The Villages of Dallas

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for the facility's 1 of 1 kitchen reviewed for pest control. The facility failed to keep an effective pest control program to ensure the facility's 1 of 1 kitchen was free of mice or rat feces. This failure could place residents at risk for food-borne illness, cross contamination, poor sanitary environment, and infection. During an observation of the facility's only kitchen on 07/28/2026 at 10:00 a.m., the following was revealed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 (200 Hall and 3000 Hall) of 2 hallways reviewed for accidents and hazards.1. The facility failed to ensure that 3 mechanical lifts were locked and secured when not in use on the 200 Hall. There was 1 mechanical lift and 1 wheelchair that blocked entry to the Fire Exit door on the 200 Hall.2. The facility failed to ensure that 3 mechanical lifts were locked and secured when not in use on the 3000 Hall. This failure could place residents, visitors and staff at risk of falls and/or injuries. Findings Included:Observation of the 200 Hall on 07/14/26 at 10:23 PM revealed 1 unlocked and unsecured mechanical lift parked on the hallway in between 2 resident rooms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable for 2 of 2 areas (Shower Room and Utility Room) on the 200 Hall reviewed for safe, and clean environment.1. The facility failed to ensure the bed liner in the Shower Room on the 200 Hall was cleared from standing water on 07/14/26.2. The facility failed to ensure the sink in the Soiled Utility Room the 200 Hall was cleared from standing water and working properly on 07/14/26. These failures place residents at risk for a diminished quality of life, infection, and clean environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an effective pest control program so the facility was free of pest and rodents two (Residents #1 and #2) of five residents reviewed for pest control. The facility failed to keep an effective pest control program to ensure the resident's rooms were free of rodents. This failure could place residents at risk for reduced quality of life and poor sanitary environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for five of five residents in a confidential group of residents. The facility failed to provide palatable food served at an appetizing temperature to residents. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction with the meals served and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. The facility failed to discard spoiled items stored in the walk-in refrigerator. These failures could place residents at risk for food-borne illness, cross contamination, and infection. During an observation of the walk-in refrigerator on 04/14/2026 at 10:20 a.m., the following was revealed: 1 large clear bin of what appeared to be 29 yellow onions. The bin had no item description or expiration date and was marked with a delivery date of 02/25/2026. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 6%, based on 31 opportunities and 2 errors, which involved 2 of 4 residents (Residents #49 and #35) and one of two staff (MA A) observed during medication administration for medication error. 1. MA A failed to administer Resident #49's MiraLAX Oral powder 17grm (for constipation) with the appropriate amount of fluid. MA A left the cup of medication with Resident #49. 2. MA A failed to administer Resident #35's MiraLAX Oral powder 17grm (for constipation) with the appropriate amount of fluid. These failures could place residents at risk for not receiving the therapeutic dosages of their medications as ordered by the physician and a decreased health status. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 (MA A, CNA B, and CNA C) staff members and 3 of 5 residents (Residents #49, #35, and #15) reviewed for infection control procedures. MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #49 and #35. CNA B and CNA C failed to change their soiled gloves and perform hand hygiene during incontinent care on Resident #15. These failures could place residents at risk for cross contamination and infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for three of five residents (Resident #1, #2, and #3) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, #2, and #3's rooms was in a position that was accessible to the residents on 09/09/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident was free from physical restraints not required to treat the residents' medical symptoms as was possible for one of five residents (Resident #4) reviewed for physical restraints. The facility failed to ensure Resident #4 had physician orders for the bolster mattress on her bed. This failure could place residents at risk of not having an environment that was free of restraints which could result in injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect the resident's recent fall on 03/08/2025. This failure could place residents at risk of not receiving appropriate care to meet their current needs.

Inspectors wroteBased on interview and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents, for one 1 of 5 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1's fall mat was on the floor, next to her bed on 03/08/2025. This was evident by the photo taken on 03/08/2025 and submitted by FM B which showed Resident #1 laying on the bare floor away from her bed with her fall mat observed underneath her bed. This failure could place the resident at risk of injuries from falls and a decreased quality of care.

