Cycle 1
Health 2025-05-01 · Fire 2025-05-01
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Plano, TX
Carrara
4-star overall rating with 4-star inspections with $18,226 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4501 Tradition Trail, Plano, TX
(469) 969-0866
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
84
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Cantex Continuing Care
Operator or chain grouping
Approved since
2017-07-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 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
0.48
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,814
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.70% · Performance 22.79% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.29
Baseline 9.00% · Performance 6.68% · Measure score 5.29 · Achievement 3.86 · Improvement 5.29
Total nurse turnover
2.31
Performance 54.25% · Measure score 2.31 · Achievement 2.31 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.64
Baseline 3.43 hours · Performance 3.83 hours · Measure score 2.64 · Achievement 2.64 · Improvement 1.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.88% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 184 · Observed rate 16.85% · Lower 95% interval 9.97% |
| Discharge to community | 48.41% |
50.57%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 182 · Observed rate 39.56% · Lower 95% interval 41.15% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 117 · Denominator 117 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 117 |
| Discharge self-care score | 51.56% |
53.69%
2.1 pts worse
|
Numerator 33 · Denominator 64 |
| Discharge mobility score | 29.69% |
50.94%
21.2 pts worse
|
Numerator 19 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 0.85% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 117 · Adjusted rate 0.71% |
| Healthcare-associated infections requiring hospitalization | 6.68% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 6.12% · Lower 95% interval 3.93% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 142 |
| Staff flu vaccination coverage | 29.27% |
42%
12.7 pts worse
|
Numerator 48 · Denominator 164 |
| Discharge function score | 59.38% |
56.45%
2.9 pts better
|
Numerator 38 · Denominator 64 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 50 · Denominator 50 |
| Transfer of health information to patient | 97.62% |
96.28%
1.3 pts better
|
Numerator 41 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 75.41% |
25.2%
50.2 pts better
|
Numerator 46 · Denominator 61 |
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 | 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 | 2.0% |
3.3%
1.3 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 3.5% · Q4 1.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
2.7%
1.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.9% · Q4 1.9% · 4Q avg 1.4% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
18.9%
10 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 7.5% · Q3 8.0% · Q4 9.6% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
10.8%
1.6 pts worse
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 15.6% · Q3 11.1% · Q4 9.5% · 4Q avg 12.4% · 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 | 7.5% |
15.4%
7.9 pts better
|
16.3%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q4 13.1% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.9% |
16.1%
10.2 pts better
|
14.9%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.1% · Q3 4.5% · Q4 13.0% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.3% · 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 | 2.5% |
15.0%
12.5 pts better
|
19.8%
17.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 6.7% · 4Q avg 2.5% |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
4.2%
5.5 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 12.2% · Q3 8.2% · Q4 6.8% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
89.7%
10.2 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
88.0%
11.6 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-02-24 · Fire 2023-02-24
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-05
F · Potential for more than minimal harm
2025-05-01
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-05-12
F · Potential for more than minimal harm
2025-05-01
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-05-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-12
F · Potential for more than minimal harm
2024-04-05
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-05-16
F · Potential for more than minimal harm
2024-04-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-04-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-04-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-04-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-16
E · Potential for more than minimal harm
2024-04-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-16
F · Potential for more than minimal harm
2023-02-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Not marked corrected
D · Potential for more than minimal harm
2025-09-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-05-01
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 2025-05-02
D · Potential for more than minimal harm
2024-12-12
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 2024-07-28
E · Potential for more than minimal harm
2024-05-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-27
E · Potential for more than minimal harm
2024-05-22
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 2024-05-27
J · Immediate jeopardy
2024-04-05
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 2023-08-03
D · Potential for more than minimal harm
2024-04-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-02
G · Actual harm
2023-07-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-23
G · Actual harm
2023-07-20
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 2023-07-23
D · Potential for more than minimal harm
2023-07-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-23
D · Potential for more than minimal harm
2023-07-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-07-03
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 2023-07-05
D · Potential for more than minimal harm
2023-04-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-04-24
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 2023-04-25
D · Potential for more than minimal harm
2023-04-24
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 2023-04-25
D · Potential for more than minimal harm
2023-03-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-03-03
E · Potential for more than minimal harm
2023-02-24
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 2023-02-26
D · Potential for more than minimal harm
2023-02-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-25
D · Potential for more than minimal harm
2023-02-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-16
Penalties and ownership
What sits behind the stars
$10,036
2024-04-05
Fine
Fine · fine $10,036
Fine
$8,190
2023-07-03
Fine
Fine · fine $8,190
Fine
Ownership
Dallas County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Castaneda, Edmundo
Corporate Officer · Individual
Cerise, Frederick
Corporate Officer · Individual
Garcia, Jennifer
Operational/Managerial Control · Individual
Plano Continuing Care Center Ltd. Co.
Operational/Managerial Control · Organization
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1-star overall rating with 1-star inspections with abuse icon flag with $79,867 in total fines with 25 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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