Deficiency Records for Dallas Retirement Village Health Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Dallas Retirement Village Health Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-07-31 | 2023-09-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-31 | 2023-09-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-07-31 | 2023-09-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-31 | 2023-09-19 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-07-31 | 2023-09-19 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-31 | 2023-09-19 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-07-31 | 2023-09-19 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-07-31 | 2023-09-19 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-31 | 2023-09-19 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-31 | 2023-09-19 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-07-31 | 2023-09-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-31 | 2023-09-19 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-07-31 | 2023-09-19 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-31 | 2023-09-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-31 | 2023-09-19 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-31 | 2023-09-19 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-07-31 | 2023-09-19 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-07-31 | 2023-09-19 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-07-31 | 2023-09-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-31 | 2023-09-19 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-07-31 | 2023-09-19 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-07-31 | 2023-09-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-31 | 2023-09-19 | Y |
| Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully. | Health | 2023-07-31 | 2023-09-19 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2023-07-31 | 2023-09-19 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-01 | 2023-09-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-08-01 | 2023-09-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-01 | 2023-09-19 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-08-01 | 2023-09-19 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-08-01 | 2023-09-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-08-01 | 2023-09-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-01 | 2023-09-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-01 | 2023-09-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-01 | 2023-09-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-01 | 2023-06-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-01 | 2023-06-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-01 | 2023-06-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-01 | 2023-06-20 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-05-01 | 2023-06-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-01 | 2023-06-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-30 | 2023-03-30 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-12-30 | 2023-02-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-30 | 2023-02-18 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-30 | 2023-02-18 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-12-30 | 2022-12-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-28 | 2022-12-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-28 | 2022-12-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-28 | 2022-12-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-01 | 2022-10-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-01 | 2022-08-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-01 | 2022-08-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-01 | 2022-08-20 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-01 | 2022-08-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-01 | 2022-08-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-01 | 2022-08-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-01 | 2022-08-20 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-05 | 2022-08-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-05 | 2022-07-19 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-07-01 | 2022-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-21 | 2022-01-27 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-12-21 | 2022-01-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-21 | 2022-01-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-21 | 2022-01-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-21 | 2022-01-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-21 | 2022-01-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-21 | 2022-01-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-21 | 2022-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-21 | 2022-01-27 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-12-21 | 2022-01-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-21 | 2022-01-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-23 | 2021-09-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-23 | 2021-09-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-23 | 2021-09-24 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-23 | 2021-09-24 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-12 | 2019-12-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-11-12 | 2019-12-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-12 | 2019-12-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-12 | 2019-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-12 | 2019-12-27 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-12 | 2019-12-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-12 | 2019-12-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-12 | 2019-12-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-12 | 2019-12-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-12 | 2019-12-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-30 | 2019-12-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-30 | 2019-12-27 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2019-10-30 | 2019-12-27 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-10-30 | 2019-12-27 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-10-30 | 2019-12-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-30 | 2019-12-27 | N |
