8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Dallas, TX
1-star overall rating with 1-star inspections with $193,656 in total fines with 8 recent health deficiencies
6825 Harry Hines Blvd, Dallas, TX
(214) 845-6200
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
150
Certified beds
Average residents
123
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
2011-09-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 2 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
RN hours / resident day
0.22
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.50
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.64
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.35
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.21
CMS adjusted RN staffing hours
Adjusted total hours
2.55
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
87%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
12,529
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
2.37
Performance 7.12% · Measure score 2.37 · Achievement 2.37 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.17
Baseline 75.93% · Performance 67.39% · Measure score 1.17 · Achievement 0 · Improvement 1.17
Adjusted total nurse staffing
0
Baseline 3.65 hours · Performance 2.93 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 6% · Lower 95% interval 6.08% |
| Discharge to community | 58.5% |
50.57%
7.9 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 48.84% · Lower 95% interval 44.57% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94% |
95.27%
1.3 pts worse
|
Numerator 47 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 71.88% |
53.69%
18.2 pts better
|
Numerator 23 · Denominator 32 |
| Discharge mobility score | 59.38% |
50.94%
8.4 pts better
|
Numerator 19 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 6% |
2.29%
3.7 pts worse
|
Numerator 3 · Denominator 50 · Adjusted rate 5.29% |
| Healthcare-associated infections requiring hospitalization | 7.13% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 222 |
| Staff flu vaccination coverage | 4.83% |
42%
37.2 pts worse
|
Numerator 10 · Denominator 207 |
| Discharge function score | 65.63% |
56.45%
9.2 pts better
|
Numerator 21 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 32 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 3.1 · Expected 4.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.1
1.3 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 5.6 · Expected 2.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
97.1%
0.3 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 98.9% · Q3 100.0% · Q4 99.0% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
97.9%
2.7 pts worse
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| 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 3.4% · Q2 5.4% · Q3 3.0% · Q4 1.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
2.7%
1.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.2% · Q4 1.2% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
3.3%
2.7 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.2% |
18.9%
7.7 pts better
|
19.6%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 13.3% · Q3 10.0% · Q4 13.0% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
10.8%
3.6 pts worse
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 13.3% · Q3 16.7% · Q4 17.2% · 4Q avg 14.4% · 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 | 14.6% |
15.4%
0.8 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 15.6% · Q3 22.1% · Q4 9.4% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.0% |
16.1%
0.9 pts worse
|
14.9%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 16.5% · Q3 16.2% · Q4 12.8% · 4Q avg 17.0% · 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 | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.6% |
15.0%
1.4 pts better
|
19.8%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 14.9% · Q3 17.1% · Q4 10.3% · 4Q avg 13.6% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.2%
1.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.7% · Q3 4.3% · Q4 2.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.9% |
89.7%
15.8 pts worse
|
81.7%
7.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 92.6% · Q3 75.9% · Q4 42.7% · 4Q avg 73.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
12.0%
3.5 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 11.1% · Expected 14.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
88.0%
2.9 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
25.9%
4.8 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 25.9% · Expected 29.3% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Quality of Life and Care (7 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Rights (7 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-20
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-10-20
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-02
Fire Safety
Install proper backup exit lighting.
Corrected 2022-09-02
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-02
Fire Safety
Use approved construction type or materials.
Corrected 2022-09-21
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-09-02
Inspection history
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 2026-01-14
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-10-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-10
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-10
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-10
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-06
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-03-06
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-15
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-22
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-17
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-06-17
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-17
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-30
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-30
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-20
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-02-12
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-02-12
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-12
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 2024-02-12
Health
Provide appropriate foot care.
Corrected 2024-01-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-19
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-19
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-19
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-19
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-10-19
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-19
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-10-19
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-10-19
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-19
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 2023-09-02
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-24
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-24
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-18
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-21
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-16
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-16
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 2023-06-16
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 2022-09-02
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-09-02
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-09-02
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 2022-09-02
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-02
Penalties and ownership
Fine · fine $10,361
Fine
Fine · fine $62,504
Fine
Fine · fine $48,641
Fine
Fine · fine $72,150
Fine
Payment Denial · denial start 2024-02-02 · 10 days
10 day denial
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
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