Cycle 1
Health 2025-07-03 · Fire 2025-07-03
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Van Alstyne, TX
Meadowbrook Care Center
2-star overall rating with 2-star inspections with $30,956 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
632 Windsor Way, Van Alstyne, TX
(903) 482-6455
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
30
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
1993-06-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing
LPN hours / resident day
0.85
Licensed practical nurse staffing
Aide hours / resident day
2.00
Nurse aide staffing
Weekend hours
3.03
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.1 |
2.1
2 pts worse
|
1.9
2.2 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
97.1%
5.8 pts worse
|
93.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.9% |
97.9%
9 pts worse
|
95.5%
6.6 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.3%
0.4 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
18.9%
3.9 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
10.8%
0.1 pts worse
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.4% |
15.4%
4 pts better
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.2% |
16.1%
3.9 pts better
|
14.9%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.5% |
15.0%
10.5 pts better
|
19.8%
15.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.2%
2.3 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 39.2% |
89.7%
50.5 pts worse
|
81.7%
42.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.1% |
12.0%
10.1 pts worse
|
12.0%
10.1 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.0% |
88.0%
40 pts worse
|
79.7%
31.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
25.9%
3.8 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2024-06-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2023-04-06 · Fire 2023-04-06
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-11
F · Potential for more than minimal harm
2025-07-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-07-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-11
C · Minimal harm
2025-07-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-11
E · Potential for more than minimal harm
2024-06-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-17
C · Minimal harm
2024-06-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-07-17
D · Potential for more than minimal harm
2023-04-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-15
C · Minimal harm
2023-04-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-28
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-31
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.
Not marked corrected
E · Potential for more than minimal harm
2026-01-31
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Not marked corrected
E · Potential for more than minimal harm
2026-01-31
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.
Not marked corrected
E · Potential for more than minimal harm
2025-07-03
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-07-03
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 2025-07-31
E · Potential for more than minimal harm
2025-07-03
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 2025-07-31
E · Potential for more than minimal harm
2025-07-03
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 2025-07-31
D · Potential for more than minimal harm
2025-07-03
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 2025-07-31
D · Potential for more than minimal harm
2025-07-03
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 2025-07-31
D · Potential for more than minimal harm
2025-07-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-03
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 2025-07-31
D · Potential for more than minimal harm
2025-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-31
E · Potential for more than minimal harm
2024-06-06
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-17
G · Actual harm
2023-06-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-31
F · Potential for more than minimal harm
2023-04-06
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 2023-05-04
E · Potential for more than minimal harm
2023-04-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-04
Penalties and ownership
What sits behind the stars
$21,645
2026-01-31
Fine
Fine · fine $21,645
Fine
$9,311
2023-06-30
Fine
Fine · fine $9,311
Fine
Ownership
Dallas County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Callies, Marilyn
Corporate Director · Individual
Cerise, Frederick
Corporate Director · Individual
Dallas County Hospital District
Operational/Managerial Control · Organization
Dohlman, John
W-2 Managing Employee · Individual
Meadowbrook Health Care LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Cedar Hollow Rehabilitation Center
Sherman, TX
2-star overall rating with 2-star inspections with $39,697 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Settlers Ridge Care Center
Celina, TX
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Focused Care at Sherman
Sherman, TX
1-star overall rating with 1-star inspections with abuse icon flag with $82,570 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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