Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
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 Villages Of Dallas during CMS and state inspections, most recent first.
Food Served at Cold and Unappetizing Temperatures: Five residents reported receiving cold meals, and survey observation showed trays sitting on the hall before being passed. A test tray was delivered from the kitchen to the hall, but when checked shortly after service, the mashed potatoes were cold and the other items were only room temperature. Staff acknowledged prior complaints about cold food, and the DON stated the tray lacked a plate warmer, contributing to the food not being hot.
Improper Storage of Spoiled Produce in Kitchen Refrigerator: Surveyors found unlabeled bins of onions and lemons in the walk-in refrigerator, including produce with black fuzzy spots, green shoots, and soft, mushy, or shriveled texture. The DM stated fresh produce was not labeled with discard dates and staff judged safety by looking at it; the facility policy did not address storing or identifying spoiled fruits or vegetables.
Medication Administration Errors Exceeded Allowed Rate: During observed med passes, an MA made 2 errors out of 31 opportunities, resulting in a 6% error rate. Two residents received MiraLAX with an unmeasured amount of fluid, and for one resident the MA left the cup of medication with the resident instead of staying to ensure the dose was taken. The DON stated staff should read the MAR before and after giving meds and should not leave residents with their medications.
Infection Control Failures During BP Checks and Incontinent Care: MA A used the same BP cuff on two residents without disinfecting it between checks, and two CNAs performed incontinent care for a severely cognitively impaired, incontinent resident without changing soiled gloves or completing hand hygiene between dirty and clean tasks. The residents involved had diagnoses including HTN, CVA, constipation, and dementia, and the DON stated staff must clean equipment between residents and change gloves and wash hands during incontinent care.
Three residents with cognitive impairment and total assistance needs were found with their call lights out of reach, despite care plans and facility policy requiring accessibility. Staff and nursing leadership confirmed the expectation for call lights to be within reach, but observations showed this was not consistently followed.
A resident identified as a fall risk was provided with a bolster mattress as a safety intervention without a physician order. The equipment was included in the care plan, but the DON acknowledged that obtaining the necessary physician order was overlooked, contrary to facility policy requiring such authorization for restraint use.
A resident with vascular dementia and coordination issues experienced a fall that was not promptly documented or reflected in their care plan. The responsible nurse failed to complete a fall assessment on the day of the incident, leading to a delay in updating the care plan. The ADON had to document the incident five days later, highlighting a lapse in communication and adherence to facility policies requiring timely updates to care plans after falls.
A resident with vascular dementia and a history of falls was found on the floor twice, with the fall mat improperly placed under the bed. The facility failed to provide adequate supervision and did not follow its fall management policy, as no assessment or documentation was completed after the incidents.
The facility failed to maintain effective infection control practices during incontinent care for three residents. CNAs did not perform proper hand hygiene or change gloves appropriately, risking cross-contamination and infection. Interviews confirmed these lapses, emphasizing the need for adherence to infection prevention protocols.
A resident with severe cognitive impairment and a pressure ulcer on the right foot did not receive proper wound care. The LVN cleaned the surrounding skin before the wound itself, using the same gauze, contrary to the facility's policy and professional standards. This improper technique could introduce contaminants into the wound, increasing infection risk. Interviews with staff confirmed the deficiency in wound care practices.
A facility failed to provide proper incontinent care for a resident with acute kidney failure, risking urinary tract infections. A CNA was observed wiping the resident's perineal area from back to front, contrary to the recommended front-to-back method. The CNA acknowledged the mistake, and the DON and ADON confirmed the correct procedure to prevent infection.
A resident with severe cognitive impairment was left with medications unattended by a medication aide, contrary to facility policy. The resident, diagnosed with hypertension, GERD, and cerebral infarction, was observed with a pill left on her table, and the aide admitted to not monitoring the administration. Interviews with the DON, ADON, and Administrator confirmed that medications should not be left with residents due to risks, highlighting a failure to follow procedures.
A resident with a history of osteoarthritis and hemiplegia was injured due to the facility's failure to provide adequate supervision and assistive devices during a transfer. The staff did not follow the No Lift policy, resulting in a fracture after an inappropriate manual lift. The facility did not obtain accurate transfer information from the previous facility, and staff failed to conduct their own assessments, leading to the incident.
The facility failed to maintain a clean and sanitary environment in six resident rooms, with observations of dirt and stains in bathrooms, air conditioning units, and mini fridges. Housekeeping staff lacked proper tools for cleaning, and the supervisor admitted to inadequate cleaning practices, contrary to facility policies.
The facility failed to maintain an effective Infection Prevention and Control Program, with staff not adhering to hand hygiene protocols during resident care. A CNA did not change gloves or sanitize hands during incontinent care, and an LVN brought a container with medical supplies into multiple residents' rooms, risking cross-contamination. Additionally, two CNAs did not perform hand hygiene after removing soiled gloves. These actions were acknowledged by staff and facility leadership as deficiencies.
The facility failed to ensure that the call light system was accessible for two residents, one with muscle weakness and Alzheimer's, and another with blindness and cognitive impairment. Both residents were found with their call lights out of reach, contrary to their care plans and facility policy, which require call lights to be within reach to ensure residents can request assistance.
A resident with chronic pain was prescribed hydrocodone-acetaminophen, but a pill was left unattended on the nightstand, which the resident forgot to take. The LVN confirmed the medication was not administered as required, posing a risk of improper medication use. The facility's policy mandates that medications be administered within prescribed time frames, which was not followed.
