Cycle 1
Health 2024-12-04 · Fire 2024-12-04
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Midlothian, TX
Midlothian Healthcare Center
2-star overall rating with 3-star inspections with $50,830 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
900 George Hopper Rd, Midlothian, TX
(972) 775-5105
Overall
2 / 5
CMS overall stars
Health inspections
3 / 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
120
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2015-02-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
Hours and turnover
RN hours / resident day
0.22
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.95
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
3.20
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,303
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.81
Baseline 19.27% · Performance 21.06% · Measure score 0.81 · Achievement 0.81 · Improvement 0
Healthcare-associated infections
0
Baseline 9.00% · Performance 9.32% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 82.14% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.90
Baseline 2.30 hours · Performance 3.14 hours · Measure score 1.90 · Achievement 0 · Improvement 1.90
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.24% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 4.76% · Lower 95% interval 6.17% |
| Discharge to community | 46.24% |
50.57%
4.3 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 40.79% · Lower 95% interval 37.78% |
| Medicare spending per beneficiary | 1.51 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 96% |
95.27%
0.7 pts better
|
Numerator 48 · Denominator 50 |
| Falls with major injury | 2% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 50 |
| Discharge self-care score | 63.33% |
53.69%
9.6 pts better
|
Numerator 19 · Denominator 30 |
| Discharge mobility score | 53.33% |
50.94%
2.4 pts better
|
Numerator 16 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 6% |
2.29%
3.7 pts worse
|
Numerator 3 · Denominator 50 · Adjusted rate 6.25% |
| Healthcare-associated infections requiring hospitalization | 9.32% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 18.92% · Lower 95% interval 5.66% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 128 |
| Staff flu vaccination coverage | 3.05% |
42%
39 pts worse
|
Numerator 6 · Denominator 197 |
| Discharge function score | 43.33% |
56.45%
13.1 pts worse
|
Numerator 13 · Denominator 30 |
| Transfer of health information to provider | 95.45% |
95.95%
0.5 pts worse
|
Numerator 21 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · 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 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.1 |
2.1
1 pts worse
|
1.9
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
97.1%
1.6 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 97.5% · Q4 98.8% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
97.9%
0.8 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.3%
1.3 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.8% · Q3 2.5% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
2.7%
1.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
3.3%
1.5 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 0.0% · Q4 3.5% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
18.9%
4.7 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 14.8% · Q3 17.5% · Q4 5.3% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.2% |
10.8%
6.6 pts better
|
16.7%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 2.4% · Q3 2.1% · Q4 1.9% · 4Q avg 4.2% · 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 | 31.3% |
15.4%
15.9 pts worse
|
16.3%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 27.2% · Q4 41.3% · 4Q avg 31.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.0% |
16.1%
10.9 pts worse
|
14.9%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 29.4% · Q4 25.0% · 4Q avg 27.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 | 22.4% |
15.0%
7.4 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 22.9% · Q3 17.3% · Q4 20.6% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.2%
2.2 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.0% · Q3 2.3% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
89.7%
8.8 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 98.4% · Q3 99.2% · Q4 100.0% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
12.0%
3.1 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 9.3% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.6% · Q4 1.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.1% |
88.0%
5.1 pts better
|
79.7%
13.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
25.9%
8 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 18.6% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-26 · Fire 2023-10-26
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
10 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-09-09 · Fire 2022-09-09
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-04
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-04-14
F · Potential for more than minimal harm
2024-12-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-26
D · Potential for more than minimal harm
2024-12-04
K321 · Smoke Deficiencies
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 2025-03-27
D · Potential for more than minimal harm
2024-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-26
F · Potential for more than minimal harm
2023-10-26
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-02-26
F · Potential for more than minimal harm
2023-10-26
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-02-26
F · Potential for more than minimal harm
2023-10-26
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-02-26
F · Potential for more than minimal harm
2023-10-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-26
F · Potential for more than minimal harm
2023-10-26
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-03-06
E · Potential for more than minimal harm
2023-10-26
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-02-23
E · Potential for more than minimal harm
2023-10-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-07
E · Potential for more than minimal harm
2023-10-26
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-03-05
D · Potential for more than minimal harm
2023-10-26
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 2024-02-26
D · Potential for more than minimal harm
2023-10-26
K321 · Smoke Deficiencies
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 2024-03-07
D · Potential for more than minimal harm
2022-09-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Not marked corrected
D · Potential for more than minimal harm
2025-12-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-03
G · Actual harm
2024-12-18
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 2025-01-22
G · Actual harm
2024-12-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-12-04
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-12-23
E · Potential for more than minimal harm
2024-12-04
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 2024-12-23
E · Potential for more than minimal harm
2024-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-23
D · Potential for more than minimal harm
2024-12-04
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 2024-12-23
G · Actual harm
2023-10-26
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 2023-11-14
F · Potential for more than minimal harm
2023-10-26
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 2023-11-14
F · Potential for more than minimal harm
2023-10-26
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-14
J · Immediate jeopardy
2023-08-28
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 2023-08-29
J · Immediate jeopardy
2023-08-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-08-28
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-08-29
E · Potential for more than minimal harm
2022-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-19
Penalties and ownership
What sits behind the stars
$2,447
2023-09-11
Fine
Fine · fine $2,447
Fine
$2,098
2023-09-05
Fine
Fine · fine $2,098
Fine
$42,091
2023-08-28
Fine
Fine · fine $42,091
Fine
$4,194
2023-08-14
Fine
Fine · fine $4,194
Fine
Ownership
West Wharton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Hawkins Spring Healthcare LLC
Operational/Managerial Control · Organization
Keetch, Chad
Corporate Officer · Individual
Patel, Deepak
Operational/Managerial Control · Individual
Stark, Katherine
Operational/Managerial Control · Individual
Thompson, Johnny
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Midtowne Meadows Health & Rehab
Midlothian, TX
5-star overall rating with 5-star inspections with $20,131 in total fines with 1 fire-safety deficiencies in the latest cycle
#2
Mansfield Medical Lodge
Mansfield, TX
4-star overall rating with 4-star inspections with $6,032 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Cedar Hill Healthcare Center
Cedar Hill, TX
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
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