Cycle 1
Health 2025-06-19 · Fire 2025-06-19
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Dallas, TX
Presbyterian Village North Special Care Ctr
4-star overall rating with 4-star inspections with $46,255 in total fines with 6 recent health deficiencies
8600 Skyline Dr, Dallas, TX
(214) 355-9000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
75
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2007-04-04
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
372
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
71.55
Composite VBP score used to determine payment impact.
Payment multiplier
1.0231
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.24
Baseline 20.28% · Performance 19.93% · Measure score 3.24 · Achievement 3.24 · Improvement 0.58
Healthcare-associated infections
7.05
Baseline 4.76% · Performance 5.73% · Measure score 7.05 · Achievement 7.05 · Improvement 0
Total nurse turnover
10
Baseline 51.52% · Performance 21.33% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
8.33
Baseline 5.21 hours · Performance 5.45 hours · Measure score 8.33 · Achievement 8.33 · Improvement 3.7
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.85% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 481 · Observed rate 9.36% · Lower 95% interval 8.62% |
| Discharge to community | 62.24% |
50.57%
11.7 pts better
|
Better than the National Rate · Eligible stays 461 · Observed rate 58.79% · Lower 95% interval 57.33% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 91.05% |
95.27%
4.2 pts worse
|
Numerator 295 · Denominator 324 |
| Falls with major injury | 0.62% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 324 |
| Discharge self-care score | 67.26% |
53.69%
13.6 pts better
|
Numerator 152 · Denominator 226 |
| Discharge mobility score | 50.88% |
50.94%
0.1 pts worse
|
Numerator 115 · Denominator 226 |
| Pressure ulcers or injuries, new or worsened | 1.54% |
2.29%
0.8 pts better
|
Numerator 5 · Denominator 324 · Adjusted rate 1.57% |
| Healthcare-associated infections requiring hospitalization | 5.73% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 278 · Observed rate 3.96% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 244 |
| Staff flu vaccination coverage | 5.69% |
42%
36.3 pts worse
|
Numerator 14 · Denominator 246 |
| Discharge function score | 58.41% |
56.45%
2 pts better
|
Numerator 132 · Denominator 226 |
| Transfer of health information to provider | 94.94% |
95.95%
1 pts worse
|
Numerator 75 · Denominator 79 |
| Transfer of health information to patient | 98.59% |
96.28%
2.3 pts better
|
Numerator 210 · Denominator 213 |
| Resident COVID-19 vaccinations up to date | 60.54% |
25.2%
35.3 pts better
|
Numerator 112 · Denominator 185 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 2.2 · 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 1.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
97.1%
1.8 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
97.9%
1.7 pts worse
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 2.6% |
2.7%
0.1 pts better
|
11.4%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 4.5% · 4Q avg 2.6% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
3.3%
4.8 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.2% |
18.9%
15.3 pts worse
|
19.6%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q4 31.8% · 4Q avg 34.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
10.8%
12.6 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.4% · 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 | 14.9% |
15.4%
0.5 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
16.1%
2.7 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.5%
0.1 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 2.5% · 4Q avg 0.6% · 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 | 16.1% |
15.0%
1.1 pts worse
|
19.8%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 24.4% · Q4 12.9% · 4Q avg 16.1% |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
4.2%
1.6 pts worse
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.8% · Q3 4.1% · Q4 11.4% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
89.7%
8.3 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 98.0% · Q3 99.7% · Q4 98.8% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
12.0%
6.6 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 4.8% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.8% · Q3 0.0% · Q4 0.4% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.0% |
88.0%
7 pts better
|
79.7%
15.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
25.9%
3.6 pts better
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 20.2% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-03-29 · Fire 2023-03-29
2 health deficiencies
Top issue: Infection Control (1 deficiency)
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
2024-05-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-13
F · Potential for more than minimal harm
2024-05-16
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-06-17
F · Potential for more than minimal harm
2024-05-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-17
E · Potential for more than minimal harm
2024-05-16
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 2024-05-17
E · Potential for more than minimal harm
2024-05-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-05-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-17
E · Potential for more than minimal harm
2024-05-16
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2024-06-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-07-02
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 2025-07-29
D · Potential for more than minimal harm
2025-07-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-19
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 2025-06-28
D · Potential for more than minimal harm
2025-06-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-28
J · Immediate jeopardy
2025-03-12
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 2025-03-04
J · Immediate jeopardy
2024-05-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-05-16
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 2024-05-17
D · Potential for more than minimal harm
2024-05-16
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 2024-05-17
D · Potential for more than minimal harm
2024-05-16
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2024-05-17
E · Potential for more than minimal harm
2023-03-29
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 2023-04-17
D · Potential for more than minimal harm
2023-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-20
Penalties and ownership
What sits behind the stars
$22,925
2025-03-12
Fine
Fine · fine $22,925
Fine
$13,580
2024-05-16
Fine
Fine · fine $13,580
Fine
$9,750
2023-03-29
Fine
Fine · fine $9,750
Fine
Ownership
Ailey, Steven
Corporate Officer · Individual
Allen, Dustin
Operational/Managerial Control · Individual
Johnson, Karen
Operational/Managerial Control · Individual
Mallad, Timothy
Corporate Officer · Individual
Polzin, Scott
Corporate Officer · Individual
Nearby options
Other facilities in reach
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1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $53,825 in total fines with 7 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#2
The Legacy Midtown Park
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5-star overall rating with 5-star inspections with $27,523 in total fines with 3 recent health deficiencies
#3
The Meadows Health and Rehabilitation Center
Dallas, TX
1-star overall rating with 1-star inspections with $35,731 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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