Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Dallas Retirement Village Health Center during CMS and state inspections, most recent first.
Staff failed to disinfect reusable lift equipment between resident uses and failed to perform hand hygiene while assisting multiple residents with meals. A CNA moved a mechanical lift and a ceiling-mounted lift between residents without cleaning them first, and during breakfast another CNA assisted two residents with food and a straw, touching a resident's face and returning to the first resident without sanitizing hands.
A resident with a stroke history and moderate cognitive impairment was hospitalized, but the record did not show that the resident or family received bed hold information. The family said no bed hold notice was provided, while staff reported that the policy was sent in a transfer packet and that follow-up to confirm receipt was not consistently done; the DON and admissions director gave differing accounts, and the administrator said bed hold information was mainly directed toward skilled residents.
A resident admitted with a nondisplaced R femur fracture did not have a baseline care plan completed within the required 48 hours of admission. Record review showed the plan was completed and reviewed after admission, and the RNCM stated baseline care plans were finalized within 72 hours, while the DNS acknowledged the plan was not completed timely.
A resident with depression and anxiety and a BIMS score indicating cognitive intactness had erythema under the neck fold that worsened in size and tenderness. An LPN documented notifying the provider, but there was no response in the provider notes, no follow-up documentation of additional calls, and no new treatment orders on the TAR.
Failure to follow a resident’s transfer care plan led to a fall. The resident had a dx of nondisplaced fx of the R femur, was dependent on staff for transfers, and was ordered to use a ceiling lift; the resident was also only to ambulate with therapy staff. Despite this, a CNA attempted to ambulate the resident with a FWW and gait belt during a transfer, and the resident lost balance and was guided to the ground. An RN later confirmed the care plan was not followed.
Failure to Assist Resident With Toileting Upon Request: A resident with chronic kidney disease, ADL self-care deficit, and mostly incontinent bowel/bladder status asked to use the bathroom, but a CNA told the resident incontinent care would wait until after lunch and left to pass meal trays. The resident attempted to stand and was later found in the bathroom. The DNS and Administrator stated residents should be assisted with toileting when requested.
The facility failed to properly clean glucometers, adhere to PPE protocols, and process laundry hygienically. Staff used alcohol wipes instead of EPA-registered wipes for glucometers, did not wear required PPE for residents on precautions, and left damp laundry overnight without rewashing. These actions increased the risk of infection spread among residents.
The facility failed to properly label and store medications, including an undated vial of tuberculin and incomplete temperature logs for medication refrigerators. Staff acknowledged these oversights, which did not meet the facility's expectations for medication management.
The facility was found to have sanitation deficiencies in food service and storage. A Dietary Aid handled a meal ticket that fell on the floor without changing gloves, and a communal refrigerator contained undated food items. Both the Dietary Aid and the Dietary Manager acknowledged the errors, and the Administrator confirmed the expectation for proper labeling.
A resident with severe cognitive impairment and post-traumatic hydrocephalus was physically abused by a CNA, as captured on video. The CNA was seen forcefully pushing the resident's legs and making a slapping motion towards the resident's face, causing distress. The facility's administrator and DNS confirmed the CNA's rough behavior, acknowledging it did not meet facility standards.
Failure to disinfect reusable equipment and perform hand hygiene between resident meal assistance
Penalty
Summary
The facility failed to disinfect reusable resident equipment between residents. On 4/6/26, Staff 7 used a mechanical lift to transfer a resident from one room and then took the lift to another room without cleaning and disinfecting it. The lift was later parked in the hallway without being cleaned, and Staff 7 stated that another staff member came through during the day and wiped off the lifts. The DNS later stated that mechanical lifts were reusable equipment and were to be disinfected between each resident. The facility also failed to ensure proper hand hygiene during meal assistance in the dining room. During a breakfast observation on 4/6/26, Staff 23 assisted Resident 35 with drinking from a straw, adjusted the straw with a hand, then assisted Resident 43 with eating yogurt and wiped the resident's mouth with a napkin without sanitizing hands, and then returned to Resident 35 to assist with eating eggs without sanitizing hands. Staff 23 stated he was not expected to sanitize his hands between residents unless he got up from the table, and the DNS stated staff were expected to perform hand hygiene between assisting residents with eating when food, straws, or the resident's face were touched.
