Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Presbyterian Village North Special Care Ctr during CMS and state inspections, most recent first.
A resident with multiple medical conditions was found to possess and self-administer a rescue inhaler at bedside without an interdisciplinary assessment or physician order, and the medication was not stored securely. Staff interviews confirmed that facility policy requires assessment and secure storage for self-administered medications, but these procedures were not followed in this case.
Surveyors found that shower chairs with stains, a shower curtain, and an empty water bottle were stored in a hallway accessible to residents, staff, and visitors. A hydration cart was left open and unattended, and a housekeeping cart with used mop water and trash was accessible to residents. Staff interviews revealed that these items were not properly cleaned or stored, and the facility could not provide a policy for maintaining a safe, clean environment.
Two residents with significant respiratory needs did not receive proper respiratory care, as staff failed to bag, date, and change oxygen and CPAP equipment according to facility policy and physician orders. Observations showed unbagged and undated respiratory devices, and staff interviews confirmed lapses in following protocols for cleaning and equipment maintenance, with no specific respiratory care policy provided by the facility.
A medication aide improperly disposed of a used Fentanyl patch by throwing it in the trash instead of following facility policy requiring destruction in a drug buster solution with a nurse witness. Nursing staff confirmed the correct procedure was not followed, and the aide was unaware of the proper disposal method.
Two residents reported that the coffee served was unpalatable and too strong, with complaints persisting for several months. The issue was confirmed by staff interviews and a surveyor's observation, and it was noted that a new coffee machine had been installed, though the coffee brand had not changed. No documentation of these concerns was found in grievance or resident council records, and there was no policy on resident satisfaction with food or beverages.
A resident with dementia and physical disabilities fell and sustained a head injury when a CNA independently transferred her using a mechanical lift, against the care plan requiring two staff members. The CNA felt rushed by the resident's family, leading to the improper transfer.
A resident with a history of heart conditions expressed a desire to be DNR, but the facility failed to update her code status in the EHR. When the resident experienced breathing difficulties, an LVN administered CPR against the resident's wishes due to the absence of the DNR in the file, leading to a violation of the resident's rights.
The facility failed to properly label and secure medications for two residents. A medication aide left medications unattended on a cart, and a resident's self-administered medications were found unsecured on a bedside table. Facility policies on medication storage and self-administration were not followed, posing risks of unauthorized access and potential harm.
A resident with severe cognitive impairment was fed by a staff member standing over her, contrary to the facility's policy of promoting dignity by sitting at eye level. The aide did not perform hand hygiene or change gloves between handling different food items. Interviews revealed that the facility expected staff to sit while feeding residents to maintain dignity, but the aide was not directly employed by the nursing facility, potentially leading to a lack of training on resident rights.
A resident's in-room refrigerator was not monitored for temperature or cleanliness, leading to potential food safety risks. The refrigerator was overfilled, preventing proper closure, and contained undated perishable items. The DON was unaware of the refrigerator's presence, and the facility's policy on refrigerator monitoring was not followed, posing a risk of food-borne illness.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the interdisciplinary team assessed and determined the safety of self-administration of medication for a resident. The resident, who was cognitively intact but required partial to moderate assistance with most activities of daily living due to conditions such as metabolic encephalopathy, hypertension, lung cancer, lupus, COPD, weakness, and debility, was observed with an unsecured rescue inhaler at her bedside. There was no documented assessment for self-administration of medication in the resident's electronic health record, nor was there a physician's order permitting self-administration. The resident reported keeping the inhaler with her and self-administering it as needed, despite the lack of formal authorization or assessment. Interviews with nursing staff, including the RN Charge Nurse, ADON, and DON, confirmed that the facility's policy required an assessment and physician order before a resident could self-administer medication, and that medications should be stored securely. Staff were unaware of any residents currently authorized to self-administer medications, and the resident's medication administration record did not reflect any requests for the PRN inhaler. The facility's policy also specified that self-administered medications must be kept in a secure location, which was not the case for this resident.
Failure to Maintain Clean and Safe Environment in Memory Unit
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as evidenced by several observations and staff interviews. Surveyors observed three shower chairs stored in a hallway outside the shower room on the memory unit, with one chair having light brown smear stains and another holding a large industrial shower curtain and an empty water bottle. The shower chairs and curtain were accessible to residents, staff, and visitors, and the area was not kept sanitary. Additionally, a hydration cart was left open and unattended with exposed ice and a metal scoop, and a housekeeping cart with used mop water and trash was left accessible to residents. These items were not properly stored or cleaned, and trash was not discarded as required. Staff interviews revealed that the shower chairs were placed in the hallway due to ongoing construction in the shower room, and that the chairs had not been used for approximately two weeks. Staff stated that cleaning and sanitizing protocols were in place, but the presence of stains and improperly stored items indicated these protocols were not followed. The DON and ADMIN confirmed that the environment should be kept safe, clean, and free of hazards, but were not aware of the specific issues until informed by surveyors. The facility was unable to provide a policy for maintaining a safe, clean, and homelike environment when requested.