The facility failed to ensure that call lights were within reach for three residents, each with significant medical conditions and cognitive impairments. Observations revealed that call lights were either on the floor or clipped to a pillow, making them inaccessible. Staff interviews confirmed the importance of accessible call lights for resident safety, yet the facility did not adhere to its policies, resulting in this deficiency.
A resident with severe cognitive impairment and a history of falls did not have a fall mat placed beside their bed as required. The mat was found folded in a bag against the wall, contrary to the care plan that ordered a low bed and floor mat. Staff interviews revealed a lack of awareness and documentation in the care plan, contributing to the oversight.
A facility failed to implement comprehensive care plans for two residents, leading to a serious incident. One resident with severe cognitive impairment wandered into another's room and was attacked, resulting in a head injury. The care plans lacked interventions for the wandering and aggressive behaviors, contributing to the incident. Staff interviews revealed a lack of communication and oversight in updating care plans, which were not revised as required.
A resident with severe cognitive impairment was physically attacked by another resident with a history of aggression, resulting in a serious head injury. The facility failed to have interventions in place to manage the aggressive resident's behaviors, despite previous incidents and staff awareness of his tendencies. This oversight in care planning led to the deficiency identified in the report.
The facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 5 days during a 6-month review period. Interviews with the DON, CNA/Staffing Coordinator, and Administrator revealed a lack of awareness and communication regarding the missed RN hours, placing residents at risk of receiving higher levels of patient care without adequate RN oversight.
The facility failed to ensure proper food storage, preparation, and sanitation in both the main kitchen and sub-kitchen. Observations revealed incorrectly dated food, dirty storage bins, and unsanitary conditions in the sub-kitchen. Staff interviews indicated confusion about cleaning responsibilities, and the facility's policies were not being followed.
The facility failed to ensure the call light system was accessible for four residents, placing them at risk of being unable to obtain assistance. Residents struggled to reach their call lights, which were not placed within their reach as required by their care plans. Staff acknowledged the importance of call lights and the potential risks if they are not accessible.
The facility failed to provide a safe, clean, and homelike environment for 11 residents, with observations revealing uncleanliness and inconsistencies in cleaning responsibilities. Interviews with staff highlighted gaps in the cleaning processes, and the Administrator acknowledged recent challenges due to a COVID outbreak.
The facility failed to provide proper respiratory care by not storing nebulizer masks correctly, having incomplete oxygen administration orders, and not changing oxygen concentrator tubing weekly as scheduled. These deficiencies were observed and confirmed through interviews and record reviews.
A facility failed to maintain a resident's wheelchair, which had a missing right armrest cushion and a torn left armrest cushion. The CNA responsible for the resident did not notice or report the damage, and other staff members, including the LVN, DON, and Occupational Therapist, were unaware of the issue. The facility lacked a specific policy for reporting and maintaining wheelchair damage.
A resident with an indwelling catheter was observed with her catheter bag visibly hanging under her wheelchair without a privacy bag, contrary to facility policy. Staff acknowledged the oversight, and the DON and Administrator confirmed the importance of using a privacy bag to maintain the resident's dignity.
A resident with an indwelling urinary catheter was observed with the catheter bag touching the floor, contrary to care plan and physician orders. Staff interviews confirmed awareness of the risk of infection but revealed lapses in consistent implementation of proper catheter care practices.
A facility failed to ensure continuous enteral feeding for a resident with a G-tube, resulting in a three-hour gap in feeding due to a lack of supplies and unclear downtime orders. The DON and Administrator acknowledged the need for clear and consistent feeding schedules.
The facility failed to document wound care treatments and pain assessments for a resident with a pressure ulcer. The resident's medical records showed gaps in documentation, and staff did not follow required procedures, which could lead to exacerbation of the wound or infection.
The facility failed to maintain an Infection Prevention and Control Program, leading to deficiencies involving a CNA not changing gloves or performing hand hygiene during incontinence care and a Dietary Manager not wearing a face mask in the kitchen during a COVID outbreak. These actions could place residents at risk of cross-contamination and infection.
Food Served at Cold and Unappetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was palatable, attractive, and served at a safe and appetizing temperature for five residents in a confidential group. During a confidential interview, five residents stated they had received cold food, and they reported that dietary staff got the food out but the carts sat on the hall for five to ten minutes before trays were passed. On 04/15/2026, an observation of a food cart on hall 1-[NAME] showed an insulated food cart with 10 food trays, and two staff members were observed passing trays. During a test tray observation on 04/16/2026, the tray left the kitchen at 12:49 PM, arrived on the hall at 12:52 PM, and the last tray was served at 12:58 PM. When the surveyor tested the tray at 1:03 PM, the mashed potatoes were cold, the chicken fried steak was room temperature, and the green beans were room temperature. Staff interviews reflected that cold food complaints had occurred, and the DM stated that the test tray was not provided with a plate warmer, which contributed to the plate not being hot. The ADM stated that food was expected to be served at a safe and appetizing temperature, and that cold food had been a major topic from residents the prior year.
