Williamsburg Village Healthcare Campus
Williamsburg Village Healthcare Campus in Desoto, TX — inspection on March 26, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The surveyor left a safety message with the receptionist to have them call me regarding Resident #1.
During an interview on 03/31/2026 at 8:49 AM, NP-A stated that the facility staff did not provide notification of Resident #1's
position) notified him that the resident was transported to the hospital by the family. NP-A stated that he had no contact with the family or hospital following Resident #1's admission. NP-A stated that he expects immediate notification when a resident falls with head injury to send out to ER for further evaluation.
The risk to the patient when MD's not notified could result in serious internal injuries.
Review of the facility's policy titled Change in a Resident's Condition or Status, revised 02/13/2023, reflected in part the following: The primary goal of identifying Acute Changes of Condition (ACOCs) is to enable staff to evaluate and manage a patient at the community and avoid transfer to a hospital or emergency room (ER). To achieve this goal, the community's staff and practitioners must recognize an ACOC (is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. (and identify its nature, severity, and cause(s).
The practitioner needs a detailed description of the patient's condition to determine whether a Symptom is problematic or simply a normal or expected variant.
Care-giving staff should describe and document the nature, extent, and severity of symptoms, abnormalities, and condition changes clearly and in sufficient detail to help Practitioners distinguish their potential causes and consequences .A brief review of the patient's known medical history (e.g., synopsis of a recent hospital course) is vital.
This was determined to be an IJ on 03/25/2026 at 5:10 PM.
The Administrator and DON were notified.
The Administrator was provided the IJ Template on 03/25/2026 at 5:19 PM.
The following Plan of Removal submitted by the facility was accepted on 03/26/2026 at 6:19 PM:Plan of removal for IJ-F-F580-State alleges facility failed to ensure physician was notified of injury post fall on one resident.IJ called at 5:10PM facility for F-F580.Medical Director Notified at 5:20PM.Ad hoc [created for a particular purpose] QA completed to address notification protocols of family and physician for incident/accidents and change of condition.[Resident #1] is currently out of facility.Immediate Correction/Client protectionDON/designee to educate licensed nurses on proper notification of physician and family for incident/accidents to include any resident change of condition.
Completion date 03/25/2026DON/designee to educate licensed nurses to notify DON and administrator of all incident/accidents and change of condition that require hospital transfer.
Completion date 03/25/2026.DON/designee performed assessments on all residents with falls in the past 30 days to ensure proper notifications and assessments in place.
Completion date: 03/25/2026MDS/designee updated care plans for all residents with falls in the last 30 days.
Completion date 03/25/2026All licensed nurses will be educated on incident/accident protocols, to include notification of DON, Administrator, physician and family and resident assessment prior to working their next assigned shift. DON/designee will complete this.
Completion date: 03/25/2026MonitoringDON and/or designee will monitor residents with falls daily to ensure notifications were appropriately made to physician and family.Administrator to review with the DON weekly to ensure continued compliance.Results of all audits will be brought to the QAPI committee by DON to review for continued recommendations and compliance.This protocol will be covered on new-hire orientation by DON/designee.
Record review of in-service training dated 02/19/2026 and 02/23/2026 titled Navigating Cognitive Changes: Dementia, Delirium, and AMS for clinical staff reflected in part: identifying changes in conduction, comprehending the stages of Dementia, understanding Delirium, and AMS (a change in mental function. It stems from certain illnesses, disorders and injuries affecting your brain.) Detecting change in SMI Patients.developing and implementing resident intervention protocols, assessing, reporting, documenting, and notifying providers.