Failure to Provide and Maintain Safe Respiratory Care Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required interventions such as tracheostomy care, tracheal suctioning, oxygen therapy, and CPAP use. Observations revealed that respiratory equipment, including nasal cannulas and CPAP masks, were not bagged or dated when not in use, and oxygen tubing and humidifier bottles were not changed or dated weekly as required by facility policy and physician orders. In one case, a resident's CPAP mask and nasal cannula were found unbagged and undated, and the resident reported that her CPAP machine and incentive spirometer had not been cleaned since admission. Another resident's oxygen concentrator was observed with visible debris, and his CPAP mask was also left unbagged and undated. Interviews with nursing staff, the ADON, and the DON confirmed that the expectation was for respiratory equipment to be changed, cleaned, and dated weekly, and for items not in use to be bagged to prevent infection. However, staff admitted to not noticing or addressing the lack of bagging and dating, and there was inconsistency in following the established protocols. The facility was unable to provide a policy specifically addressing respiratory care, CPAP storage, and tubing care and labeling, only producing a policy related to fire safety and oxygen cylinder storage. Both residents involved had significant respiratory diagnoses, including chronic heart failure, acute respiratory failure with hypoxia, and obstructive sleep apnea, and were dependent on staff for assistance with activities of daily living and respiratory equipment management. The failure to adhere to professional standards of practice and facility protocols for respiratory care and infection prevention was directly observed and confirmed through staff interviews and record review.
Improper Disposal of Fentanyl Patch by Medication Aide
Penalty
Summary
A medication aide (MA) failed to properly dispose of a used Fentanyl transdermal patch for a female resident with diagnoses including colon cancer and a Stage IV pressure ulcer. During a medication pass, the MA removed the resident's used Fentanyl patch and discarded it in the trash, contrary to facility policy. The MA stated she believed this was the correct procedure and was unaware of any alternative method for disposal. The resident's care plan included administration of pain medication as ordered, and physician orders specified the use of a Fentanyl patch every 72 hours. Interviews with nursing staff, including an RN and the DON, confirmed that the correct procedure required the used Fentanyl patch to be destroyed in a drug buster solution with a nurse witness, and not to be thrown in the trash. The facility's policy also required a co-signature for removal and destruction of the patch. The DON acknowledged that in-services had been conducted in the past, but there was no current oversight or monitoring of the Fentanyl destruction process. The MA later retrieved the patch from the trash and, with guidance from other staff, disposed of it according to policy.
Failure to Provide Palatable Coffee to Residents
Penalty
Summary
The facility failed to provide palatable coffee to meet the needs and preferences of residents, as evidenced by observations, interviews, and record review. During a meal observation, the surveyor noted that the coffee served was bitter and did not taste good. Two residents reported that the coffee tasted bad, was too strong, and had been unsatisfactory for a couple of months. Both residents stated they had informed staff about their dissatisfaction with the coffee. The issue was also acknowledged by the Dietitian Consultant and the Dietary Manager, who were aware of resident complaints and noted that a new coffee machine had been installed within the past year, although the coffee brand remained unchanged. Record review showed no documentation of coffee-related grievances or discussion in resident council meetings over the past three months. Additionally, the facility did not have a policy addressing resident satisfaction with food or beverages. The deficiency was limited to the palatability of coffee, with no negative nutritional outcomes reported, but it resulted in residents being unable to enjoy their beverage of choice.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to care plans for a resident requiring mechanical lift transfers. A certified nursing assistant (CNA) independently transferred a resident using a mechanical lift, contrary to the care plan and facility protocol that required two staff members for such transfers. This action resulted in the resident falling from the lift and sustaining a head laceration that required staples. The resident involved was an elderly female with diagnoses including dementia, age-related physical disability, and muscle weakness. Her care plan specified the need for a mechanical lift with two staff members to assist in transfers due to her moderate cognitive impairment and need for staff assistance. Despite this, the CNA proceeded with the transfer alone, leading to the resident sliding out of the sling and injuring her head. The incident was reported, and the resident was sent to the hospital for evaluation and treatment. The CNA admitted to knowing the requirement for two staff members during mechanical lift transfers but felt pressured by the resident's family member to expedite the process. The facility's policy clearly stated the need for two nursing assistants for safe mechanical lift transfers, which was not followed in this case.