Dallas Retirement Village Health Center

In the surveyor’s words

From the most serious findings on record at Dallas Retirement Village Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 1, 2023

  1. Based on observation, interview and record review it was determined the facility failed to ensure Resident 8 was safe from sexual abuse for 1 of 5 sampled residents (#8) reviewed for abuse. This failure was determined to be an immediate jeopardy situation because the facility failed to prevent Resident 13 from sexually abusing Resident 8 three times in the past six months. Findings include: Resident 8 was admitted to the facility in 7/2022 with diagnoses including dementia. A 1/16/23 Quarterly MDS revealed Resident 8 was unable to be interviewed and the staff's cognitive assessment revealed Resident 8 had long term and short term memory problems. Resident 13 was admitted to the facility in 7/2022 with diagnoses including surgical amputation. […]

• Actual harm, isolatedF684Aug 23, 2021

  1. Based on interview and record review it was determined the facility failed to ensure a resident's urine test and or results were communicated with the resident's physician in a timely manner for 1 of 3 sampled residents (#2) reviewed for change of condition. Resident 2 continued to show symptoms of an infection, was transferred to the emergency room to start antibiotics and was later admitted to the hospital and diagnosed with [CONDITION(S)] related to a UTI. Findings include: Resident 2 was admitted to the facility in 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 2/16/20 CAA indicated the resident had a Foley catheter which placed the resident at increased risk for UTIs. Progress Notes revealed on 4/2/20 the resident had a fever of 100.4 F. […]

• No harm, potential for more than minimal, widespreadF880Dec 6, 2024

  Based on observation, interview, and record review it was determined the facility failed to ensure community use CBG glucometers were properly cleaned and sanitized between resident use, failed to follow transmission based precautions, and failed to process laundry to produce hygienically clean laundry to prevent the spread of infection for 4 of 6 sampled residents (#s 33, 80, 83, and 84) and 1 of 1 laundry room reviewed for infection control. This placed residents at risk for bloodborne illness, exposure to infections, and contaminated laundry. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF838Jul 31, 2023

  Based on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment for 1 of 1 sampled facility. This placed residents at risk for lack of quality of care and quality of life. Findings include: On 7/31/23 at 12:20 PM the 6/8/23 Facility Assessment was reviewed. The assessment was not comprehensive and did not include information on the following: -Facility staffing levels; -Staff competencies that were necessary to provide the level and types of care needed for the resident population; -Ethnic or cultural factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services; -The facility's resources, including but not limited to all… […]

• No harm, potential for more than minimal, widespreadF846Jul 31, 2023

  Based on interview and record review, it was determined the facility failed to have policies and procedures in place in the event of a facility closure for 1 of 1 sampled facility. This placed residents at risk for displacement. Findings include: On 7/31/23 the facility was asked to provide a policy and procedure in the event of a pending or potential facility closure. On 7/31/23 at 11:31 AM Staff 1 (Administrator) stated the facility did not have a policy and procedure for pending or potential facility closure.