Policy Offering/Serving Snacks undated revealed It is the practice of this
preference and requested on a daily basis.
Policy Explanation and Compliance Guidelines: 1.The nursing staff offers snacks to all residents in accordance with the residents' needs, preference and request on a daily basis. 2.All diabetic residents are provided with a bedtime snack.
676363 04/01/2026
Mustang Park Therapy and Living Center 4501 Plano Parkway Carrollton, TX 75010
by date 10/07/2027.1 gallon zipper bag with sliced cheese, receive date 03/24/2026, best by date
were placed in the DM's office and that the size or location of the dent did not matter.
She further
decision.
The [NAME] stated that the dates written on the cans reflected the date the items were received.
She stated that, if residents were served food that was left open or food from dented cans, residents could become sick.In a record review of the facility's Food Receiving and Storage, dated November 2022, revealed: Dry Food Storage.3.
Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use.4.
Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date).
Such foods are rotated using a first in - first out system.Refrigerated/Frozen Storage1.
All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).7.
Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.
Review of the U.S.
FDA Food Code 2022, Chapter 3, 3-202.15 Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. If the integrity of the packaging has been compromised, contaminants.may find their way into the food.
Review of the U.S. FDA Food Code 2022 reflected: .
Section 6-301.20 Disposable Towels, Waste Receptacle.
Waste Receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents.
676363 04/01/2026
Mustang Park Therapy and Living Center 4501 Plano Parkway Carrollton, TX 75010
The facility failed to ensure CNA/MA D performed hand hygiene between Residents #31 and #23 during medication administration.
The facility failed to ensure CNA E performed hand hygiene during incontinence care for Resident #6.
This failure placed residents at risk for healthcare associated cross contamination and infections.
Findings included: Review of Resident# 31's Quarterly MDS Assessment, dated 01/01/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE].
Her BIMS score was 15.
Her cognitive skills were intact.
Her diagnoses included end-stage renal disease and schizophrenia.
Review of Resident 23's Quarterly MDS Assessment, dated 01/02/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE].
Her BIMS score was
- Her cognitive skills were moderately impaired.
Her diagnoses included stroke, diabetes, and non-Alzheimer's dementia. An observation on 03/31/26 at 9:05 AM of medication administration with CNA/MA D revealed she administered medications to Resident #31. CNA/MA D returned to the medication cart and did not perform hand hygiene. CNA/MA D prepared medication for Resident #23, administered them, returned to the medication cart, and CNA/MA D did not perform hand hygiene. An interview on 03/31/26 at 9:25 AM with CNA/MA D revealed she did not know she was supposed to perform hand hygiene between residents.
She said she had never been trained to. CNA/MA D did say it was important to perform hand hygiene between residents because of spread of infection.
Review of Resident 6's Annual MDS Assessment, dated 02/19/26, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE].
His BIMS score was 11.
His cognitive skills were moderately impaired.
His diagnoses included end-stage renal disease, diabetes, and schizophrenia. An observation on 04/01/26 at 1:22 PM of incontinence care for Resident #6 revealed CNA E prepared supplies. CNA E put on gloves, removed the resident's brief and changed gloves. CNA E cleaned the resident's penis and scrotum and changed gloves and did not perform hand hygiene. CNA E cleaned the resident's buttocks, changed gloves, and did not perform hand hygiene. CNA E laid down a clean brief, changed gloves, and did not perform hand hygiene. CNA E applied barrier cream to the resident's buttocks, changed gloves, and did not perform hand hygiene. CNA E fastened the resident's brief. An interview on 04/01/26 at 1:30 PM, CNA E revealed she was supposed to perform hand hygiene when she changed gloves. CNA E said she had been trained to perform hand hygiene but did not do it this time because of nerves. CNA E said it was important to perform hand hygiene for infection control. An interview on 04/01/26 at 1:20 PM, DON revealed staff were supposed to perform hand hygiene between residents and staff were trained to do so.
The DON said she monitored hand hygiene 1-2 times per week.
The DON said hand hygiene was important to prevent the spread of infection.
Record review of the facility in-service, Proper Hand-washing Technique, dated 03/24/26, reflected: All nurses and CNAs are to wash hands using either hand sanitizer or soap and water before and after every encounter with residents.
This will prevent the spread of infection and bacteria.The in-service was not signed by CNA/MA D or CNA E.
Record review of the facility policy, Hand Washing/Hand Hygiene, revised October 2023, reflected: The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.
676363 04/01/2026
Mustang Park Therapy and Living Center 4501 Plano Parkway Carrollton, TX 75010
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Carrollton, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Mustang Park Therapy and Living Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.