Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Ventana By Buckner during CMS and state inspections, most recent first.
Grievance information was not made available to residents, and no clear method for anonymous filing was posted or provided. No grievance forms were found in common areas, residents were unaware of where to obtain them, and staff gave inconsistent responses about how grievances should be submitted. The DON stated she did not know a system was needed for anonymous grievances, and the facility policy did not address anonymous submission.
A resident with dementia, severe cognitive impairment, falls history, and hospice services had a mechanical lift left unlocked and unsecured in her bathroom on 300 Hall. The lift was observed in the doorway of the bathroom on multiple occasions while not in use. The LVN, CNA, DON, and hospice RN all stated the lift should be locked when not in use, and the DON stated the facility had no policy regarding mechanical lifts and accidents and hazards.
A resident with a midline IV had a dressing that was not changed per the physician order for weekly dressing changes. During observation, the dressing was dated several days earlier, and an LVN was unsure when it was due. The DON stated charge nurses were responsible for the dressing changes and that no staff member was assigned to verify they were done on time; the ADON, who was also the infection preventionist, said the dressing should have been changed per order and facility policy.
A CNA failed to perform hand hygiene between glove changes while providing incontinence care to a resident with moderate dementia and incontinence. The CNA changed gloves multiple times without sanitizing or washing hands, despite handling soiled briefs and cleaning the resident. The DON and facility policy confirmed that hand hygiene is required before and after care and during glove changes.
A resident's Quarterly MDS Assessment was not completed within the required 92-day period, as it was submitted nearly two months late. The MDS Nurse acknowledged missing the deadline, and the DON suggested using a calendar with reminders to prevent future delays. The facility's policy requires adherence to federal and state timeframes for assessments.
A facility failed to ensure a resident's Quarterly MDS Assessment accurately reflected her status, as required interviews were not conducted within the designated timeframes. The MDS Nurse completed the assessment late and used previous data instead of conducting new interviews. The DON was unaware of these errors, which are crucial for care planning.
A facility failed to implement an effective discharge planning process for a resident intending to return to the community. The resident, who required assistance with ADLs and had a goal to return home, was discharged without a comprehensive plan or documentation in his EHR. The social worker responsible for discharge planning had left, leading to the oversight. The facility's policy emphasizes the need for a post-discharge plan to ensure continuity of care, which was not followed, potentially risking the resident's care needs upon discharge.
A facility failed to complete a discharge summary for a resident who was discharged home, missing essential information like a recapitulation of the stay, medication reconciliation, and a post-discharge plan of care. The resident, who was cognitively intact and required assistance with ADLs, was discharged without the necessary documentation due to the departure of the responsible social worker. Interviews revealed the risk of medication discrepancies and treatment changes due to this oversight.
A resident with severe cognitive impairment received medications incorrectly through a gastrostomy tube, resulting in a 23% medication error rate. An LVN mixed 14 medications together without a physician's order, contrary to facility policy requiring individual administration with flushing. The DON confirmed the error and the absence of an order for such administration.
A facility failed to maintain an infection prevention and control program when a CNA did not perform proper hand hygiene while providing incontinence care to a resident with Alzheimer's and dementia. Despite the facility's policy and recent training, the CNA did not wash hands before gloving, change gloves, or perform hand hygiene after removing a soiled brief, only completing hand hygiene after care was finished. This lapse was confirmed by the ADON and DON, who acknowledged the importance of hand hygiene in preventing infection.
Grievance Information Not Made Available to Residents
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to residents for 2 of 2 confidential residents reviewed for grievances. Observation on 03/16/26 at 2:45 PM found no grievance forms available in any common areas and no indication of where grievance forms could be found. Interviews with six confidential residents showed they were unaware of where grievance forms were located and stated they did not know how to anonymously file a grievance. Interviews with staff showed inconsistent and incomplete guidance for grievance submission. A CNA stated that if a resident or family wanted to file a grievance, she would tell an Administrator, and that there were no grievance forms available. A SW stated she would assist with grievances if available, but if forms were unavailable for anonymous filing, a resident or family member would feel they did not have a way to express concerns. The DON stated she did not know there needed to be a system for residents to file grievances anonymously and acknowledged there was potential risk for harm if a resident did not have a way to file a grievance anonymously. Review of the facility's grievance policy showed residents and families may submit complaints or suggestions to the Grievance Official, department head, or Executive Director, but the policy contained no information about anonymous submission.
