3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Irving, TX
3-star overall rating with 2-star inspections with $24,542 in total fines with 3 recent health deficiencies
225 N Sowers Rd, Irving, TX
(972) 253-4173
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hamilton County Hospital District
Operator or chain grouping
Approved since
2002-03-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.48
Registered nurse staffing
LPN hours / resident day
1.05
Licensed practical nurse staffing
Aide hours / resident day
2.23
Nurse aide staffing
Weekend hours
3.38
Weekend nurse staffing
RN turnover
74%
Annual RN turnover
Total nurse turnover
72%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.1
1.4 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
97.9%
0.5 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
2.7%
0.4 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
18.9%
9.4 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 4.6% |
10.8%
6.2 pts better
|
16.7%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.6% |
15.4%
4.2 pts worse
|
16.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.2% |
16.1%
7.1 pts worse
|
14.9%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.7% |
0.5%
3.2 pts worse
|
1.0%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
0.8%
1.6 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
15.0%
5.5 pts worse
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.2%
2.3 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
89.7%
7.3 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.1% |
12.0%
7.9 pts better
|
12.0%
7.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
88.0%
10.5 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
25.9%
7.1 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-01
Fire Safety
Use approved construction type or materials.
Corrected 2023-06-08
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-01
Inspection history
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-01
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-08-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-02
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2024-08-20
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-20
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-20
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-04-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-27
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-27
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-27
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-27
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-10-27
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-06-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-22
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-06-22
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-06-22
Penalties and ownership
Fine · fine $17,096
Fine
Fine · fine $7,446
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Mortgage Interest · Organization
Corporate Officer · Individual
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Mortgage Interest · Individual
Nearby options
Irving, TX
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Irving, TX
1-star overall rating with 1-star inspections with abuse icon flag with $285,320 in total fines with 7 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
Irving, TX
3-star overall rating with 2-star inspections with abuse icon flag with $25,259 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
Jump out