Cycle 1
Health 2025-03-06 · Fire 2025-03-06
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Balch Springs, TX
Balch Springs Nursing Home
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4200 Shepherd Ln, Balch Springs, TX
(972) 286-0335
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Advanced Healthcare Solutions
Operator or chain grouping
Approved since
1992-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
30 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.29
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.97
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.57
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,232
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9902
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.42
Baseline 87.81% · Performance 44.23% · Measure score 6.42 · Achievement 4.76 · Improvement 6.42
Adjusted total nurse staffing
0.96
Baseline 3.29 hours · Performance 3.35 hours · Measure score 0.96 · Achievement 0.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 87 |
| Staff flu vaccination coverage | 90.67% |
42%
48.7 pts better
|
Numerator 68 · Denominator 75 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
97.9%
2.6 pts worse
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.3%
0.1 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.8% · Q3 2.8% · Q4 4.4% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
3.3%
2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.1% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.4% |
18.9%
12.5 pts better
|
19.6%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.1% · Q3 4.8% · Q4 6.5% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.2% |
10.8%
6.6 pts better
|
16.7%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.3% · Q3 5.7% · Q4 0.0% · 4Q avg 4.2% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.8% |
15.4%
1.6 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 16.6% · Q4 0.0% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
16.1%
2.3 pts better
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 14.8% · Q3 11.7% · Q4 13.6% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.3% |
15.0%
0.7 pts better
|
19.8%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 11.5% · Q3 12.1% · Q4 13.8% · 4Q avg 14.3% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.2%
0.4 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.5% · Q3 6.6% · Q4 3.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
89.7%
6.7 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 92.7% · Q3 96.6% · Q4 100.0% · 4Q avg 96.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.0% |
88.0%
5 pts better
|
79.7%
13.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-14 · Fire 2024-02-14
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
4 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-04-06
C · Minimal harm
2025-03-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-06
F · Potential for more than minimal harm
2024-02-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-14
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-02-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-19
E · Potential for more than minimal harm
2024-02-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-02-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-16
E · Potential for more than minimal harm
2023-01-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-02
E · Potential for more than minimal harm
2023-01-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-02
E · Potential for more than minimal harm
2023-01-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-02
D · Potential for more than minimal harm
2023-01-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-02
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-06
E · Potential for more than minimal harm
2025-03-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-06
E · Potential for more than minimal harm
2025-03-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-04-06
E · Potential for more than minimal harm
2025-03-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-06
D · Potential for more than minimal harm
2024-08-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-05-31
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-06-03
F · Potential for more than minimal harm
2024-02-14
F838 · Administration Deficiencies
Health
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.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-02-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-02-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-19
E · Potential for more than minimal harm
2024-02-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-02-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-02-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-19
E · Potential for more than minimal harm
2023-01-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-02
E · Potential for more than minimal harm
2023-01-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-02-02
E · Potential for more than minimal harm
2023-01-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-02
E · Potential for more than minimal harm
2023-01-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-02
Penalties and ownership
What sits behind the stars
Ownership
Balch Springs Hc LLC
Operational/Managerial Control · Organization
Hooper, Grady
Corporate Director · Individual
Hooper, Grady
Corporate Officer · Individual
Muxworthy, Neil
Corporate Director · Individual
Scheiner, Eliezer
Operational/Managerial Control · Individual
Silberstein, Ari
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Mesquite Tree Nursing Center
Mesquite, TX
4-star overall rating with 3-star inspections with $26,046 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Mesquite Village Wellness & Rehabilitation
Mesquite, TX
3-star overall rating with 3-star inspections with $8,021 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
The Manor at Seagoville
Seagoville, TX
2-star overall rating with 2-star inspections with $96,616 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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