Unsecured Mechanical Lift Left in Resident Bathroom
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible on 300 Hall when a mechanical lift in a resident’s bathroom was observed unlocked and unsecured while not in use. The resident involved was a female admitted with diagnoses including dementia, hypertension, a displaced comminuted left femur fracture, osteoarthritis, metabolic encephalopathy, atrial fibrillation, arteriosclerotic heart disease, and hearing loss. Her quarterly MDS reflected a BIMS score of 06, indicating severe cognitive impairment. She was incontinent, required total assistance with ADL care, and received hospice services. The resident’s care plan documented a history of falls and included interventions such as keeping areas free of obstructions to reduce the risk of falls or injury. During multiple observations, the mechanical lift was seen parked inside the doorway of the bathroom and remained unlocked and unsecured. The lift was observed in that condition repeatedly over several days, including during observations in the morning and afternoon. The resident stated that the lift had been in her room for a while and that staff used it when giving her a bath, but she could not confirm how long it had been there or identify who used it. Staff interviews showed that the LVN assigned to the hall was unaware the lift was unlocked and stated she did not know the lift needed to be locked in the bathroom area when not in use. A CNA assigned to the hall also stated she had observed the lift on several occasions but had never checked whether it was locked or unlocked. The DON stated she was unaware the lift had been observed unlocked and unsecured, confirmed that the expectation was for all mechanical lifts to be locked when not in use, and stated the facility did not have a policy regarding mechanical lifts and accidents and hazards. The hospice nurse stated she had observed CNAs use the lift for care and also stated that mechanical lifts should always be locked when not in use.
Midline Dressing Not Changed Per Order
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids was not ensured for Resident #90 when the facility failed to change the resident’s midline dressing according to the physician order. Resident #90 was a female admitted with diagnoses including pressure-induced deep tissue damage of the left heel, dementia, and a chronic ulcer of the heel and midfoot. Her care plan reflected that she had a midline, and a physician order dated 03/01/26 directed that the central line/midline dressing be changed every seven days. On observation, Resident #90 was in a wheelchair with a midline in the upper left arm, and the dressing was dated 3/5/26. The resident was not interviewable. An LVN stated she was not sure when the midline dressing was supposed to be changed, though she acknowledged it needed to be changed per orders to keep the midline in place and prevent infection. The DON stated the dressing was expected to be changed weekly and as needed per physician orders, that charge nurses were responsible for the dressing changes, and that no staff member was assigned to check whether the dressing was changed timely. The ADON, who served as infection preventionist, stated she was informed the dressing had not been changed and expected the charge nurse to complete the dressing change per physician order and facility policy. The only policy provided addressed PICC lines and stated an RN normally provides dressing changes as needed and as ordered, though an LVN may do so if trained and checked off.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to perform proper hand hygiene during the provision of incontinence care to a male resident with moderate vascular dementia, hypertension, and anxiety. The resident was always incontinent and required extensive assistance with activities of daily living, including hygiene. During the observed care, CNA A changed gloves multiple times without performing hand hygiene between glove changes, despite handling soiled briefs and cleaning the resident's perineal and buttocks areas. The CNA acknowledged not sanitizing or washing hands between glove changes and stated awareness of the correct procedure. The Director of Nursing (DON) confirmed that staff are expected to sanitize hands upon entering the resident's room, before and after care, and specifically during glove changes in incontinence care. Facility policy, revised earlier in the year, also required hand hygiene after removing gloves and before client contact. The failure to follow these procedures was directly observed and confirmed through staff interviews and policy review.
Failure to Complete Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to conduct a timely quarterly assessment for a resident, as required by state and federal regulations. Specifically, the Quarterly MDS Assessment for a resident was not completed within the mandated 92-day period following the previous assessment. The resident's previous assessment had an Assessment Reference Date of July 25, 2024, and was completed on August 5, 2024. However, the subsequent assessment, which should have been completed by October, was only created and submitted on December 17, 2024. This delay was acknowledged by the MDS Nurse, who admitted to missing the assessment deadline. Interviews with facility staff revealed that the MDS Nurse was responsible for ensuring the timely completion of assessments, but failed to do so in this instance. The Director of Nursing (DON) was informed of the oversight on the day the assessment was finally submitted and suggested the MDS Nurse use a calendar with reminders to prevent future occurrences. The facility's policy mandates that assessments be completed and submitted in accordance with federal and state timeframes, which was not adhered to in this case.
Failure to Accurately Complete Resident Assessment
Penalty
Summary
The facility failed to ensure that a resident's Quarterly MDS Assessment accurately reflected her status, specifically regarding the completion of required interviews within the designated timeframes. The resident, a female with non-Alzheimer's dementia and depression, had her Quarterly MDS Assessment created and submitted significantly late. The assessment, which should have included interviews conducted within a specific look-back period, was completed using information from the resident's clinical record rather than direct interviews. The MDS Nurse admitted to missing the assessment deadline and acknowledged entering information from a previous assessment in error, which she planned to correct. The Director of Nursing (DON) was informed of the missed assessment on the day it was submitted and stated that the MDS Nurse was responsible for the timely completion and accuracy of assessments. The DON was unaware of the errors in the BIMS and mood interviews, which are critical for care planning. The facility's policy requires accurate resident assessments and timely submission in accordance with federal and state guidelines, but these standards were not met in this instance, potentially impacting the resident's care planning.
