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Inspection visit

Inspection

DALLAS RETIREMENT VILLAGE HEALTH CENTERCMS #38520734 citations on this visit
34 citations recorded

Citations

34 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0585GeneralS&S Dpotential for harm

    F585 - Grievances

    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.

  • 0756GeneralS&S Dpotential for harm

    F756 - Drug Regimen Review

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0921GeneralS&S Dpotential for harm

    F921 - Other Environmental Conditions

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  • 0550GeneralS&S Dpotential for harm

    F550 - Resident Rights

    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  • 0557GeneralS&S Dpotential for harm

    F557 - Respect and Dignity

    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  • 0561GeneralS&S Epotential for harm

    F561 - Self-determination

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  • 0578GeneralS&S Dpotential for harm

    F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

    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.

  • 0582GeneralS&S Dpotential for harm

    F582 - The facility must—

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    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.

  • 0660GeneralS&S Dpotential for harm

    F660 - Quality of life

    Plan the resident's discharge to meet the resident's goals and needs.

  • 0661GeneralS&S Dpotential for harm

    F661 - Quality of life

    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

  • 0684GeneralS&S Dpotential for harm

    F684 - Quality of care

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0685GeneralS&S Dpotential for harm

    F685 - Vision and hearing

    Assist a resident in gaining access to vision and hearing services.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0697GeneralS&S Dpotential for harm

    F697 - Pain Management

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0698GeneralS&S Dpotential for harm

    F698 - Dialysis

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

  • 0745GeneralS&S Dpotential for harm

    F745 - The facility must provide medically-related social services to attain or

    Provide medically-related social services to help each resident achieve the highest possible quality of life.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    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.

  • 0790GeneralS&S Dpotential for harm

    F790 - Dental services

    Provide routine and 24-hour emergency dental care for each resident.

  • 0804GeneralS&S Epotential for harm

    F804 - Food and drink

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0825GeneralS&S Dpotential for harm

    F825 - Specialized rehabilitative services

    Provide or get specialized rehabilitative services as required for a resident.

  • 0838GeneralS&S Fpotential for harm

    F838 - Facility assessment

    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

  • 0842GeneralS&S Epotential for harm

    F842 - Resident-identifiable information

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  • 0846GeneralS&S Fpotential for harm

    F846 - Facility closure

    Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.

  • 0850GeneralS&S Fpotential for harm

    F850 - Social worker

    Hire a qualified full-time social worker in a facility with more than 120 beds.

  • 0006GeneralS&S Fpotential for harm

    Conduct risk assessment and an All-Hazards approach.

  • 0007GeneralS&S Fpotential for harm

    Address patient/client population and determine types of services needed.

  • 0015GeneralS&S Fpotential for harm

    Address subsistence needs for staff and patients.

  • 0018GeneralS&S Fpotential for harm

    Establish procedures for tracking staff and patients during an emergency.

  • 0035GeneralS&S Fpotential for harm

    Provide family notifications of emergency plan.

  • 0223GeneralS&S Dpotential for harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  • 0353GeneralS&S Dpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0355GeneralS&S Dpotential for harm

    Properly select, install, inspect, or maintain portable fire extinguishes.

  • 0372GeneralS&S Dpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

FAQ · About this visit

Common questions about this visit

What happened during the July 31, 2023 survey of DALLAS RETIREMENT VILLAGE HEALTH CENTER?

This was a inspection survey of DALLAS RETIREMENT VILLAGE HEALTH CENTER on July 31, 2023. The surveyor cited 34 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at DALLAS RETIREMENT VILLAGE HEALTH CENTER on July 31, 2023?

Yes, 34 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grie..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.