Improper Storage of Spoiled Produce in Kitchen Refrigerator
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen reviewed for food safety. During observation of the walk-in refrigerator, surveyors found a large clear bin of approximately 29 yellow onions with no item description or expiration date and marked with a delivery date of 02/25/2026. Seven onions had black, fuzzy soot-like spots covering more than half of the surface, two had long green shoots extending from the ends, and six were soft, mushy, and slimy to the touch. Surveyors also observed a large clear bin of several dozen lemons with no item description or expiration date and marked with a delivery date of 03/30/2026. Two lemons were soft, spongy, and mushy to the touch, and two were wrinkled, bumpy, shriveled, and hard to the touch. During interview, the DM stated that fresh fruits and vegetables were not labeled with expiration or discard dates and that staff determined whether produce was no longer safe by physically looking at it. The DM stated that if a resident were served spoiled produce, they might get sick. A review of the facility’s Infection Control Policy Food Service dated 10/2025 showed nothing about storing or identifying spoiled fruits or vegetables.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. During observed medication administration, MA A made 2 errors out of 31 opportunities, resulting in a 6% medication error rate and involving 2 residents. For Resident #49, who had diagnoses including hypertension, cerebrovascular accident, and constipation, the physician ordered MiraLAX oral powder 17 gm/scoop every 24 hours as needed for constipation mixed with 4 to 8 ounces of fluid. During administration, MA A gave the MiraLAX with an undetermined amount of fluid and left the cup of medication with the resident without staying to observe completion of the dose. For Resident #35, who had diagnoses including hypertension, cerebrovascular accident, non-Alzheimer's dementia, and constipation, the physician ordered MiraLAX oral powder 17 gm/scoop every 24 hours as needed for constipation mixed with 4 to 8 ounces of fluid. During observation, MA A administered the MiraLAX with an undetermined amount of fluid, using an unmarked cup that was filled without measuring the amount. In interview, MA A stated she had not measured the fluid and had just filled the cup, and the DON stated staff should read the MAR before and after giving medication and should not leave residents with their medications. The facility policy stated medications must be administered according to the attending physician's orders and the right dose.
Infection Control Failures During BP Checks and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 3 staff members and 3 residents reviewed for infection control procedures. MA A did not disinfect the blood pressure cuff between blood pressure checks for two residents, and CNA B and CNA C did not change soiled gloves or perform hand hygiene during incontinent care for a resident who was incontinent of bowel and bladder and required two staff for assistance with activities of daily living. Resident #49 was an alert and oriented female with diagnoses including hypertension, cerebral vascular accident, and constipation. Her physician orders included blood pressure monitoring one time a day on each shift. Resident #35 was a female with diagnoses including hypertension, cerebral vascular accident, non-Alzheimer's dementia, and constipation. She had moderate cognitive impairment, was unable to make decisions, required assistance with activities of daily living, and also had an order for blood pressure monitoring one time a day on each shift. On observation, MA A checked Resident #49's blood pressure and then used the same cuff on Resident #35 without sanitizing the cuff before or after either use. Resident #15 was a severely cognitively impaired female with diagnoses including hypertension and cerebrovascular accident, and she was incontinent of bowel and bladder. During incontinent care, CNA B and CNA C entered the room, transferred the resident to bed, and performed perineal care while wearing gloves that became soiled, but they did not change gloves or clean their hands between dirty and clean tasks. The DON, who was also the infection control preventionist, stated staff must clean equipment such as blood pressure cuffs after contact with each resident and must change gloves and wash hands or use hand sanitizer during incontinent care. The facility's infection prevention and control, hand hygiene, and perineal/incontinent care policies also reflected cleaning equipment between residents and hand hygiene before and after glove use.
Call Lights Not Accessible to Residents Requiring Total Assistance
Penalty
Summary
The facility failed to ensure that call light systems were accessible to residents who required total assistance and were identified as fall risks. During observations, three residents with moderate to severe cognitive impairment and significant physical limitations were found with their call lights out of reach. One resident's call light was under the bed, another's was approximately three feet away from the bed, and a third resident's call light was hanging behind the bed frame. These residents' care plans specifically included interventions to keep call lights within reach and encourage their use. Staff interviews confirmed that call lights were not always placed within reach, despite facility policy and care plan requirements. Certified nursing assistants and licensed vocational nurses acknowledged the importance of call light accessibility and stated that staff were expected to check rooms regularly to ensure compliance. The Director of Nursing also confirmed that call lights should be within reach and that measures such as clips had been implemented to help maintain their placement. However, on the day of the survey, the call lights for these residents were not accessible, contrary to both policy and individualized care plans.
Failure to Obtain Physician Order for Bolster Mattress Used as Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. Specifically, a bolster mattress was placed on the resident's bed as an intervention for fall risk, but there was no physician order authorizing its use. The resident's care plan included the bolster mattress for safety, and the Director of Nursing acknowledged that the equipment was provided due to the resident's fall risk and that it was her responsibility to obtain a physician order, which she failed to do. Record review showed that the resident had diagnoses including unsteadiness on feet and repeated falls, required extensive assistance with activities of daily living, and was unable to complete a BIMS interview. Observations confirmed the presence of the bolster mattress, and interviews with facility staff confirmed that the required physician order was missing. Facility policy requires physician notification and adherence to state regulations when restraints are used, but this process was not followed in this case.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team following a recent fall. The resident, who has vascular dementia, lack of coordination, and muscle weakness, experienced a fall on 03/08/2025, which was not documented in the care plan. The resident's care plan did not reflect this incident, and the fall assessment was not completed by the responsible nurse on the day of the fall. Instead, a late entry was made by the Assistant Director of Nursing (ADON) five days later, indicating a delay in documentation and assessment. Interviews with staff revealed that the incident was not communicated promptly, and the necessary documentation was not completed in a timely manner. The ADON only became aware of the fall two days after it occurred and had to complete the documentation himself due to the initial nurse's failure to do so. The facility's policies require that care plans be updated after each fall, and the lack of timely updates could potentially result in residents not receiving the most efficient care. The facility's Care Planning and Fall Management System policies emphasize the importance of timely documentation and care plan updates to ensure appropriate care for residents.
