Bonham, TX

Seven Oaks Nursing & Rehabilitation

4-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

901 Seven Oaks Rd, Bonham, TX

(903) 583-2191

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

108

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Creative Solutions In Healthcare

Operator or chain grouping

Approved since

1994-03-04

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

149 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

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

0.36

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.78

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.76

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

2.89

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.14

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.69

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.26

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.45

CMS adjusted RN staffing hours

Adjusted total hours

3.61

CMS adjusted total nurse staffing hours

Case-mix index

1.10

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

23%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,767

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

19.18

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.41

Performance 20.78% · Measure score 1.41 · Achievement 1.41 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

Performance 9.35% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

5.09

Baseline 36.67% · Performance 42.86% · Measure score 5.09 · Achievement 5.09 · Improvement 0

Adjusted total nurse staffing

1.17

Baseline 3.52 hours · Performance 3.41 hours · Measure score 1.17 · Achievement 1.17 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.2%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 40 · Observed rate 7.5% · Lower 95% interval 6.28%
Discharge to community	33.36%	50.57% 17.2 pts worse	Worse than the National Rate · Eligible stays 25 · Observed rate 16% · Lower 95% interval 20.45%
Medicare spending per beneficiary	1.24	1.02 0.2 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 29 · Denominator 29
Falls with major injury	3.45%	0.77% 2.7 pts worse	Numerator 1 · Denominator 29
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	3.45%	2.29% 1.2 pts worse	Numerator 1 · Denominator 29 · Adjusted rate 2.99%
Healthcare-associated infections requiring hospitalization	9.35%	7.12% 2.2 pts worse	No Different than the National Rate · Eligible stays 30 · Observed rate 20% · Lower 95% interval 5.35%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 46
Staff flu vaccination coverage	15.63%	42% 26.4 pts worse	Numerator 10 · Denominator 64
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.8	2.1 0.7 pts worse	1.9 0.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 3.0 · Expected 2.0 · 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 1.6 · Expected 1.8 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	97.1% 2.9 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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	3.5%	3.3% 0.2 pts worse	3.3% 0.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.1% · Q4 5.4% · 4Q avg 3.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.5%	2.7% 1.2 pts better	11.4% 9.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.7% · 4Q avg 1.5%
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	8.5%	18.9% 10.4 pts better	19.6% 11.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.1% · Q3 10.0% · Q4 9.4% · 4Q avg 8.5%
Percentage of long-stay residents who received an antipsychotic medication	2.1%	10.8% 8.7 pts better	16.7% 14.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · 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	7.0%	15.4% 8.4 pts better	16.3% 9.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 7.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	17.1%	16.1% 1 pts worse	14.9% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 21.4% · Q3 16.7% · Q4 12.9% · 4Q avg 17.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	0.5% 0.3 pts worse	1.0% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.7%	0.8% 0.1 pts better	1.7% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.0%	15.0% 2 pts better	19.8% 6.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 12.1% · Q3 14.6% · Q4 13.1% · 4Q avg 13.0%
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 0.0% · Q2 4.0% · Q3 4.2% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.7% 10.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	16.3%	12.0% 4.3 pts worse	12.0% 4.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 16.7% · Expected 11.4% · Used in QM five-star
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 · 4Q avg 0.0% · 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	14.6%	25.9% 11.3 pts better	23.9% 9.3 pts better	Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 16.7% · Expected 27.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-23 · Fire 2025-07-23

8 health deficiencies

Top issue: Nutrition and Dietary (5 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-06-18 · Fire 2024-06-18

7 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

5 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Cycle 3 Health 2023-04-18 · Fire 2023-04-18

13 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2025-07-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-07-23

C · Minimal harm 2025-07-23

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Not marked corrected

C · Minimal harm 2025-07-23

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

F · Potential for more than minimal harm 2024-06-18

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-06-18

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-07-24

E · Potential for more than minimal harm 2024-06-18

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-07-26

C · Minimal harm 2024-06-18

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Not marked corrected

C · Minimal harm 2024-06-18

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

F · Potential for more than minimal harm 2023-04-18

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-06-01

E · Potential for more than minimal harm 2023-04-18

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 2023-06-01

C · Minimal harm 2023-04-18

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-05-04

C · Minimal harm 2023-04-18

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-07-23

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2025-07-24

D · Potential for more than minimal harm 2025-07-23

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-07-24

D · Potential for more than minimal harm 2025-07-23

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-07-24

D · Potential for more than minimal harm 2025-07-23

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-07-24

D · Potential for more than minimal harm 2025-07-23

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2025-07-24

D · Potential for more than minimal harm 2025-07-23

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2025-07-24

D · Potential for more than minimal harm 2025-07-23

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 2025-07-24

B · Minimal harm 2025-07-23

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 2025-07-24

D · Potential for more than minimal harm 2024-07-19

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 2024-07-20

E · Potential for more than minimal harm 2024-06-18

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 2024-06-19

E · Potential for more than minimal harm 2024-06-18

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 2024-06-19

D · Potential for more than minimal harm 2024-06-18

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-06-19

D · Potential for more than minimal harm 2024-06-18

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2024-06-19

D · Potential for more than minimal harm 2024-06-18

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 2024-06-19

D · Potential for more than minimal harm 2024-06-18

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2024-06-19

E · Potential for more than minimal harm 2023-04-18

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 2023-05-10

E · Potential for more than minimal harm 2023-04-18

F636 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected 2023-05-10

E · Potential for more than minimal harm 2023-04-18

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-05-10

E · Potential for more than minimal harm 2023-04-18

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 2023-05-10