Record review of CNA-O's personnel file reflected CNA O's date of hire was 0
675756 03/26/2026
Williamsburg Village Healthcare Campus 941 Scotland Dr Desoto, TX 75115
to the Abuse Coordinator.Upon receiving an allegation abuse, neglect, exploitation or misappropriation,
of Operations and Regional Nurse Consultant determine whether the allegation is reportable under
Regulatory Agency, Adult Protective Services (where state law provides for jurisdiction in skilled nursing or assisted living facilities), and in certain cases, local law enforcement, within the following timeframes: a. not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or b. not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
Record review of the facility's Fall Management policy, dated 01/12/2022, reflected the following: Purpose: 1.
The community will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls.
The community will manage falls by providing an environment that is free from potential hazards.2.The qualified staff will complete the Fall Risk Data Collection upon admission and quarterly with fall or change of condition.3.A resident fall management program will be implemented that educates staff in creative, functional strategies while recognizing resident's rights and their need to maintain the highest practical level of function.Definitions:A fall can be defined as when a resident is found on the floor, a resident slides to the floor unassisted, a resident rolls off the bed or chair onto the floor, a resident falls off or out of equipment/apparatus used for therapy or a transfer. A fall also includes when a resident trips or slips and complains of or sustains bodily injury or an episode where a resident lost his or her balance and would have fallen, were it not for staff intervention (intercepted fall). A fall may also be reported by a resident, visitor, or family member.Procedures:1.The qualified staff assesses all residents for fall risk through the admission Nursing Assessment form upon admission, quarterly, and with a significant change.2.Upon determination that the resident is at risk, the qualified staff creates an individualized plan of care that includes the appropriate preventative interventions to reduce potential for fall.3.Part of the management program is the implementation of visual identifiers for those residents at risk.4.If a fall occurs, the qualified staff assesses for injury from the fall, immediately investigates the reason and determines the intervention to prevent future falls - complete the Incident/Accident Report in the EHR.5.The physician and family are notified.6.All reports of resident falls within the community are monitored through the QAPI process within the community at the Standards of Care Meeting.7.Data is also reported in the community's monthly QAPI Meeting.
675756 03/26/2026
Williamsburg Village Healthcare Campus 941 Scotland Dr Desoto, TX 75115
During a second interview on 03/24/2026 at 9:45 AM with the Administrator, he reported that after being notified that Resident #1 was hospitalized for a witnessed on 03/22/2026.
Administrator stated he was later informed that Resident #1 sustained injuries to the liver and fractures to his ribs.
The Administrator stated that he had not investigated the incident.
However, he said further follow-up that included staff interviews of Resident #1's fall on 03/24/2026 ruled out abuse.
During an interview with the DON-T on 03/24/2026 at 9:55 AM she stated that once she was notified that Resident #1 was in the hospital for a fall RN-J she did not investigate the incident, due to the hospital report that the resident was not experiencing any changes other than the bruised liver and fractured ribs.
During a second interview with DON-T on 03/26/2026 at 3:50 PM, she stated that after further follow up and interviews she was provided more information about the incident by the assigned nurse, LVN-L on 03/24/2026 and 3/25/2026 and hospital records that Resident #1 had sustained internal injuries of adrenal hematoma, fractures of the right 6th and 7th lateral ribs (Right 6th and 7th lateral rib fractures are common chest wall injuries, usually caused by blunt trauma. and sharp pain.), right adrenal hematoma (Adrenal hematoma is a collection of blood within the adrenal gland, often resulting from trauma, severe infection, or anticoagulant use.), and grade 3 Liver laceration involving segments 5 and 8 (These are shallower tears, often less than 3 cm). DON-T said she proceeded to follow up with the staff that was on duty 03/22/2026, RN-J on 03/22/2026, FM-S and FM-A on 03/24/2026, contact with the MD, LVN-L, and other staff, ruled out abuse or neglect.
DON-T stated that failing to investigate allegations of abuse, neglect, resident rights, and exploitation could result in further injuries and abuse to the resident.During a second interview with the Administrator on 03/26/2026 at 3:59 PM, he stated that once DON-T was notified that Resident #1 had fallen, she proceeded to review EHR records, contacting LVN-L, and interview LVN-B, CNA-O, LVN-G, RP, FM-S. and RN-J for more information, and the incident findings ruled out abuse and neglect of Resident #1.
