Cycle 1
Health 2025-04-24 · Fire 2025-04-24
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Flower Mound, TX
Hollymead
3-star overall rating with 3-star inspections with $9,110 in total fines with 10 recent health deficiencies
4101 Long Prairie Road, Flower Mound, TX
(214) 285-3200
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cantex Continuing Care
Operator or chain grouping
Approved since
2014-09-24
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
0.47
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.73
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.36
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
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,978
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.96% · Performance 22.44% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.88
Baseline 7.49% · Performance 7.57% · Measure score 0.88 · Achievement 0.88 · Improvement 0
Total nurse turnover
5.12
Baseline 100.00% · Performance 57.78% · Measure score 5.12 · Achievement 1.44 · Improvement 5.12
Adjusted total nurse staffing
1.38
Baseline 2.90 hours · Performance 3.44 hours · Measure score 1.38 · Achievement 1.29 · Improvement 1.38
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.34% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 144 · Observed rate 14.58% · Lower 95% interval 9.04% |
| Discharge to community | 53.14% |
50.57%
2.6 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 46.83% · Lower 95% interval 45.36% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 130 · Denominator 130 |
| Falls with major injury | 0.77% |
0.77%
About the same
|
Numerator 1 · Denominator 130 |
| Discharge self-care score | 56.79% |
53.69%
3.1 pts better
|
Numerator 46 · Denominator 81 |
| Discharge mobility score | 32.1% |
50.94%
18.8 pts worse
|
Numerator 26 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 2.31% |
2.29%
About the same
|
Numerator 3 · Denominator 130 · Adjusted rate 2.34% |
| Healthcare-associated infections requiring hospitalization | 7.57% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 8.24% · Lower 95% interval 4.36% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 138 |
| Staff flu vaccination coverage | 13.33% |
42%
28.7 pts worse
|
Numerator 28 · Denominator 210 |
| Discharge function score | 51.85% |
56.45%
4.6 pts worse
|
Numerator 42 · Denominator 81 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 45 · Denominator 45 |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 57 · Denominator 60 |
| Resident COVID-19 vaccinations up to date | 29.58% |
25.2%
4.4 pts better
|
Numerator 21 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.4 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 76.5% |
97.1%
20.6 pts worse
|
93.4%
16.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 65.3% · Q4 36.2% · 4Q avg 76.5% |
| 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 | 2.7% |
3.3%
0.6 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.6% · Q3 1.4% · Q4 2.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
3.3%
0.2 pts worse
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.0% · Q3 5.0% · Q4 3.1% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.2% |
18.9%
0.3 pts worse
|
19.6%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 20.0% · Q3 16.1% · Q4 16.9% · 4Q avg 19.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.0% |
10.8%
8.8 pts better
|
16.7%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 0.0% · Q3 3.9% · Q4 0.0% · 4Q avg 2.0% · 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 | 13.2% |
15.4%
2.2 pts better
|
16.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 17.2% · Q3 12.1% · Q4 16.3% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
16.1%
4.2 pts better
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 8.8% · Q3 6.5% · Q4 10.9% · 4Q avg 11.9% · 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 | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
15.0%
2.7 pts worse
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 9.0% · Q3 22.4% · Q4 22.6% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
4.2%
1.5 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.4% · Q3 7.2% · Q4 5.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.5% |
89.7%
23.2 pts worse
|
81.7%
15.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 81.0% · Q3 59.4% · Q4 32.9% · 4Q avg 66.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
12.0%
2.5 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 15.5% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.7% · Q4 2.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.5% |
88.0%
9.5 pts worse
|
79.7%
1.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.5% |
25.9%
2.6 pts worse
|
23.9%
4.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.5% · Observed 28.2% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-02-09 · Fire 2023-02-09
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-15
F · Potential for more than minimal harm
2024-03-21
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-03-21
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-03-21
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-03-21
K261 · Egress Deficiencies
Fire Safety
Have properly spaced exits within rooms.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-03-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-05-02
F · Potential for more than minimal harm
2023-02-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-03-02
E · Potential for more than minimal harm
2023-02-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-24
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 2025-05-19
E · Potential for more than minimal harm
2025-04-24
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 2025-04-26
E · Potential for more than minimal harm
2025-04-24
F688 · Quality of Life and Care Deficiencies
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 2025-05-18
E · Potential for more than minimal harm
2025-04-24
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 2025-04-26
E · Potential for more than minimal harm
2025-04-24
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 2025-04-26
D · Potential for more than minimal harm
2025-04-24
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-24
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 2025-05-02
D · Potential for more than minimal harm
2025-04-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-26
D · Potential for more than minimal harm
2025-02-20
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
G · Actual harm
2025-01-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-27
D · Potential for more than minimal harm
2025-01-02
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 2025-01-27
D · Potential for more than minimal harm
2024-08-07
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 2024-09-06
D · Potential for more than minimal harm
2024-08-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-07
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-04-30
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 2024-05-01
E · Potential for more than minimal harm
2024-03-21
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 2024-03-22
D · Potential for more than minimal harm
2024-03-21
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 2024-03-22
D · Potential for more than minimal harm
2024-03-21
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-03-21
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-27
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 2024-02-28
D · Potential for more than minimal harm
2023-03-16
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-03-16
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-10
E · Potential for more than minimal harm
2023-02-09
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 2023-02-10
D · Potential for more than minimal harm
2023-02-09
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 2023-02-10
D · Potential for more than minimal harm
2023-02-09
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 2023-02-10
D · Potential for more than minimal harm
2023-02-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-10
Penalties and ownership
What sits behind the stars
$9,110
2025-01-02
Fine
Fine · fine $9,110
Fine
Ownership
Castaneda, Edmundo
Corporate Officer · Individual
Cerise, Frederick
Corporate Officer · Individual
Dean, Lisa
Operational/Managerial Control · Individual
Hollymead Continuing Care Center Ltd. Co.
Operational/Managerial Control · Organization
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