Presbyterian Village North: Medication Safety Failure - TX
Federal inspectors documented the violation during a complaint inspection on September 17, 2025. The finding affected few residents and was classified as minimal harm or potential for actual harm, but the gap between what happened and what the facility's own policy required was direct.
The facility's self-administration policy, last revised in February 2021, states that before any resident may manage their own medications, an interdisciplinary team must evaluate that person's cognitive and physical abilities and determine the arrangement is clinically safe. Medications are then to be stored in a locked box accessible only to that resident.
None of that happened here.
The Assistant Director of Nursing, identified in the report as ADON B, told inspectors the risk was straightforward: if a nurse doesn't know what a resident is taking, she cannot do an accurate assessment. The Director of Nursing, who said she had worked at the facility for three years, told inspectors she was unaware of any residents self-medicating and said any such arrangement would require an assessment, an order, and a lock box issued to the resident. She named the same risk her colleague had, adding that a resident could receive double doses.
The resident was doing it anyway. Without the order. Without the assessment. Without the box.
The Director of Nursing learned about it from the inspectors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Presbyterian Village North Special Care Ctr from 2025-09-17 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
PRESBYTERIAN VILLAGE NORTH SPECIAL CARE CTR in DALLAS, TX was cited for violations during a health inspection on September 17, 2025.
Federal inspectors documented the violation during a complaint inspection on September 17, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.