Failure to Ensure Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, the facility did not ensure that a fall mat was properly placed on the floor next to the resident's bed, as evidenced by a photo showing the resident lying on the bare floor with the fall mat underneath the bed. This oversight was noted for a resident with vascular dementia, lack of coordination, and muscle weakness, who had a history of falls without injury. The resident's care plan indicated a risk for falls due to decreased mobility and impaired cognition, with interventions including keeping the bed in the lowest position and placing a fall mat on the floor. However, on the day of the incident, the resident was found on the floor twice, with the fall mat not properly positioned. Interviews with staff revealed that the fall mat was folded and placed in the corner when the resident was not in bed, and the resident was unable to walk or transfer herself, indicating a lack of proper supervision and adherence to the care plan. The facility's policy required a physical assessment and documentation in the medical record following a fall, but the nurse involved did not complete these tasks, as there were no injuries. The incident was categorized as an unwitnessed fall, and the lack of documentation and assessment was acknowledged by the facility's administration. The facility's policies on fall management and response to significant changes in condition were not followed, contributing to the deficiency.
Inadequate Infection Control Practices During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and glove use during incontinent care for three residents. Resident #58, a female with a urinary tract infection and moderate cognitive impairment, was observed receiving care from CNA B, who did not sanitize her hands before donning new gloves from her pocket and failed to change gloves after cleaning the resident's bottom before handling a new brief. Similarly, Resident #45, a male with severe cognitive impairment and muscle weakness, received care from CNA B and CNA C. Both CNAs failed to perform hand hygiene between glove changes, and CNA C did not change gloves after handling soiled materials. CNA B admitted to not sanitizing her hands between glove changes and acknowledged the risk of infection from such practices. Resident #42, a female with acute kidney failure, was also subject to improper infection control practices. CNA D did not sanitize her hands between glove changes and failed to change gloves after cleaning the resident's perineal area before adjusting the brief. Interviews with the CNAs and facility leadership confirmed the lapses in protocol, highlighting the risk of cross-contamination and infection due to inadequate hand hygiene and glove use.
Improper Wound Care Technique for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in wound care practices. The resident, an elderly male with severe cognitive impairment and a history of sepsis and muscle weakness, had a pressure ulcer on his right foot. The care plan required specific wound care procedures, including cleaning the wound with normal saline, applying collagen, and covering it with a dry dressing. However, during an observation, it was noted that the Licensed Vocational Nurse (LVN) did not follow the correct procedure for cleaning the wound. The LVN was observed cleaning the surrounding skin of the wound before the wound itself, using the same gauze for both areas, which is contrary to professional standards. The correct procedure, as outlined in the facility's policy, requires cleaning from the least contaminated area (the wound) to the most contaminated area (the surrounding skin) and using a new piece of gauze for each stroke to prevent contamination. The LVN's actions could potentially introduce contaminants from the surrounding skin into the wound, increasing the risk of infection. Interviews with the LVN, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) confirmed the improper wound care technique. The DON acknowledged that the wound should be cleaned from the inside out, and the gauze should be changed with each stroke to avoid contamination. The ADON reiterated the importance of removing debris, bacteria, and exudate from the wound to reduce infection risk. The facility's policy also supports this method, emphasizing the need to wash from the center of the wound to the periphery, from the least to the most contaminated area.
Improper Incontinent Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a potential risk of urinary tract infections. The incident involved a cognitively intact female resident with acute kidney failure, who was always incontinent of bowel and bladder. During an observation, a CNA was seen cleaning the resident's perineal area incorrectly by wiping from back to front, which is against the recommended practice of wiping from front to back to prevent cross-contamination and infection. The CNA admitted to wiping incorrectly due to the resident's position but acknowledged the importance of following the correct procedure regardless of the resident's position. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the proper procedure should always be from front to back to avoid infection. The facility's policy also supports this practice, emphasizing washing from the cleanest to the dirtiest area to prevent irritation or infection.
Failure to Monitor Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was provided with medications and pharmaceutical services in accordance with their needs. Specifically, the medication aide (MA) left the resident's medications inside the resident's room without monitoring the administration of the medications. This occurred despite the resident having a severe cognitive impairment, as indicated by a BIMS score of 00, and no assessment for self-administration of medications was documented. The resident, who was diagnosed with hypertension, gastro-esophageal reflux disease, and cerebral infarction, was observed with a plastic cup containing a white, round pill on her overbed table. The resident mentioned that she had already taken two out of three pills left by the staff and intended to take the remaining pill shortly. The MA admitted to leaving the medications with the resident because the resident preferred to take them every five minutes, acknowledging that she should have stayed with the resident until all medications were taken. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator confirmed that staff should not leave medications with residents due to the risk of choking, not taking the medications, or potential overdose. The facility's policy requires that medications be administered as prescribed and not left unattended with residents, highlighting a failure to adhere to these procedures in this instance.
