Cycle 1
Health 2025-09-04 · Fire 2025-09-04
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Midlothian, TX
Midtowne Meadows Health & Rehab
5-star overall rating with 5-star inspections with $20,131 in total fines with 1 fire-safety deficiencies in the latest cycle
110 Dylan Way, Midlothian, TX
(972) 775-5538
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2023-06-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.21
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.25
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
0.21
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,623
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.38
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
How the VBP score is built
Readmission
0
Performance 25.43% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.27% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.41
Performance 4.05 hours · Measure score 3.41 · Achievement 3.41 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.66% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 7.94% · Lower 95% interval 6.61% |
| Discharge to community | 41.76% |
50.57%
8.8 pts worse
|
Worse than the National Rate · Eligible stays 129 · Observed rate 35.66% · Lower 95% interval 34.47% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 94.03% |
95.27%
1.2 pts worse
|
Numerator 189 · Denominator 201 |
| Falls with major injury | 0.5% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 201 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 40 · Denominator 120 |
| Discharge mobility score | 28.33% |
50.94%
22.6 pts worse
|
Numerator 34 · Denominator 120 |
| Pressure ulcers or injuries, new or worsened | 1% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 201 · Adjusted rate 0.85% |
| Healthcare-associated infections requiring hospitalization | 8.27% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 157 · Observed rate 9.55% · Lower 95% interval 5.08% |
| Staff COVID-19 vaccination coverage | 7.98% |
8.2%
0.2 pts worse
|
Numerator 15 · Denominator 188 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 34.17% |
56.45%
22.3 pts worse
|
Numerator 41 · Denominator 120 |
| Transfer of health information to provider | 91.89% |
95.95%
4.1 pts worse
|
Numerator 68 · Denominator 74 |
| Transfer of health information to patient | 97.73% |
96.28%
1.5 pts better
|
Numerator 86 · Denominator 88 |
| Resident COVID-19 vaccinations up to date | 1.01% |
25.2%
24.2 pts worse
|
Numerator 1 · Denominator 99 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 3.0 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
97.1%
0.5 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 91.2% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.4% |
97.9%
2.5 pts worse
|
95.5%
0.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| 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 3.4% · Q2 3.3% · Q3 1.4% · Q4 0.0% · 4Q avg 2.0% · 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 0.0% · Q3 1.6% · Q4 1.7% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 10.9% |
3.3%
7.6 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 13.6% · Q3 11.9% · Q4 10.4% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.3% |
18.9%
6.4 pts worse
|
19.6%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 28.3% · Q3 23.4% · Q4 24.5% · 4Q avg 25.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
10.8%
4 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.9% · Q3 5.0% · Q4 5.6% · 4Q avg 6.8% · 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 | 20.3% |
15.4%
4.9 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.6% |
16.1%
2.5 pts better
|
14.9%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 7.3% · Q3 6.8% · Q4 20.8% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
0.5%
2.2 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.6% · Q3 1.0% · Q4 2.5% · 4Q avg 2.7% · 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 1.7% · Q2 0.0% · Q3 0.0% · 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 | 8.9% |
15.0%
6.1 pts better
|
19.8%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 15.9% · Q3 8.4% · Q4 8.8% · 4Q avg 8.9% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.2%
1.7 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 5.9% · Q4 2.6% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
89.7%
0.7 pts worse
|
81.7%
7.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 89.3% · Q3 87.7% · Q4 84.5% · 4Q avg 89.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
12.0%
0.6 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 12.1% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.2% · Q3 0.6% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.9% |
88.0%
6.1 pts worse
|
79.7%
2.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.8% |
25.9%
9.9 pts worse
|
23.9%
11.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.8% · Observed 34.2% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-15 · Fire 2024-08-15
2 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-06-20 · Fire 2023-06-20
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-12-04
E · Potential for more than minimal harm
2024-08-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-28
E · Potential for more than minimal harm
2024-08-15
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 2024-09-28
D · Potential for more than minimal harm
2024-08-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-28
D · Potential for more than minimal harm
2024-08-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-28
D · Potential for more than minimal harm
2024-08-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-15
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 2024-09-29
D · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-29
Penalties and ownership
What sits behind the stars
$3,798
2024-02-12
Fine
Fine · fine $3,798
Fine
$9,116
2024-01-22
Fine
Fine · fine $9,116
Fine
$2,279
2024-01-08
Fine
Fine · fine $2,279
Fine
$1,764
2024-01-02
Fine
Fine · fine $1,764
Fine
$3,174
2023-12-11
Fine
Fine · fine $3,174
Fine
Ownership
Hawley, Gracen
5% Or Greater Direct Ownership Interest · Individual
Hawley, Russell
5% Or Greater Direct Ownership Interest · Individual
Arze, Steven
Operational/Managerial Control · Individual
Bcp Investments LLC
5% Or Greater Mortgage Interest · Organization
Broadmore Health Realty Ltd
5% Or Greater Mortgage Interest · Organization
Cl Healthcare LLC
5% Or Greater Mortgage Interest · Organization
Ellis Mid Healthcare LLC
5% Or Greater Mortgage Interest · Organization
Hawley, Gracen
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Midlothian Healthcare Center
Midlothian, TX
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
#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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