Cycle 1
Health 2025-09-11 · Fire 2025-09-11
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Dallas, TX
Continuing Care At Highland Springs
3-star overall rating with 2-star inspections with $45,705 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
7910 Frankford Road, Dallas, TX
(972) 656-3500
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Erickson Senior Living
Operator or chain grouping
Approved since
2013-02-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 3 health / 5 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
1.05
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.92
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
1.25
CMS adjusted RN staffing hours
Adjusted total hours
5.19
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,771
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.84
Composite VBP score used to determine payment impact.
Payment multiplier
1.0015
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.83
Baseline 20.57% · Performance 18.27% · Measure score 6.83 · Achievement 6.83 · Improvement 6
Healthcare-associated infections
3.13
Baseline 6.44% · Performance 6.90% · Measure score 3.13 · Achievement 3.13 · Improvement 0
Total nurse turnover
3.75
Baseline 41.67% · Performance 48.33% · Measure score 3.75 · Achievement 3.75 · Improvement 0
Adjusted total nurse staffing
5.43
Baseline 3.94 hours · Performance 4.62 hours · Measure score 5.43 · Achievement 5.43 · Improvement 3.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.65% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 4.23% · Lower 95% interval 6.54% |
| Discharge to community | 48.56% |
50.57%
2 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 47.46% · Lower 95% interval 37.67% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 34 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 21.88% |
53.69%
31.8 pts worse
|
Numerator 7 · Denominator 32 |
| Discharge mobility score | 31.25% |
50.94%
19.7 pts worse
|
Numerator 10 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.9% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 4.88% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 98 |
| Staff flu vaccination coverage | 50% |
42%
8 pts better
|
Numerator 65 · Denominator 130 |
| Discharge function score | 25% |
56.45%
31.5 pts worse
|
Numerator 8 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · 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 | 84.3% |
97.1%
12.8 pts worse
|
93.4%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.3% · Q2 87.8% · Q3 92.7% · Q4 100.0% · 4Q avg 84.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
97.9%
2.4 pts worse
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.3%
0.2 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.4% · Q3 4.9% · Q4 2.6% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
2.7%
1.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
3.3%
2.8 pts worse
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.4% · Q3 2.9% · Q4 6.1% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
18.9%
6.8 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 15.2% · Q3 8.8% · Q4 9.1% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
10.8%
5.3 pts worse
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 17.2% · Q3 21.9% · Q4 13.3% · 4Q avg 16.1% · 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 | 31.0% |
15.4%
15.6 pts worse
|
16.3%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.4% |
16.1%
10.3 pts worse
|
14.9%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.3% · Q2 25.8% · Q3 18.8% · Q4 9.4% · 4Q avg 26.4% · 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 | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.3% |
15.0%
7.3 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 15.3% · Q3 23.1% · Q4 29.5% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
4.2%
2.2 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 3.6% · Q3 5.9% · Q4 6.7% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.4% |
89.7%
31.3 pts worse
|
81.7%
23.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.1% · Q2 50.0% · Q3 64.0% · Q4 69.6% · 4Q avg 58.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 4.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
88.0%
8.4 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-01 · Fire 2024-08-01
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-24 · Fire 2023-05-24
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-09-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-10-23
F · Potential for more than minimal harm
2024-08-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-08-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-10
F · Potential for more than minimal harm
2023-05-24
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-05-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-05-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-07
Inspection history
Recent health citations
K · Immediate jeopardy
2026-01-21
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2026-01-22
J · Immediate jeopardy
2026-01-21
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 2026-01-22
E · Potential for more than minimal harm
2025-09-11
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 2025-10-23
D · Potential for more than minimal harm
2025-09-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-23
D · Potential for more than minimal harm
2025-09-11
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 2025-10-23
F · Potential for more than minimal harm
2024-08-01
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-01
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-01
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-01
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 2024-09-10
E · Potential for more than minimal harm
2024-08-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-10
E · Potential for more than minimal harm
2024-08-01
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 2024-09-10
D · Potential for more than minimal harm
2024-08-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-01
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 2024-09-10
E · Potential for more than minimal harm
2024-02-08
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 2023-12-11
D · Potential for more than minimal harm
2024-02-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-05-24
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-05-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-07
Penalties and ownership
What sits behind the stars
$45,705
2026-01-21
Fine
Fine · fine $45,705
Fine
Ownership
National Senior Communities, Inc
5% Or Greater Direct Ownership Interest · Organization
Oak Investment Trust Ii
5% Or Greater Indirect Ownership Interest · Organization
Oak Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Ancheta, Heather
Operational/Managerial Control · Individual
Brown, Ian
Corporate Director · Individual
Brown, Patricia
Corporate Director · Individual
Butler, Richard
Operational/Managerial Control · Individual
Clupper, Katherine
Corporate Director · Individual
Colins, Mary
Corporate Director · Individual
Colins, Mary
Corporate Officer · Individual
Embley, Mark
Operational/Managerial Control · Individual
Embley, Mark
Corporate Officer · Individual
Erickson Senior Living LLC
Operational/Managerial Control · Organization
Erstad, Eileen
Corporate Director · Individual
Erstad, Eileen
Corporate Officer · Individual
Gantert, Neal
Operational/Managerial Control · Individual
Gantert, Neal
Corporate Officer · Individual
Hall, John
Operational/Managerial Control · Individual
Hall, John
Corporate Officer · Individual
Jacque, Zina
Corporate Director · Individual
Leonard, Monty
Corporate Director · Individual
Moscato, Mary
Corporate Director · Individual
National Senior Communities, Inc
Operational/Managerial Control · Organization
Paulk, Pamela
Corporate Director · Individual
Paulk, Pamela
Corporate Officer · Individual
Pomeranz, William
Corporate Director · Individual
Reel, Stephanie
Corporate Director · Individual
Roskiewicz, Michael
Corporate Director · Individual
Sawicki, Scott
Corporate Officer · Individual
Sharp, Russel
Corporate Director · Individual
Stiner, Pamela
Operational/Managerial Control · Individual
Stiner, Pamela
Corporate Officer · Individual
Studley, Jill
Operational/Managerial Control · Individual
Sweetser, Christian
Operational/Managerial Control · Individual
Tyler, Daniel
Corporate Officer · Individual
Wallick, Daniel
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Healthcare Resort Of Plano
Plano, TX
3-star overall rating with 3-star inspections with $16,438 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Hillcrest Of North Dallas
Dallas, TX
1-star overall rating with 1-star inspections with $236,449 in total fines with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Carrara
Plano, TX
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
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