Failure to Provide Adequate Supervision and Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were provided to prevent accidents, specifically for a resident who required a mechanical lift for transfers. The staff did not adhere to the facility's No Lift policy, which mandates the use of a total mechanical lift for individuals who can bear weight on their legs but require minimal assistance. This failure resulted in the resident experiencing uncontrolled pain and being diagnosed with a right distal tibial spiral fracture after an inappropriate transfer. The resident, who had a history of osteoarthritis, hemiplegia, and a previous knee replacement, was admitted to the facility with a need for moderate assistance from one or two persons due to left-sided hemiplegia. Despite this, the facility did not obtain accurate transfer status information from the referring facility prior to admission. During the transfer, a staff member attempted to lift the resident manually, ignoring requests from the resident and her family to use a mechanical lift, leading to the resident's injury. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's transfer needs. The staff relied on incomplete or inaccurate information from the previous facility and did not conduct their own assessments to determine the appropriate level of assistance required. This oversight, combined with the staff's failure to listen to the resident's and her family's concerns, contributed to the incident and the resident's subsequent injury.
Facility Fails to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in six out of ten rooms reviewed. Observations revealed that the bathrooms had built-up dirt particles along the walls, and the bases of the toilets had thick brownish stains. The air conditioning units in the rooms were found with dirt stains on top and thick black dirt between the vents. Additionally, mini fridges in some rooms had noticeable stains, indicating a lack of thorough cleaning and sanitization. Interviews with housekeeping staff and the supervisor confirmed that the cleaning procedures were not adequately followed. The housekeeping staff admitted to not having the proper tools to clean the air conditioning vents and mentioned that the base of the toilets appeared rusty. The housekeeping supervisor acknowledged the deficiencies and stated that deep cleaning was scheduled once a week, but the mini fridges were not regularly cleaned unless visibly dirty. The facility's policies on cleaning and disinfection were not adhered to, potentially posing health risks to the residents.
Infection Control Deficiencies in Hand Hygiene and Equipment Handling
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in several deficiencies related to hand hygiene and the handling of medical equipment. During an observation, a CNA providing incontinent care to a resident did not perform hand hygiene before putting on gloves, nor did she change gloves or sanitize her hands after handling soiled items and before touching clean items. This lapse in protocol was acknowledged by the CNA, who admitted that hand hygiene is crucial to prevent the spread of germs. Another deficiency was observed with an LVN who brought a plastic container containing lancets, test strips, and alcohol wipes into the rooms of multiple residents while checking their blood sugar levels. The LVN placed the container on residents' beds and tables, which could lead to cross-contamination. Additionally, the LVN did not wear gloves while administering insulin injections, further increasing the risk of infection transmission. The LVN recognized the potential for cross-contamination and acknowledged the importance of hand hygiene and proper glove use. A similar issue was noted with two CNAs providing incontinence care to another resident. They failed to perform hand hygiene after removing soiled gloves and before putting on new ones. Both CNAs admitted the importance of hand hygiene in preventing contamination and infection. Interviews with facility leadership, including the DON and ADON, confirmed that staff are expected to follow hand hygiene protocols to minimize infection risks, and they acknowledged the deficiencies observed during the survey.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system in the rooms of two residents was accessible, which is a deficiency in accommodating the needs and preferences of residents. Resident #6, an elderly female with muscle wasting, muscle weakness, and unsteadiness, was found in her bed unable to locate her call light, which was pressed between the mattress and the bed frame. This resident required substantial assistance for personal hygiene, toileting, and showering, and her care plan specifically noted the importance of having the call light within reach due to her risk of falls related to Alzheimer's disease. Similarly, Resident #7, an elderly male diagnosed with muscle weakness, unsteadiness, and blindness, was found with his call light hanging on the wall, out of reach. This resident had a severe cognitive impairment and required substantial assistance with daily activities. His care plan also emphasized the need for the call light to be within reach due to his risk of falls. During observations, the resident was unable to indicate the location of his call light, highlighting the inaccessibility of the device. Interviews with staff, including a CNA, the DON, the Administrator, and the ADON, confirmed the importance of call lights as a means of communication for residents to request assistance. The facility's policy, revised in 2007, mandates that call devices be placed within residents' reach before staff leave the room. However, the failure to adhere to this policy resulted in the call lights being inaccessible to the residents, potentially compromising their ability to obtain assistance when needed.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident, specifically for one resident who was reviewed for pharmaceutical services. The resident, who was cognitively intact and had a history of chronic venous insufficiency, chronic osteomyelitis, and localized swelling in the left leg, was prescribed hydrocodone-acetaminophen for chronic pain. An observation revealed that a white oblong pill was left in a medicine cup on the resident's nightstand, which the resident had not taken. The resident stated that the nurse had left the pill the previous evening, and she forgot to take it. A CNA found the pill on the resident's chest and placed it back in the medicine cup on the nightstand. The LVN, upon being notified, confirmed that the pill was hydrocodone-acetaminophen and stated that it should not have been left in the room. The LVN disposed of the pill in the sharps container and reported the incident to the ADON. The LVN expressed concern that a confused resident could have mistakenly ingested the pill, highlighting the importance of ensuring residents take their medication in the presence of a nurse to prevent choking or other issues. The DON acknowledged that the night nurse should have observed the resident taking the medication before leaving the room. The facility's policy on drug administration requires medications to be administered within prescribed time frames, which was not adhered to in this instance.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents' call lights were within reach, compromising their ability to call for assistance. This deficiency was observed in three residents, each with significant medical conditions and cognitive impairments. Resident #1, with severe cognitive impairment and multiple health issues, had his call pad on the floor under his bed, making it inaccessible. Similarly, Resident #2, who was severely cognitively impaired and had an indwelling catheter, also had his call button on the floor, out of reach. Resident #3, with mild cognitive impairment and total dependence for personal care, had his call button clipped to a pillow, which was not accessible from his wheelchair. Interviews with staff, including the Administrator in Training, LVN, CNA, ADON, and DON, revealed a consensus that call lights should be within reach of residents to ensure their safety and ability to call for assistance. Staff acknowledged the importance of this practice, noting that failure to provide accessible call lights could lead to residents attempting to meet their own needs, potentially resulting in falls and injuries. Despite this understanding, observations indicated that the call lights for Residents #1, #2, and #3 were not placed within their reach, highlighting a lapse in adherence to facility policies. The facility's policies on call lights and resident safety clearly state that call devices should be placed within residents' reach and that room checks should be conducted routinely to ensure safety and quality of life. However, the observations and interviews suggest that these policies were not consistently followed, leading to the deficiency. The lack of accessible call lights for these residents represents a failure to accommodate their needs and preferences, as outlined in their comprehensive care plans.
