Cycle 1
Health 2024-10-17 · Fire 2024-10-17
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Highland Village, TX
Rambling Oaks Courtyard Extensive Care Community
3-star overall rating with 3-star inspections with $21,640 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
112 Barnett Blvd, Highland Village, TX
(972) 317-1174
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
70
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-01-24
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
0.42
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.56
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.10
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,470
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.85
Composite VBP score used to determine payment impact.
Payment multiplier
0.9928
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.38
Baseline 22.29% · Performance 20.24% · Measure score 3.38 · Achievement 2.56 · Improvement 3.38
Healthcare-associated infections
5.56
Baseline 6.16% · Performance 6.17% · Measure score 5.56 · Achievement 5.56 · Improvement 0
Total nurse turnover
4.82
Baseline 80.88% · Performance 51.06% · Measure score 4.82 · Achievement 3.09 · Improvement 4.82
Adjusted total nurse staffing
2.17
Baseline 4.11 hours · Performance 3.70 hours · Measure score 2.17 · Achievement 2.17 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 203 · Observed rate 9.36% · Lower 95% interval 7.14% |
| Discharge to community | 53.88% |
50.57%
3.3 pts better
|
No Different than the National Rate · Eligible stays 175 · Observed rate 48% · Lower 95% interval 45.63% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.13% |
95.27%
3.9 pts better
|
Numerator 114 · Denominator 115 |
| Falls with major injury | 1.74% |
0.77%
1 pts worse
|
Numerator 2 · Denominator 115 |
| Discharge self-care score | 67.12% |
53.69%
13.4 pts better
|
Numerator 49 · Denominator 73 |
| Discharge mobility score | 69.86% |
50.94%
18.9 pts better
|
Numerator 51 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 115 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.17% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 4.51% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 76 |
| Staff flu vaccination coverage | 5.56% |
42%
36.4 pts worse
|
Numerator 4 · Denominator 72 |
| Discharge function score | 73.97% |
56.45%
17.5 pts better
|
Numerator 54 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 43 · Denominator 43 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.8 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.8 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
97.1%
2.1 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.0% · 4Q avg 99.2% |
| 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 | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.0% · Q3 3.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
2.7%
0.2 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.5% · Q4 3.3% · 4Q avg 2.5% |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.5% |
18.9%
8.6 pts worse
|
19.6%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 26.9% · Q3 25.9% · Q4 32.0% · 4Q avg 27.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
10.8%
10.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · 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 | 9.6% |
15.4%
5.8 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.7% |
16.1%
1.4 pts better
|
14.9%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 25.0% · Q3 15.4% · Q4 8.7% · 4Q avg 14.7% · 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 | 0.0% |
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 | 21.8% |
15.0%
6.8 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 15.2% · Q3 28.4% · Q4 29.6% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 10.8% |
4.2%
6.6 pts worse
|
5.1%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 13.5% · Q3 15.5% · Q4 4.9% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
89.7%
9.6 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.8% · 4Q avg 99.3% |
| 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 8.7% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.9% |
25.9%
4 pts better
|
23.9%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 21.7% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-14 · Fire 2023-09-14
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-07-28 · Fire 2022-07-28
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-10-17
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 2024-11-14
F · Potential for more than minimal harm
2023-09-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-29
F · Potential for more than minimal harm
2023-09-14
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-29
F · Potential for more than minimal harm
2023-09-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-29
E · Potential for more than minimal harm
2023-09-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-09-14
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 2023-10-29
D · Potential for more than minimal harm
2023-09-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-29
D · Potential for more than minimal harm
2023-09-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-29
F · Potential for more than minimal harm
2022-07-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-08-26
F · Potential for more than minimal harm
2022-07-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-02
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 2025-09-03
E · Potential for more than minimal harm
2025-09-02
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 2025-09-03
D · Potential for more than minimal harm
2025-07-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-01
E · Potential for more than minimal harm
2024-10-17
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 2024-11-14
E · Potential for more than minimal harm
2024-10-17
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 2024-11-14
E · Potential for more than minimal harm
2024-10-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-10-17
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 2024-11-14
E · Potential for more than minimal harm
2024-10-17
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 2024-11-14
E · Potential for more than minimal harm
2024-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-17
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 2024-11-14
D · Potential for more than minimal harm
2024-10-17
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-11-14
J · Immediate jeopardy
2024-06-14
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 2024-07-11
F · Potential for more than minimal harm
2023-09-14
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 2023-10-12
E · Potential for more than minimal harm
2023-09-14
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 2023-10-12
E · Potential for more than minimal harm
2023-09-14
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 2023-10-12
E · Potential for more than minimal harm
2023-09-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-14
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-14
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 2023-10-12
D · Potential for more than minimal harm
2023-09-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-09-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-12
E · Potential for more than minimal harm
2022-07-28
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 2022-08-27
D · Potential for more than minimal harm
2022-07-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-27
Penalties and ownership
What sits behind the stars
$21,640
2024-06-14
Fine
Fine · fine $21,640
Fine
Ownership
Thomas, Brian
5% Or Greater Direct Ownership Interest · Individual
Villa, Ricardo
5% Or Greater Direct Ownership Interest · Individual
Crawford, Christopher
W-2 Managing Employee · Individual
Tgr Healthcare, LLC
Operational/Managerial Control · Organization
Thomas, Brian
Corporate Officer · Individual
Villa, Ricardo
Corporate Officer · Individual
Nearby options
Other facilities in reach
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#2
Cross Timbers Rehabilitation and Healthcare Center
Flower Mound, TX
3-star overall rating with 3-star inspections with $8,281 in total fines with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Lake Village Nursing And Rehabilitation Center
Lewisville, TX
2-star overall rating with 3-star inspections with $24,585 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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