Failure to Provide Bed Hold Information After Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident or the resident’s representative was provided bed hold information when the resident was hospitalized. Resident 8 was admitted to the facility in 4/2025 with a diagnosis of stroke, and the 10/24/25 quarterly MDS indicated the resident was moderately cognitively impaired. Progress notes showed the resident was admitted to the hospital on 11/28/25, but the clinical record did not show that the resident or the resident’s representative received bed hold information. During interview, the resident’s family member stated that when the resident was admitted to the hospital in 11/2025, no bed hold information was provided. Staff stated that a transfer packet, including the bed hold policy, was sent with residents when they went to the hospital, and one staff member said she did not follow up to ensure the resident or representative received it. Another staff member stated the admissions director reviewed the bed hold policy with the resident or representative if a resident was admitted to the hospital, but the admissions director did not recall whether she followed up with Resident 8 or the family. The administrator stated residents on the long-term care unit were always allowed back to the facility and that bed hold information was more directed toward skilled residents.
Untimely Baseline Care Plan Completion
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for Resident 59, who was admitted with a diagnosis of nondisplaced fracture of the right femur. Review of the resident’s baseline care plan showed it was completed and reviewed with the resident on 3/30/26, after the 3/27/26 admission date. The facility’s Baseline Care Plan policy dated 1/2026 stated that a baseline plan of care to meet the resident’s immediate needs shall be developed for each resident within 48 hours of admission. During interviews, Staff 20 (RNCM) stated baseline care plans for newly admitted residents were finalized within 72 hours of admission, and Staff 2 (DNS) acknowledged that Resident 59’s baseline care plan was not completed timely and needed to be finalized within 48 hours of admission.
Failure to Obtain Provider Orders for Worsening Skin Impairment
Penalty
Summary
The facility failed to obtain physician orders for treatment when Resident 80’s skin impairment under the neck fold worsened. Resident 80 was admitted with diagnoses including depression and anxiety, and the 10/2/25 Quarterly MDS indicated a BIMS score of 13, showing the resident was cognitively intact. A 10/22/25 physician order directed staff to monitor erythema under the neck fold every shift and notify the provider if the area deteriorated. On 12/3/25, Staff 8 documented that the erythema had increased in size and was tender to the touch, and noted that the provider was notified and staff were waiting for a response. However, provider progress notes on 12/3/25, 12/5/25, and 12/7/25 showed no response to the notification, and the resident’s progress notes contained no follow-up documentation of additional calls or provider direction. The 12/2025 TAR also showed no new treatments for the worsening erythema.
Failure to Follow Transfer Care Plan Led to Resident Fall
Penalty
Summary
The facility failed to implement appropriate transfer interventions to prevent falls for one resident who had been admitted with a diagnosis of nondisplaced fracture of the right femur. The resident’s care plan, initiated 3/30/26, directed nursing staff to use a ceiling lift for transfers, and a care plan initiated 4/1/26 stated the resident was only to ambulate with therapy staff. A 3/31/26 Functional Abilities Evaluation showed the resident was dependent on facility staff for transfers. Despite these directions, a 3/31/26 Incident Report documented a witnessed fall without injury in the resident’s room when a CNA attempted to ambulate the resident with a front wheel walker and gait belt. The CNA stated the resident lost balance during a transfer and was guided to the ground with low impact. A nursing progress note also stated the resident’s care plan directed staff to use a ceiling lift and that the resident was only to ambulate with therapy staff. The resident later stated the fall occurred during a standing transfer with nursing staff in the room, and an RN confirmed the resident’s care plan directed use of a ceiling lift and that the resident fell when the care plan was not followed.
Failure to Assist Resident With Toileting Upon Request
Penalty
Summary
The facility failed to ensure staff assisted a resident with toileting when requested. Resident 67 was readmitted to the facility in 4/2023 with a diagnosis of chronic kidney disease. The care plan revised on 4/2/26 identified the resident as having an ADL self-care deficit, being mostly incontinent of bowel and bladder, occasionally using a bedside commode for toileting, and requiring a mechanical lift for transfers. On 4/7/26 at 12:45 PM, Staff 15 entered the resident’s room and the resident stated he/she had to go to the bathroom. Staff 15 told the resident that he/she had an incontinent brief on and that incontinent care would be provided after lunch, then left the room to distribute other residents’ meal trays. The resident was observed attempting to stand, and when Staff 15 returned, the resident was located in the bathroom. Staff 15 later stated the resident did not always like to use the bedpan, was usually incontinent, and had not walked for at least three weeks. The DNS stated that if two staff were in the hall, one should assist residents with toileting upon request, and the Administrator stated a resident should be assisted with toileting when requested.