Failure to Ensure Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents. Specifically, the facility did not place a fall mat on the floor next to the bed of a resident who was at risk for falls. The resident, who had severe cognitive impairment and required extensive assistance with daily activities, had a history of falls and was ordered to have a low bed and floor mat as part of his care plan. However, during an observation, the fall mat was found folded in a plastic bag against the wall instead of being placed beside the bed. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan. The LVN acknowledged that the resident was at risk of injury without the fall mat in place, and the CNA was unsure why the mat was not positioned correctly. The DON admitted that the fall mat was not documented in the care plan, which contributed to the oversight. The facility's policy required routine room checks to ensure resident safety, but this was not effectively implemented, leading to the deficiency.
Failure to Implement Comprehensive Care Plans Leads to Resident Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which resulted in a serious incident. Resident #1, who had severe cognitive impairment due to dementia and a history of traumatic brain injury, did not have interventions in place to address his wandering behavior. On June 5, 2024, Resident #1 wandered into another resident's room and was physically attacked, resulting in a serious head injury. The care plan for Resident #1 was not updated to include measures to prevent such incidents, despite his known wandering tendencies. Resident #2, who had intact cognition but exhibited aggressive behaviors, also lacked a comprehensive care plan addressing his potential for physical aggression. Despite previous incidents of combative behavior, interventions were not documented in his care plan until after the incident with Resident #1. The facility's failure to document and implement appropriate interventions for Resident #2's aggressive behavior contributed to the incident where he pushed Resident #1, causing a serious injury. Interviews with facility staff revealed that there was a lack of communication and oversight in updating care plans to reflect changes in residents' conditions and behaviors. The MDS Coordinator and DON acknowledged that care plans were not updated as required, which led to improper care being provided. The facility's policy required care plans to be reviewed and revised quarterly or as needed with changes in condition, but this was not adhered to, resulting in the deficiency.
Failure to Prevent Resident Abuse Due to Inadequate Care Planning
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an incident where one resident was physically attacked by another. The resident who was attacked had severe cognitive impairment and a history of traumatic brain injury, which made him vulnerable. On the day of the incident, the resident wandered into another resident's room and was pushed, leading to a serious head injury. The facility did not have interventions in place to prevent such aggressive behavior from the resident who attacked, despite his history of aggression. The resident who committed the attack had a history of dementia and poor impulse control, yet his care plan lacked interventions to manage his aggressive behaviors until after the incident occurred. Prior to the incident, there were no documented interventions to address his aggression, even though he had previously exhibited aggressive behavior towards other residents. The facility's staff were aware of his tendency to become upset when others entered his room, but no effective measures were in place to prevent such incidents. Interviews with staff and family members revealed that the facility was aware of the aggressive resident's behaviors and the potential for harm, yet failed to implement necessary interventions. The Director of Nursing and other staff acknowledged the oversight in care planning, which contributed to the incident. The facility's failure to update and implement appropriate care plans for residents with aggressive behaviors directly led to the deficiency identified in the report.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 5 days during the 6-month review period. Specifically, the facility did not have the required RN coverage on Saturdays and Sundays for 5 days between July 2023 and December 2023. The dates with insufficient RN coverage included 11/04/23, 11/25/23, 12/02/23, 12/09/23, and 12/16/23, with recorded hours ranging from 1.15 to 3.4 hours. This deficiency placed residents at risk of receiving higher levels of patient care without adequate RN oversight. Interviews with the Director of Nursing (DON) and the CNA/Staffing Coordinator revealed a lack of awareness and communication regarding the missed RN hours. The DON stated she was unaware of any missed RN hours and believed she had covered any shortages. However, the dates she provided did not match the dates with insufficient coverage. The CNA/Staffing Coordinator also believed there were no concerns with RN coverage and stated that the DON usually covered any shortages. The Administrator was also unaware of the lapse in RN coverage and stated he would follow up with the DON. The facility's policy on RN coverage, which requires an RN to provide services for at least 8 consecutive hours a day, 7 days a week, was not adhered to during the review period.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed that a gallon container of sweet relish in the walk-in refrigerator was incorrectly dated, and large white bins containing sugar, flour, and thickener had dried food particles and blackish stains. Additionally, the sub-kitchen on the skilled nursing floor had stained counters and walls, and the refrigerator contained undated food items and staff food, with the door not closing properly. The ice machine also had dirt and rust stains, indicating a lack of proper sanitation. