Cycle 1
Health 2025-08-22 · Fire 2025-08-22
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Richardson, TX
Cottonwood Creek Healthcare Community
5-star overall rating with 4-star inspections with $7,443 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1111 W Shore Dr, Richardson, TX
(972) 783-8000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Dynasty Healthcare Group
Operator or chain grouping
Approved since
1994-03-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
0.68
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.63
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.82
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.80
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,731
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
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
0
Baseline 62.50% · Performance 63.46% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.54
Baseline 3 hours · Performance 4.37 hours · Measure score 4.54 · Achievement 4.54 · Improvement 4.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 14 · 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 16 · 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 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · 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 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 20.45% |
8.2%
12.2 pts better
|
Numerator 9 · Denominator 44 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 90 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · 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 | 98.0% |
97.1%
0.9 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 97.6% · Q3 100.0% · Q4 100.0% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.3% |
97.9%
4.6 pts worse
|
95.5%
2.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| 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 · 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 who have depressive symptoms | 6.6% |
2.7%
3.9 pts worse
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 10.0% · Q3 8.3% · Q4 3.2% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
3.3%
1.8 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.1% |
18.9%
0.2 pts worse
|
19.6%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 18.9% · Q3 16.7% · Q4 20.0% · 4Q avg 19.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
10.8%
0.3 pts worse
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 8.3% · Q3 14.8% · Q4 17.4% · 4Q avg 11.1% · 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 | 7.7% |
15.4%
7.7 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
16.1%
5.5 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 14.3% · Q3 18.8% · Q4 0.0% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.5%
0.8 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.8% · Q4 1.8% · 4Q avg 1.3% · 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 | 12.1% |
15.0%
2.9 pts better
|
19.8%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 7.7% · Q3 19.2% · Q4 15.0% · 4Q avg 12.1% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
4.2%
0.9 pts worse
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 7.3% · Q4 6.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.2% |
89.7%
12.5 pts worse
|
81.7%
4.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 78.1% · Q3 97.0% · Q4 96.0% · 4Q avg 77.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
1.5%
2.5 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.7% |
88.0%
23.3 pts worse
|
79.7%
15 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-30 · Fire 2024-07-30
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-04-20 · Fire 2023-04-20
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-08-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-29
F · Potential for more than minimal harm
2024-07-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-07-30
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-07-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-07-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-12
F · Potential for more than minimal harm
2023-04-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-28
F · Potential for more than minimal harm
2023-04-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-22
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 2025-09-12
E · Potential for more than minimal harm
2025-08-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-22
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 2025-08-29
D · Potential for more than minimal harm
2025-05-01
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 2025-05-28
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-08
F · Potential for more than minimal harm
2024-07-30
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 2024-09-12
E · Potential for more than minimal harm
2024-07-30
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 2024-09-12
E · Potential for more than minimal harm
2024-07-30
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 2024-09-12
E · Potential for more than minimal harm
2024-07-30
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 2024-09-12
D · Potential for more than minimal harm
2023-12-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-12-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-11-02
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 2023-11-10
D · Potential for more than minimal harm
2023-11-02
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 2023-11-10
G · Actual harm
2023-09-06
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 2023-09-15
D · Potential for more than minimal harm
2023-06-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-06-28
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 2023-07-07
E · Potential for more than minimal harm
2023-04-20
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 2023-04-28
E · Potential for more than minimal harm
2023-04-20
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 2023-04-28
D · Potential for more than minimal harm
2023-04-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-04-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-04-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-04-20
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
$7,443
2023-09-06
Fine
Fine · fine $7,443
Fine
Ownership
Olney- Hamilton Hospital District
5% Or Greater Direct Ownership Interest · Organization
Cohen, Bradford
Operational/Managerial Control · Individual
Dhc Opco-Richardson, LLC
Operational/Managerial Control · Organization
Huff, Michael
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Richardson Nursing And Rehabilitation
Richardson, TX
1-star overall rating with 2-star inspections with $36,140 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
The Plaza At Richardson
Richardson, TX
3-star overall rating with 3-star inspections with $7,763 in total fines with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
The Reserve At Richardson
Richardson, TX
3-star overall rating with 3-star inspections with $29,835 in total fines with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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