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's advance directive, specifically a Do-Not-Resuscitate (DNR) order, which resulted in the administration of CPR against the resident's wishes. The resident, an elderly female with a history of myocardial infarction, congestive heart failure, heart disease, and atrial fibrillation, had expressed her desire to be DNR during a care plan meeting. This was confirmed by both the resident and her responsible party. However, the DNR order was not completed and entered into the electronic health record in a timely manner. On the day of the incident, the resident experienced difficulty breathing and was found gasping for air. Despite the responsible party's objections and the resident's expressed wishes, the Licensed Vocational Nurse (LVN) initiated CPR and called 911 because the DNR papers were not in the resident's file. The paramedics continued the resuscitation efforts, which led to a confrontation with the resident's responsible party. The resident was eventually pronounced deceased by the paramedics. Interviews with facility staff revealed that the social worker had scanned the DNR form to the physician, who signed and returned it the same day. However, the social worker had left for the day, and the nursing staff was unaware of the signed DNR. This lack of communication and failure to update the resident's code status in the electronic health record led to the violation of the resident's rights and the administration of unwanted medical intervention.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards. This deficiency was observed in the cases of two residents. For Resident #22, the medication aide (MA D) left the medication cart unattended with medications on top, which included Allopurinol, Lisinopril, Glucophage, Ferrous Sulfate, Docusate Sodium, and Cholecalciferol. MA D admitted to being nervous due to the presence of a surveyor and acknowledged that it was against facility policy to leave medications unsecured, as it posed a risk of accidental ingestion by other residents. In the case of Resident #323, the resident was assessed as safe to self-administer medications. However, the medications, including eye drops and a medicated cream, were found unsecured on the bedside table. The resident confirmed that she kept the medications accessible for self-administration, but there was no mention of a lock box being used for secure storage. The facility's policy required that self-administered medications be stored in a secure place, such as a lock box, to prevent access by other residents. Interviews with the Director of Nursing (DON) and other staff revealed that the facility had protocols in place for securing medications, but these were not followed in the observed instances. The DON emphasized the importance of keeping medications locked to prevent unauthorized access and potential harm. The facility's policies on medication labeling and storage, as well as self-administration, were not adhered to, leading to the identified deficiencies.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to uphold the dignity of a resident during mealtime, as observed when a staff member stood over the resident while feeding her. The resident, a female with severe cognitive impairment and multiple health issues including dementia, malnutrition, and difficulty swallowing, was seated in a wheelchair in the dining room. Despite the resident's care plan indicating the need for assistance with eating, the staff member did not sit at eye level, which is important for maintaining the resident's dignity and comfort. The staff member, identified as Aide G, was observed feeding the resident while standing, without performing hand hygiene or changing gloves between handling different food items. This action was contrary to the facility's policy on promoting dignity and respect during dining. The aide admitted to standing due to a lack of seating and acknowledged that sitting would be more appropriate for the resident's dignity. Interviews with the charge nurse and the Director of Nursing (DON) revealed that the facility's expectation was for staff to sit at eye level with residents during feeding to promote dignity and communication. However, the aide was not directly employed by the nursing facility but was part of a separate program, which may have contributed to a lack of training on resident rights and dignity. The facility's policies emphasize the importance of treating residents with respect and dignity, which was not adhered to in this instance.
Failure to Monitor In-Room Refrigerator for Food Safety
Penalty
Summary
The facility failed to adhere to professional standards for food safety concerning a resident's in-room refrigerator. The resident, an elderly male with severe cognitive impairment and multiple health conditions, had a refrigerator in his room that was not being monitored for temperature or cleanliness. Observations revealed that the refrigerator was overfilled, preventing the door from closing properly, and contained undated perishable items such as an open yogurt cup and half-eaten sandwiches. Interviews with private caregivers indicated a lack of awareness regarding responsibility for monitoring the refrigerator's temperature and the duration the refrigerator had been in the room. The Director of Nursing (DON) was unaware of the refrigerator's presence until it was brought to her attention, and the facility's policy on refrigerator monitoring was not being followed. The facility's policy required monthly tracking of refrigerator temperatures and regular cleaning, which was not being done in this case. The lack of temperature monitoring and proper food dating posed a risk of food-borne illness to the resident, as the refrigerator's temperature was not being logged, and perishable items were not being discarded in a timely manner.
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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) |
|---|---|---|---|---|
| The Highlands Guest Care Center | 0.3 mi | ★★★★★ | 19 | 0 |
| The Legacy Midtown Park | 1.2 mi | ★★★★★ | 3 | 0 |
| The Meadows Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 8 | 0 |
| Walnut Place | 1.8 mi | — | 0 | 0 |
| Pure Health Transitional Care At Texas Health Pres | 2.2 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.