Infection Control Deficiencies in Glucometer Use, PPE Compliance, and Laundry Processing
Penalty
Summary
The facility failed to ensure proper cleaning and sanitization of community use blood glucose (CBG) glucometers between resident uses. Staff members were observed using alcohol wipes instead of the required EPA-registered wipes to disinfect the glucometers, contrary to the facility's policy and manufacturer instructions. This practice was noted among multiple staff members who used the glucometers for several residents, including a resident with diabetes, increasing the risk of bloodborne illness. The facility also did not adhere to transmission-based precautions for residents requiring enhanced barrier precautions and those on contact and droplet precautions. Staff members were observed not wearing the necessary personal protective equipment (PPE) such as isolation gowns when assisting a resident with lung cancer, who required enhanced barrier precautions. Additionally, staff failed to perform proper hand hygiene and PPE usage when handling food trays and entering isolation rooms for residents with COVID-19, including a resident with a recent positive test for COVID-19 and another with a diagnosis of clostridioides difficile. Furthermore, the facility's laundry processing practices were inadequate, as damp laundry was left in machines overnight and not rewashed before drying. This practice was confirmed by laundry staff and the Environmental Services Department Manager, who acknowledged that wet laundry was left in the washing machine overnight and transferred to the dryer the next morning without being rewashed, contrary to CDC guidelines for hygienically clean laundry.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications and biologicals, as observed during a survey. An open and undated vial of tuberculin was found in the nurses' station three medication room refrigerator, contrary to the manufacturer's instructions which require discarding the medication 30 days after opening. Staff 11, an LPN, acknowledged the vial was open and not labeled with an open date, and Staff 2, the DNS, confirmed that the expectation was for staff to label tuberculin with an open date. Additionally, the facility did not maintain accurate temperature logs for medication storage refrigerators. The temperature logs for the nurses' station one hall medication room refrigerator were blank from November 1 through November 25, and Staff 12, an LPN, acknowledged this oversight. Similarly, the temperature logs for the nurses' station two hall medication room refrigerator were blank on November 17 and November 29, with Staff 13, an RNCM, acknowledging the missing entries. Staff 2, the DNS, stated that the expectation was for the medication room refrigerator temperatures to be checked and logged twice daily, but acknowledged the lapses in documentation.
Sanitation Deficiencies in Food Service and Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in food service and storage, as observed in two separate incidents. In the first incident, a Dietary Aid was seen serving lunch in the second-floor kitchen when a meal ticket fell off the serving station onto the dining room floor. The Dietary Aid picked up the ticket with a gloved hand, returned it to the service station, and continued to handle service items without changing gloves. Both the Dietary Aid and the Dietary Manager acknowledged that the meal ticket should not have been placed back on the service station and that gloves should have been changed after touching the floor. In the second incident, a communal refrigerator in the facility's pantry area contained a clear container filled with meat covered in gravy and another container with leftover white cake, both without any date labels. The facility's Administrator stated that it was expected for food items to be dated and labeled with the resident's room number to which the item belonged.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, as evidenced by an incident involving a certified nursing assistant (CNA) and a resident with severe cognitive impairment and post-traumatic hydrocephalus. The resident, who required substantial assistance with bed mobility and primarily spoke Spanish, was reportedly treated roughly and slapped by a CNA. The incident was captured on video footage, which showed the CNA forcefully pushing the resident's legs and making a slapping motion towards the resident's face, accompanied by audible distress from the resident. The video evidence was reviewed by the facility's administrator and director of nursing services (DNS), who confirmed the CNA's rough and aggressive behavior towards the resident. Despite the CNA's denial of the actions, the facility's staff identified the CNA in the video and acknowledged that the care provided did not meet the facility's standards and expectations. The resident expressed feeling unsafe in the facility, further highlighting the failure to protect the resident from abuse.
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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) |
|---|---|---|---|---|
| Independence Health And Rehabilitation | 7.7 mi | ★★★★★ | 17 | 0 |
| Rivers Edge Rehabilitation And Care | 11.9 mi | ★★★★★ | 21 | 0 |
| Avamere Transitional Care At Sunnyside | 14 mi | ★★★★★ | 0 | 0 |
| Windsor Health And Rehabilitation | 14.2 mi | ★★★★★ | 6 | 0 |
| Avamere Court At Keizer | 15 mi | ★★★★★ | 19 | 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.