Cycle 1
Health 2026-01-15 · Fire 2026-01-15
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Dallas, TX
C C Young Memorial Home
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4849 W. Lawther Dr., Dallas, TX
(214) 827-8080
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
129
Certified beds
Average residents
115
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-05-02
CMS approved date
Coverage
Medicare
Participation flags
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
0.81
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.06
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
5.17
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.10
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.71
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.35
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
5.15
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
595
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.82
Composite VBP score used to determine payment impact.
Payment multiplier
1.0206
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.79
Baseline 19.67% · Performance 18.28% · Measure score 6.79 · Achievement 6.79 · Improvement 4.76
Healthcare-associated infections
10
Baseline 4.76% · Performance 4.56% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
3.42
Baseline 54.70% · Performance 49.69% · Measure score 3.42 · Achievement 3.42 · Improvement 1.18
Adjusted total nurse staffing
6.51
Baseline 4.76 hours · Performance 4.93 hours · Measure score 6.51 · Achievement 6.51 · Improvement 1.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.78% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 911 · Observed rate 9% · Lower 95% interval 7.64% |
| Discharge to community | 50.92% |
50.57%
0.4 pts better
|
No Different than the National Rate · Eligible stays 819 · Observed rate 45.79% · Lower 95% interval 47.67% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.15% |
95.27%
1.1 pts worse
|
Numerator 483 · Denominator 513 |
| Falls with major injury | 0.19% |
0.77%
0.6 pts better
|
Numerator 1 · Denominator 513 |
| Discharge self-care score | 56.46% |
53.69%
2.8 pts better
|
Numerator 236 · Denominator 418 |
| Discharge mobility score | 54.31% |
50.94%
3.4 pts better
|
Numerator 227 · Denominator 418 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 513 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 4.56% |
7.12%
2.6 pts better
|
Better than the National Rate · Eligible stays 500 · Observed rate 3.4% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 11.33% |
8.2%
3.1 pts better
|
Numerator 17 · Denominator 150 |
| Staff flu vaccination coverage | 42.91% |
42%
0.9 pts better
|
Numerator 360 · Denominator 839 |
| Discharge function score | 62.2% |
56.45%
5.8 pts better
|
Numerator 260 · Denominator 418 |
| Transfer of health information to provider | 97.38% |
95.95%
1.4 pts better
|
Numerator 409 · Denominator 420 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 12.74% |
25.2%
12.5 pts worse
|
Numerator 33 · Denominator 259 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.1
1.6 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
97.1%
3.2 pts worse
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 92.6% · Q3 92.6% · Q4 100.0% · 4Q avg 93.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.3%
2.4 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 1.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
2.7%
1.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 2.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
3.3%
1.4 pts worse
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 6.9% · Q3 6.2% · Q4 3.0% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.4% |
18.9%
2.5 pts worse
|
19.6%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 19.4% · Q3 21.2% · Q4 24.2% · 4Q avg 21.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.9% |
10.8%
7.9 pts better
|
16.7%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 7.7% · 4Q avg 2.9% · 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 | 24.3% |
15.4%
8.9 pts worse
|
16.3%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
16.1%
3.1 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 13.3% · Q3 12.9% · Q4 20.0% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
0.8%
0.2 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.5% |
15.0%
1.5 pts better
|
19.8%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 26.5% · Q3 7.6% · Q4 9.4% · 4Q avg 13.5% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.2%
0.9 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.0% · Q3 4.3% · Q4 2.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
89.7%
3.3 pts better
|
81.7%
11.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 93.6% · Q3 93.2% · Q4 92.9% · 4Q avg 93.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
12.0%
5.6 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 5.8% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.1% · Q3 0.8% · Q4 0.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
88.0%
0.9 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
25.9%
2.6 pts better
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 21.5% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-03 · Fire 2024-10-03
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-08-31 · Fire 2023-08-31
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
C · Minimal harm
2026-01-15
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2026-02-01
C · Minimal harm
2026-01-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-10
C · Minimal harm
2024-10-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-25
F · Potential for more than minimal harm
2023-08-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-22
C · Minimal harm
2023-08-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
E · Potential for more than minimal harm
2026-01-15
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Not marked corrected
E · Potential for more than minimal harm
2026-01-15
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
D · Potential for more than minimal harm
2024-10-03
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 2024-10-04
E · Potential for more than minimal harm
2023-08-31
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-25
D · Potential for more than minimal harm
2023-08-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-27
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Five Points at Lake Highlands Nursing and Rehab
Dallas, TX
1-star overall rating with 1-star inspections with $72,182 in total fines with 24 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Villages of Lake Highlands
Dallas, TX
2-star overall rating with 1-star inspections with $28,814 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Pure Health Transitional Care At Texas Health Pres
Dallas, TX
5-star overall rating with 5-star inspections with 2 recent health deficiencies
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