Inspectors wroteBased observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #42, Resident #45, and Resident #58) of eight residents reviewed for Infection Control. 1. The facility failed to ensure CNA B performed hand hygiene, changed her gloves, and did not put the gloves on her pocket while providing incontinent care to Resident #58 on 02/04/2025. 2. The facility failed to ensure CNA B and CNA C changed their gloves and performed hand hygiene while providing incontinent care to Resident #45 on 02/04/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for one (Resident #45) of four residents reviewed for pressure ulcers (open wound on the skin caused by prolonged pressure to bony prominences). The facility failed to ensure that LVN A cleaned Resident #45's wound to right 5th toe from inside to outside on 02/05/2025. This failure could place the residents with pressure ulcers at risk for worsening of existing pressure ulcers and infection.

Inspectors wroteBased observations, interviews, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #42) of three residents observed for Incontinent Care. The facility failed to ensure that CNA D did not wipe Resident #42's perineal (area between the legs) area from back to front while providing incontinent care on 02/05/2025. This failure could place the residents at risk of cross-contamination and development of urinary tract infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one (Resident #59) of five residents was provided medications and pharmaceutical services, including the accurate administering of all drugs, to meet their needs. The facility failed to ensure MA did not leave Resident #59's medications inside the resident's room and failed to monitor the administration of the medications on 02/04/2025. This failure could place the residents at risk of chocking or not receiving medications as ordered by the physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents in facility received adequate supervision and assistance devices to prevent accidents 1 of 5 residents (Resident #10) reviewed for accidents and supervision. The facility staff member failed to follow the facility's No Lift policy, which indicated the total mechanical lift will be used for individuals who can bear weight on their legs and can only offer minimal assistance with their transfers/lifts. The facility failed to provide assistive devices (mechanical lift) during transfers as required per their No Lift policy and after requested by Resident #10 and her POA on 04/04/24. After the inappropriate transfer, Resident #10 had uncontrolled pain (even after administration of opioid analgesic), was sent to the hospital via 911 and was diagnosed with a fracture. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (room [ROOM NUMBER], #2, #3, #4, #5, and #6) of 10 resident rooms reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, and #6 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #1, Resident #3, Resident #4, Resident #5, and Resident #9) of eleven residents observed for Infection Control. 1. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #1. 2. The facility failed to ensure that LVN A would not bring a plastic container containing push button lancets (small, sharp needle used to prick the skin and draw blood), a container of test strips, and alcohol wipes inside Resident #3, Resident #4, and Resident #5's room when she checked the residents' blood sugar. 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #6 and Resident #7) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #6 and Resident #7's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident when 1 (Resident #8) of 3 residents were reviewed for pharmaceutical services. Resident #8 had 1 oblong white pill in a medicine cup on the nightstand that Resident #8 had not taken. This failure could place residents at risk of not receiving their medications as ordered by their physician. Review of Resident #8's Face Sheet, dated 09/24/24, reflected that Resident #8 admitted [DATE] with chronic venous insufficiency (veins in legs are damaged and cannot pump blood back to the heart properly), chronic osteomyelitis (bone infection) in tibia and fibula (bones in lower leg) of left leg, and localized swelling, mass and lump, of left lower leg. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #1, #2, and #3) of 9 residents reviewed for call lights in reach. Resident #1's call pad was on the floor, under his bed, and not within reach, while he was in bed. Resident #2's call button was on the floor, under his bed, and not within reach, while he was in bed. Resident #3's call button was clipped to his pillow, and not within reach, while he was in his wheelchair at the foot of his bed. These failures could place residents at risk of not having their needs and preferences met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' environment remained as free of accident hazards as is possible; and residents received adequate supervision and assistance devices to prevent accidents, for one (Resident #1) of nine residents reviewed for accident hazards. The facility failed to ensure Resident #1's fall mat was on the floor, next to his bed. This failure could place the resident at risk of injuries from falls and a decreased quality of care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 2 (Resident #1and Resident #2) of 8 residents reviewed for care plans. - The facility failed to document measurable objectives, interventions, or timeframes to address Resident #1's wandering behavior r/t diagnosis of dementia. On 06/05/24 Resident #1 wandered into Resident #2's room and was physically attacked and sustained a serious injury. -The facility failed to document measurable objectives, interventions, or timeframes to address Resident #2's aggressive behaviors after he exhibited combative behaviors in 12/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to be free from abuse for one (Resident #1) of eight residents reviewed for abuse. -The facility failed to have interventions in place to prevent Resident #1 from being abused by Resident #2, who had a history of being aggressive with no interventions care planned until 06/06/24, after the incident. On 06/05/24 Resident #1 wandered into Resident #2's room where he was physically attacked and sustained a serious injury. The non-compliance was identified as past non-compliance (PNC). The IJ began on 06/05/24 and ended on 06/06/24. The facility had corrected the non-compliance before the state's investigation began. These failures could place all residents at risk for abuse that could lead to serious injury, harm, impairment, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #97, #49, and #60) of eight residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #97, #49 and #60's rooms was in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency, or cause resident's unnecessary injuries.