Cedar Hill, TX
3-star overall rating with 3-star inspections with $16,799 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
224 W Pleasant Run Rd, Cedar Hill, TX
(972) 291-5977
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
125
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cantex Continuing Care
Operator or chain grouping
Approved since
2006-08-31
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
RN hours / resident day
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.72
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
9,604
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7
Baseline 24.19% · Performance 18.82% · Measure score 7 · Achievement 5.64 · Improvement 7
Healthcare-associated infections
0
Baseline 6.43% · Performance 8.21% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 65.26% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.26
Baseline 3.34 hours · Performance 3.72 hours · Measure score 2.26 · Achievement 2.26 · Improvement 1.06
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.78% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 14.88% · Lower 95% interval 8.64% |
| Discharge to community | 56.2% |
50.57%
5.6 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 46.9% · Lower 95% interval 46.57% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 90.12% |
95.27%
5.1 pts worse
|
Numerator 73 · Denominator 81 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 81 |
| Discharge self-care score | 59.26% |
53.69%
5.6 pts better
|
Numerator 32 · Denominator 54 |
| Discharge mobility score | 61.11% |
50.94%
10.2 pts better
|
Numerator 33 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 1.23% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 81 · Adjusted rate 1.3% |
| Healthcare-associated infections requiring hospitalization | 8.21% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 10.11% · Lower 95% interval 5.1% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 123 |
| Staff flu vaccination coverage | 30.98% |
42%
11 pts worse
|
Numerator 57 · Denominator 184 |
| Discharge function score | 68.52% |
56.45%
12.1 pts better
|
Numerator 37 · Denominator 54 |
| Transfer of health information to provider | 88.89% |
95.95%
7.1 pts worse
|
Numerator 24 · Denominator 27 |
| Transfer of health information to patient | 92.11% |
96.28%
4.2 pts worse
|
Numerator 35 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 22.64% |
25.2%
2.6 pts worse
|
Numerator 12 · Denominator 53 |
Quality measures
| 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 | 0.4% |
3.3%
2.9 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · 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 | 0.5% |
3.3%
2.8 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% |
| 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 8.7% · Q2 10.0% · Q3 5.4% · Q4 2.0% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
10.8%
7.7 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.4% · Q3 2.2% · Q4 2.4% · 4Q avg 3.1% · 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 | 24.2% |
15.4%
8.8 pts worse
|
16.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
16.1%
3.4 pts better
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 16.2% · Q3 4.8% · Q4 9.5% · 4Q avg 12.7% · 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 | 0.0% |
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 | 8.5% |
15.0%
6.5 pts better
|
19.8%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 16.4% · Q3 3.3% · Q4 6.7% · 4Q avg 8.5% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
4.2%
0.5 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.9% · Q3 4.5% · Q4 10.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
89.7%
7 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 94.8% · Q3 97.1% · Q4 100.0% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
12.0%
1 pts better
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 12.2% · Expected 12.3% · Used in QM five-star |
| 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% · Q3 0.0% · Q4 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 | 95.3% |
88.0%
7.3 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
25.9%
3.8 pts better
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 26.8% · Expected 28.9% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-25
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-04-25
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-22
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-03-22
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-22
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-22
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-03-22
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-17
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-17
Inspection history
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-25
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-25
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-25
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-18
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 2024-10-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-18
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-18
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-03-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-03-22
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-22
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-22
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2023-06-13
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-13
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2023-06-13
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-06-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-13
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2023-06-13
Health
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected 2023-06-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-10
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-10
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-02-10
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 2023-02-10
Penalties and ownership
Fine · fine $16,799
Fine
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Nearby options
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1-star overall rating with 2-star inspections with $22,503 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Duncanville, TX
3-star overall rating with 4-star inspections with $38,522 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Duncanville, TX
1-star overall rating with 1-star inspections with $116,171 in total fines with 17 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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