F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and interview the facility failed to ensure each resident had the right to a safe, clean,
comfortable and homelike environment, which included but not limited to receiving treatment and supports
for daily living for 4 of 20 Residents (Resident #3, #32, #12, #10 ) reviewed for environmental concerns.
1. The facility failed to clean the restroom in Resident #3 and Resident #32's room.
2. The facility failed to ensure Resident #12 and Resident #10 had a lever on the doorhandle.
These failures could place residents at risk by exposing them to an unsanitary and an unsafe environment.
Findings include:
Record review of Resident #3's face sheet, dated 04/12/2024, revealed a [AGE] year-old female who
admitted to the facility on [DATE] with diagnosis of anoxic brain damage and dementia.
Record review of Resident #3's Quarterly MDS, undated, revealed a BIMS score of 6, indicating sever
cognitive impairment. Further review of the MDS revealed Resident #3 was always incontinent of bowel and
bladder.
Observation on 04/09/2024 at 11:09 AM revealed a foul odor in room in Resident #3's room. Observation of
the bathroom revealed a dried black substance which appeared to be fecal matter on the floor in front of the
toilet bowl and on the toilet seat. Attempted interview with Resident #3 was unsuccessful and Resident #32
was not in the room.
Record review of Resident #12's face sheet, dated 04/12/2024, revealed an [AGE] year-old female who
admitted on [DATE] with diagnosis of unspecified dementia.
Record review of Resident #12's Annual MDS, undated, revealed a BIMS of 14, indicating intact cognition.
Record review of Resident #10's face sheet, dated 04/12/2024, revealed [AGE] year-old female who
admitted on [DATE] with a diagnosis of bipolar disorder.
Record review of Resident #10's Annual MDS, undated, revealed a BIMS score of 9, indicating moderate
cognitive impairment.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
675783
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675783
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Villa at Mountain View
2918 Duncanville Rd
Dallas, TX 75211
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Observation and interview on 04/09/2024 at 11:29 AM, in Resident #12 and #10's room, revealed the lever
on the inside of the room door was missing. There was no knob or handle to turn and the door was hard to
open from the inside when closed. Resident #12 stated they (Resident #12 and Resident #10) leave the
door open and do not close it at night. Resident #12 stated the lever had been missing for a while, but it did
not bother her. She stated no one came in the room but the nurse and she pulled the curtain for privacy.
Resident #10 was not interviewable.
Interview on 04/12/2024 at 2:01 PM, the DON stated if there were feces on the ground that was not
cleaned up the risk would be touching or stepping on it. The Administrator stated Resident #32 utilized the
bathroom, and Resident #3 would not go to the bathroom. She stated housekeeping did rounds and rooms
were cleaned daily. She stated the CNAs could disinfect and then housekeeping would follow up as well.
When asked about 201's door handle, the Administrator stated one resident did not come out of the room
and the door handle was fixed immediately upon notification. The Administrator stated she could not
confirm how long the lever was missing. The Administrator stated the risk was not being able to open the
door to leave in any state of emergency. The Administrator stated the residents in 201 had never mentioned
any concerns wanting the door closed and Resident #12 always has the privacy curtain drawn.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675783
If continuation sheet
Page 2 of 2