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for cleaning and maintaining the kitchen areas. The Dietary Manager admitted to ongoing issues with staff not cleaning the bins properly and stated that the risk of these concerns could result in food-borne illnesses. The CNA/Staffing Coordinator and LVN provided conflicting information about who was responsible for cleaning the refrigerators and other kitchen equipment, indicating a lack of clear protocols and communication among staff. The Housekeeping Supervisor acknowledged the unacceptable condition of the kitchen areas and attributed it to new staff still learning their roles. The Administrator confirmed that a new staff member had been hired to manage nourishment snacks and clean the sub-kitchens but did not comment on the potential impact on residents. The facility's policy on food storage and supplies, dated 2012, was not being followed, as evidenced by the observations and staff interviews. The FDA Code also mandates proper labeling and protection of food from contamination, which the facility failed to adhere to.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure the call light system in the rooms of four residents was accessible, which could place them at risk of being unable to obtain assistance when needed. Resident #97, a male with muscle weakness and cognitive impairment, struggled to find his call light, which was hanging lower than the bed. He had to twist and search for two minutes to locate it, indicating it was not placed within his reach as required by his care plan. This resident had a history of falls and required extensive assistance for daily activities. Resident #49, a male with low back pain and muscle weakness, was found sitting on a chair with his call light placed on a side table on the opposite side of the bed. The CNA acknowledged forgetting to place the call light within the resident's reach after assisting him to transfer from bed to chair. This oversight could lead to the resident falling while trying to reach the call light. The resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #60, a female with a history of falling and muscle weakness, was observed sitting in her wheelchair with her call light on the floor under the bed. She was unable to see or reach her call light, which was confirmed by both the resident and staff. The DON and other staff members acknowledged the importance of call lights for residents to communicate their needs and the potential risks if call lights are not accessible. Despite recent in-service training on proper call light placement, the facility failed to ensure compliance, leading to this deficiency.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 11 residents. Observations revealed multiple instances of uncleanliness, including brownish stains on walls, dirt on air-condition units, and stained bedside tables. Specific rooms had issues such as scrape marks on walls, dirt particles on shelves, and stained toilets, indicating a lack of proper cleaning and maintenance. Interviews with staff, including a CNA/Staffing Coordinator, the DON, and the Housekeeping Supervisor, revealed that there were inconsistencies in the cleaning responsibilities and processes. The CNA/Staffing Coordinator mentioned that she would notify housekeeping and the nurse on duty when rooms were dirty, but there was uncertainty about who was responsible for cleaning mini fridges. The DON stated that the ADON was required to observe residents' rooms daily, but leadership did not conduct regular rounds to check rooms. The Housekeeping Supervisor admitted that she could not perform audit checks as often as needed due to other responsibilities. The Administrator acknowledged the concerns and mentioned that the facility had recently dealt with a COVID outbreak, which diverted attention to other areas. The Plant Manager and Housekeeping Supervisor provided details on the cleaning protocols, but it was evident that these were not consistently followed. The facility's policy on Environmental Services outlined the need for a clean and safe environment, but the observed conditions did not meet these standards, leading to potential infection control issues and a decreased quality of life for the residents.
Deficiencies in Respiratory Care
Penalty
Summary
The facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the facility did not properly store nebulizer masks for two residents, did not have a clear order for oxygen administration for one resident, and did not change the oxygen concentrator tubing weekly as scheduled for two residents. These deficiencies were observed during a survey and confirmed through interviews and record reviews. Resident #2's nebulizer mask was found inside a drawer on top of an incontinent brief and was not bagged, which could lead to infections. Similarly, Resident #99's nebulizer mask was found inside a drawer touching the top of the nebulizer machine and was also not bagged. Interviews with the LVNs confirmed that the masks should have been bagged when not in use to prevent infections. Resident #34 had incomplete physician orders for oxygen administration, lacking the specific rate and route of administration. This oversight was acknowledged by the LVN, who stated that the incomplete orders could result in confusion and unmet respiratory needs. Additionally, the tubing for the oxygen concentrators of Resident #23 and Resident #41 was not changed weekly as scheduled, with dates on the tubing indicating they had not been replaced as required. The DON and Administrator confirmed the importance of proper storage and complete orders for respiratory care equipment and procedures.
Failure to Maintain Wheelchair and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and maintenance of assistive devices for Resident #6, who has severe cognitive impairment and requires a three-person assist for all transfers. The resident's wheelchair was found to be in poor condition, with a missing right armrest cushion and a torn left armrest cushion. This issue was not reported by the CNA responsible for the resident's care, who admitted to not noticing the damage until it was pointed out by the surveyor. Further interviews revealed that the LVN, DON, and other staff members were unaware of the wheelchair's condition. The CNA was expected to report such damages to the charge nurse and document it in the resident's chart, but this did not occur. The LVN stated that the maintenance or therapy department would be responsible for repairs if the issue was reported through the TELS system, but no such report was made. The facility lacked a specific policy for reporting and maintaining wheelchair damage. The Occupational Therapist and Maintenance Director also confirmed that they were not aware of the issue, as it had not been reported to them. The Administrator stated that either the therapy or maintenance department would handle such repairs if reported, but he did not believe the missing or torn armrest cushions posed a risk to the resident.
