Cycle 1
Health 2024-11-07 · Fire 2024-11-07
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Dallas, TX
Lakewest Rehabilitation and Skilled Care
1-star overall rating with 2-star inspections with $21,645 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2450 Bickers St, Dallas, TX
(214) 879-0888
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
92
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Momentum Skilled Services
Operator or chain grouping
Approved since
2011-05-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 2 health / 1 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
0.16
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.18
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
70%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,081
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.99
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.45
Baseline 19.74% · Performance 20.76% · Measure score 1.45 · Achievement 1.45 · Improvement 0
Healthcare-associated infections
3.38
Baseline 7.41% · Performance 6.83% · Measure score 3.38 · Achievement 3.38 · Improvement 1.91
Total nurse turnover
0
Baseline 70.00% · Performance 74.75% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.76
Baseline 3.15 hours · Performance 3.29 hours · Measure score 0.76 · Achievement 0.76 · Improvement 0.04
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 12.7% · Lower 95% interval 6.88% |
| Discharge to community | 40.9% |
50.57%
9.7 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 28.57% · Lower 95% interval 29.07% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 66.67% |
95.27%
28.6 pts worse
|
Numerator 36 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 58.62% |
53.69%
4.9 pts better
|
Numerator 17 · Denominator 29 |
| Discharge mobility score | 41.38% |
50.94%
9.6 pts worse
|
Numerator 12 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 1.85% |
2.29%
0.4 pts better
|
Numerator 1 · Denominator 54 · Adjusted rate 1.4% |
| Healthcare-associated infections requiring hospitalization | 6.82% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 6.98% · Lower 95% interval 3.05% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 104 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 55.17% |
56.45%
1.3 pts worse
|
Numerator 16 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · 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 | 38.71% |
25.2%
13.5 pts better
|
Numerator 12 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.2 |
2.1
2.1 pts worse
|
1.8
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 3.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
97.1%
0.8 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.8% · Q3 96.6% · Q4 97.6% · 4Q avg 97.9% |
| 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 | 0.6% |
3.3%
2.7 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
2.7%
1.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.5% · Q3 1.3% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 2.0% |
3.3%
1.3 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 5.0% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.6% |
18.9%
0.7 pts worse
|
19.6%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 15.4% · Q3 18.1% · Q4 21.8% · 4Q avg 19.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.7% |
10.8%
7.9 pts worse
|
16.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 18.0% · Q3 22.9% · Q4 18.4% · 4Q avg 18.7% · 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 | 16.6% |
15.4%
1.2 pts worse
|
16.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 5.1% · Q3 10.0% · Q4 24.9% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
16.1%
3.9 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 12.2% · Q3 16.2% · Q4 27.0% · 4Q avg 20.0% · 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 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
15.0%
3.6 pts worse
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 8.9% · Q3 16.7% · Q4 30.8% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.2%
0.8 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.7% · Q3 3.2% · Q4 2.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
89.7%
4.4 pts better
|
81.7%
12.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 95.4% · Q3 95.4% · Q4 95.7% · 4Q avg 94.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
12.0%
1.4 pts worse
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 14.6% · Expected 12.1% · 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 | 93.8% |
88.0%
5.8 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.7% |
25.9%
2.8 pts worse
|
23.9%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.7% · Observed 29.2% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-09-01 · Fire 2022-09-01
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-07
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 2024-12-05
E · Potential for more than minimal harm
2023-10-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-26
C · Minimal harm
2022-09-01
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-09-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-14
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2026-01-18
D · Potential for more than minimal harm
2025-08-06
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 2025-09-04
D · Potential for more than minimal harm
2025-06-13
F761 · Pharmacy Service Deficiencies
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 2025-06-16
E · Potential for more than minimal harm
2025-05-13
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 2025-05-20
E · Potential for more than minimal harm
2025-03-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-02-24
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-11-07
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 2024-12-03
E · Potential for more than minimal harm
2024-11-07
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 2024-12-03
E · Potential for more than minimal harm
2024-11-07
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 2024-12-03
E · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-07
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-07
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-09-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-08-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-09-18
E · Potential for more than minimal harm
2023-10-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-19
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 2023-11-16
D · Potential for more than minimal harm
2023-10-19
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-11-16
E · Potential for more than minimal harm
2023-10-05
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 2023-10-26
E · Potential for more than minimal harm
2023-10-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-10-26
E · Potential for more than minimal harm
2023-10-05
F761 · Pharmacy Service Deficiencies
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 2023-10-26
E · Potential for more than minimal harm
2023-10-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-05
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-10-05
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 2023-10-26
D · Potential for more than minimal harm
2023-10-05
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 2023-10-26
E · Potential for more than minimal harm
2023-06-13
F761 · Pharmacy Service Deficiencies
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 2023-06-26
D · Potential for more than minimal harm
2023-06-13
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-06-13
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 2023-06-26
D · Potential for more than minimal harm
2023-05-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-20
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2023-05-25
Penalties and ownership
What sits behind the stars
$21,645
2025-06-11
Fine
Fine · fine $21,645
Fine
Ownership
Dallas County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bradley, Shannan
Corporate Director · Individual
Caretrust Reit Inc
5% Or Greater Mortgage Interest · Organization
Castaneda, Edmundo
Corporate Officer · Individual
Cerise, Frederick
Corporate Officer · Individual
Ctr Partnership LP
5% Or Greater Mortgage Interest · Organization
Next Gen P, LLC
Operational/Managerial Control · Organization
Threadgill, Sharlyn
Operational/Managerial Control · Individual
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