Record review of the facility's Abuse, Neglect and Exploitation and Misappropriation of Resident Property Internal Investigation Guidelines Event and Concern Form, policy dated 06/23/2017, reflected the following: Purpose The purpose of this policy is to ensure that all healthcare facilities comply with federal and state regulations regarding (i) protecting facility patients and residents from abuse, neglect, exploitation and misappropriation of resident property, and (ii) timely investigation of and reporting to state and local agencies all allegations of abuse, neglect, exploitation and misappropriation of resident property.
All managed healthcare facilities and all management company staff members or third parties providing services to such facilities and/or their residents.
675756 03/26/2026
Williamsburg Village Healthcare Campus 941 Scotland Dr Desoto, TX 75115
injuries, complete neurological checks including assessing eyes for alertness and focus.
The DON
jeopardy to resident health or fall with an injury could be causing further harm to the resident.
The Administrator and DON were safety notified of Immediate Jeopardy (IJ) on 03/25/2025 at 5:10 PM, due to the above failures and the IJ Template was provided at 5:19 PM.
The following Plan of Removal submitted by the facility and
failed to ensure proper assessment and documentation on one resident post fall.1. IJ called at 5:10PM facility for F-F684.2.
Medical Director Notified at 5:20PM.3. Ad hoc [as need] QA completed to address notification protocols of family and physician for incident/accidents and change of condition to include proper assessments and documentation.4. [Resident #1] is currently out of facility.5.
Immediate Correction/Client protectiona. DON/designed to educate licensed nurses on proper assessments and documentation for incident/accidents to include any resident change of condition.
Completion date 03/25/2026.b. DON/designee to educate licensed nurses to notify DON and administrator of all incident/accidents and change of condition that require hospital transfer.
Completion date 03/25/2026. c. DON/designee performed assessment on all residents with falls in the past 30 days to ensure proper notifications and assessments in place.
Completion date: 03/25/2026.d. MDS/designee updated care plans for all residents with falls in the last 30 days.
Completion date 03/25/2026.e.
All licensed nurses will be educated on incident/accident protocols, to include notification of DON, Administrator, physician and family and resident assessment and documentation prior to working their next assigned shift. DON/designee will complete this.
Completion date: 03/25/2026.6.
Monitoring:a. DON and/or designee will monitor residents with falls daily to ensure notifications, assessments, and documentation are in place.b.
Administrator to review with the DON weekly to ensure continued compliance.c.
Results of all audits will be brought to QAPI committee by DON to review for continued recommendations and compliance.d.
This protocol will be covered on new-hire orientation by DON/designee.
Monitoring of the POR included the following: Record review of facility all staff in-service dated 03/25/2026, completed by Staff Development Nurse, the staff development coordinator titled Incidents and Accidents: Reporting, Investigating, and Notifying the provider, ADON, DON, Administrator and Family.to do list by ADON: Patient falls, and patient transferring to hospital.
Change in condition: assessing, documenting and reporting to physician and family., recognizing change in condition, and when to notify physician of a change in condition all staff in-services received a posttest over the following materials: behavior health monitoring, fall prevention, and Dementia, changes in condition, reporting and documenting resident abuse, neglect, changes and incidents immediately to provider, DON, RP, and Administrator.On 03/26/2026 the investigator began monitoring (12:17 PM through 4:00 PM) to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Observations, interviews, and record reviews on 03/26/2026 9:00 AM-11:00 AM of Residents #1, 2, 3, 4, and 5 were all a fall risk and stated they had no concerns regarding falls, assistance, and supervision.
Residents EHR reflected plans, interventions and documentation addressing the resident falls.
Record reviews of Residents #1, #2, #3, #4, and #5 EHR fall a