Failure to Provide Privacy Bag for Catheter
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not providing a privacy bag for her catheter bag. The resident, an elderly female with an indwelling catheter, was observed in her wheelchair with the catheter bag visibly hanging under the seat without a privacy bag. This was confirmed by multiple staff members, including an LVN and a CNA, who acknowledged the oversight and the potential for embarrassment to the resident. The Director of Nursing (DON) and the Administrator also confirmed that the catheter bag should have been covered with a privacy bag to maintain the resident's dignity. The facility's policy on indwelling urinary catheter care explicitly states that a privacy bag should be used to cover the drainage bag. Despite this policy, the staff failed to adhere to the procedure, resulting in a deficiency in maintaining the resident's dignity and quality of life.
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received proper care to prevent urinary tract infections. Specifically, the catheter bag of a cognitively intact female resident was observed touching the floor while she was in her wheelchair. This observation was made despite the resident's care plan indicating that catheter care should be provided every shift and physician orders specifying that the catheter bag should be positioned below the level of the bladder but off the floor. Interviews with the LVN, CNA, and DON confirmed that the catheter bag touching the floor could lead to infections and that it was the staff's responsibility to ensure the catheter bag was properly positioned. The resident's catheter bag was found touching the floor during an observation, and subsequent interviews revealed that the staff were aware of the importance of keeping the catheter bag off the floor but failed to consistently implement this practice. The CNA admitted to not noticing the catheter bag touching the floor, and the LVN acknowledged the issue and took corrective action by changing the catheter bag and reminding the CNA. The DON emphasized that all staff were responsible for ensuring proper catheter care and mentioned plans to remind staff through an in-service. The facility's policy on indwelling urinary catheter care also highlighted the importance of maintaining hygiene and preventing infection, which was not adhered to in this instance.
Failure to Maintain Continuous Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not maintain continuous feeding through a gastrostomy tube (G-tube) as ordered for Resident #2. The resident's feeding formula was found to be empty, and the feeding pump was off for a three-hour gap, contrary to the physician's order for continuous feeding with a specified downtime. The Licensed Vocational Nurse (LVN) responsible for the resident's care acknowledged the gap and cited a lack of necessary supplies as the reason for the interruption. Additionally, there was no clear and complete order for the downtime, leading to potential confusion among the nursing staff about when to stop and resume feeding. The Director of Nursing (DON) confirmed that the order for continuous feeding should have no gaps except for the specified downtime and that the downtime should be clearly stated in the order. The DON admitted responsibility for monitoring the orders and ensuring compliance. The Administrator also acknowledged the need for coordination with clinicians to ensure that the feeding schedule is clear and adhered to. The facility's policies on gastrostomy tube care and physician orders were reviewed, indicating that orders must include specific details such as quantity, duration, dosage, and frequency, which were not adequately followed in this case.
Failure to Document Wound Care Treatments and Pain Assessments
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practice for a resident with a pressure ulcer. Specifically, the facility did not document wound care treatments and pain assessments during wound care treatments for the resident. The resident, an elderly female with a pressure ulcer on the sacral region, had a physician's order for daily wound care treatment. However, the treatment was not documented on two specific dates, and pain assessments were not recorded before, during, or after the wound care on those dates. Interviews with the LVN and DON confirmed that the treatments were either not performed or not documented, which is against the facility's policy and could lead to exacerbation of the wound or infection. The resident's medical records showed that she was cognitively intact and had a comprehensive care plan indicating the need for daily wound care to promote healing and prevent infection. Despite this, the administrative record revealed gaps in documentation, and the staff responsible for wound care did not follow the required procedures. The DON acknowledged the importance of daily treatment for proper wound healing and confirmed that the lack of documentation indicated that the treatments were not done. The administrator also expected the staff to follow the orders and best practices for wound care, although he was not familiar with the specific procedures.
Infection Control Deficiencies in Hand Hygiene and Face Mask Usage
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program, leading to two specific deficiencies. The first deficiency involved a Certified Nursing Assistant (CNA) who did not change her gloves or perform hand hygiene while providing incontinence care to a resident. The resident, a cognitively intact male with chronic respiratory failure and chronic obstructive pulmonary disease, required extensive assistance for daily activities. During the care, the CNA failed to change her gloves after cleaning the resident's buttocks and before handling a clean brief, which she acknowledged could cause contamination and infection. The Director of Nursing (DON) confirmed that the gloves should have been changed to prevent cross-contamination and infection, emphasizing the importance of hand hygiene and glove changes during such procedures. The second deficiency involved the Dietary Manager (DM), who was observed not wearing a face mask while in the kitchen preparing food, despite a facility-wide requirement due to a recent COVID outbreak. The DM acknowledged that all kitchen staff were required to wear face masks to prevent the spread of infection. The Administrator also confirmed that all staff were expected to wear face masks at all times, especially in the kitchen, to prevent residents from getting sick. The facility's policy on infection control and hand hygiene, revised in October 2022, mandates that healthcare workers perform hand hygiene based on accepted standards, including washing hands with soap and water when visibly soiled. The failure to adhere to these policies and procedures by both the CNA and the DM could place residents at risk of cross-contamination and infection, as noted in the observations and interviews conducted during the survey.
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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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southern Oaks Therapy And Living Center | 1.8 mi | — | 0 | 0 |
| Southern Oaks Therapy And Living Center | 1.8 mi | — | 22 | 0 |
| Skyline Nursing Center | 4.8 mi | — | 14 | 0 |
| Fair Park Health & Rehabilitation Center | 5.3 mi | — | 6 | 0 |
| The Renaissance At Kessler Park | 5.5 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.