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 11 (Residents #1, 10, 18, 23, 28, 34, 48, 53, 71, 72, and 75's) of 27 residents observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Residents #1, 10, 18, 23, 28, 34, 48, 53, 71, 72, and 75's rooms were cleaned, sanitized, and maintained. This failure could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for five (Resident #2, #23, #34, #41, and #99) of eight residents reviewed for respiratory care. The facility failed to ensure Resident #2 and #99's nebulizer mask was properly stored. The facility failed to ensure Resident #34 had a clear order for O2 administration. The facility failed to ensure Resident #23, and #41's tubing for their oxygen concentrators were changed weekly as scheduled. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 5 days of the 6-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the services of a registered nurse for at least 8 consecutive hours a day on Saturdays and Sundays for 5 days of the four months (July 2023 - December 2023) reviewed. This failure placed residents at risk of receiving higher levels of patient care.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's main kitchen and the sub-kitchen, located in the skilled nursing area, reviewed for labeling and dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines and in a sanitary manner. The facility failed to ensure expired food was disgarded. The facility failed to ensure that the refrigerator, in the sub-kitchen was clean, sanitized, and did not contain staff foods. The facility failed to ensure the kitchen equipment in the main kitchen and sub-kitchen was clean and sanitized. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #99) of 5 residents reviewed for dignity. The facility failed to treat Resident #99 with dignity and promote enhancement of her quality of life when the resident was not provided a privacy bag for her catheter bag. This failure placed residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of eight residents (Resident #6) reviewed for accident hazards and supervision. The facility failed to properly maintain wheelchairs for Residents #6. This failure could place residents at risk for discomfort, pain, and injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was incontinent of bladder received services and assistance to prevent urinary tract infections for one (Resident #99) of two residents reviewed for urinary incontinence. The facility failed to prevent Resident #99's indwelling urinary foley catheter device from contact with the floor. These failures could place the resident with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #2) of one resident reviewed for gastrostomy tube management. The facility failed to ensure Resident #2 had a continuous feeding through a G-tube (A tube directly inserted through the skin to the stomach to deliver nutrition) as per ordered. The facility failed to ensure LVN M had the enteral feeding supplies needed to change the feeding formmula of Resident #2. The facility failed to ensure Resident #2 had a clear and complete order for the downtime. These failures could place residents who receive enteral feedings by G-tube at risk for infection, underfeeding or overfeeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practice for one (Resident #99) of 5 residents reviewed for pressure ulcers. The facility failed to document wound care treatments and pain assessment during wound care treatments. This failure could place resident at risks for incomplete medical records.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Dietary Manager and CNA M) of five staff observed for infection control. The facility failed to ensure that CNA M changed her gloves and perform hand hygiene while providing incontinence care to Resident #49. The facility failed to ensure the Dietary Manager was wearing a face mask while in the kitchen area preparing food, when the facility required all staff to wear a face mask as a result of a COVID outbreak in the building. These failures could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1one of 1 (3000 Medication Carts) medication carts reviewed for medication storage. The facility failed to ensure the 3000-medication cart was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 1 of 2 residents (Resident #1) reviewed for preference. The facility failed to honor Resident #1's food dislikes. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Resident #2, Resident #3 and Resident#4 ) reviewed for infection control practices, in that: The facility failed to ensure Medication Aide A performed hand hygiene between medication administration for Residents #3,#4 and #2, and sanitized the blood pressure cuff between use on Resident #3 and #2. These failures could place residents at risk for infection, transmission for communicable diseases and/or a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of one resident (Resident #1) observed for infection control. Facility failed to ensure Wound Treatment LVN A performed hand hygiene while providing wound care to Resident #1. This failure could place the residents at risk for infection.