Failure in Discharge Planning for Resident Returning to Community
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident who intended to return to the community. The resident, a cognitively intact male with a history of urinary tract infection, diabetes, and depression, required partial to maximum assistance with activities of daily living (ADLs) and used a cane for mobility. Despite the resident's goal to return to the community, the facility did not create a comprehensive discharge plan to address his needs, including the provision of necessary durable medical equipment and assistive devices, as well as determining the need for home health services or outpatient therapy. The resident's discharge was unplanned, and there was no documentation of discharge planning in his electronic health record (EHR). The facility's administrator acknowledged that the social worker, who was responsible for discharge planning, had left, resulting in the oversight. The Director of Nursing (DON) stated that the resident returned to the facility's Assisted Living unit after receiving skilled therapy and did not believe additional services were required. However, the lack of discharge planning documentation and the absence of a physician's order for discharge indicate a failure to ensure continuity of care and address potential changes in the resident's medication or treatment needs. The facility's policy on discharge summaries emphasizes the importance of a post-discharge plan of care to assist residents in adjusting to their new living environment. This includes ensuring continuity of care information and reviewing the discharge plan with the resident or their representative before discharge. The failure to adhere to this policy and the lack of a documented discharge plan for the resident could place residents at risk of not receiving necessary care and services upon discharge.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a discharge summary was completed for Resident #67, who was discharged home from the facility. This discharge summary was supposed to include a recapitulation of the resident's stay, medication reconciliation, and a post-discharge plan of care. The absence of this documentation could place residents at risk by not providing necessary information to ensure continuity of care once they return home. Resident #67 was a cognitively intact male who required partial to maximum assistance with activities of daily living (ADLs) and had diagnoses including urinary tract infection, diabetes, and depression. His goal was to be discharged to the community, and active discharge planning was in place. However, the discharge was marked as unplanned, and no discharge summary was found in his electronic health record (EHR). Interviews with the facility's Administrator and Director of Nursing (DON) revealed that the social worker responsible for completing discharge summaries had left, and Resident #67's discharge summary was missed. The DON acknowledged the risk of not completing a discharge summary, such as potential discrepancies in medication and treatment changes. Despite efforts to locate any documentation, only a clinical note from the assisted living facility was found, indicating that medications had been verified and ordered.
Medication Administration Error Through G-Tube
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 23% due to 10 errors out of 43 opportunities. This involved a resident who received medications through a gastrostomy tube. The error occurred when an LVN crushed and mixed 14 different medications together, administering them through the resident's gastrostomy tube without individual flushing as required by the facility's policy. This practice was not supported by a physician's order and contradicted the facility's policy, which mandates administering medications one at a time with a flush of at least 15cc before and after each medication unless otherwise specified by a physician. The resident involved was an elderly male with severe cognitive impairment and multiple diagnoses, including pneumonitis, hypertension, and gastro-esophageal reflux disease, among others. The resident required assistance with activities of daily living and was receiving tube feedings. The LVN involved admitted to the error, stating that in previous employment, medications were mixed together if ordered, but acknowledged that this was not the case for the resident in question. The Director of Nursing confirmed that the medications should not have been mixed due to potential interactions and the absence of a specific order to do so.
Infection Control Lapse During Incontinence Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not perform proper hand hygiene while providing incontinence care to a resident. The resident, a female with a history of Alzheimer's disease and dementia, was observed receiving care from CNA Z, who did not wash hands before gloving, did not change gloves or perform hand hygiene after removing a soiled brief, and only completed hand hygiene after the care was finished. This lapse in protocol was confirmed through interviews with the CNA, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), all of whom acknowledged the importance of hand hygiene in preventing infection and stated that the facility's policy required hand hygiene before and after care, as well as when transitioning from dirty to clean tasks during incontinence care. The facility's policy on hand hygiene, revised in January 2024, emphasizes the importance of hand hygiene in preventing the spread of infections and outlines specific instances when hand hygiene should be performed. Despite this policy and recent in-service training on infection control, the CNA failed to adhere to these guidelines, potentially placing residents at risk for infection. The ADON and DON both stated that it was their responsibility, along with the unit nurses, to ensure compliance with the hand hygiene policy, highlighting a gap between policy and practice in the facility's infection control measures.
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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) |
|---|---|---|---|---|
| Simpson Place | 1 mi | ★★★★★ | 16 | 0 |
| Avir At Dallas | 1.2 mi | ★★★★★ | 1 | 0 |
| Fair Park Health & Rehabilitation Center | 1.7 mi | ★★★★★ | 7 | 0 |
| Lakewest Rehabilitation And Skilled Care | 4 mi | ★★★★★ | 25 | 1 |
| The Renaissance At Kessler Park | 4.4 mi | ★★★★★ | 5 | 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.