Cycle 1
Health 2025-02-13 · Fire 2025-02-13
21 health deficiencies
Top issue: Resident Rights (8 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Dallas, TX
Signature Pointe
2-star overall rating with 2-star inspections with $38,436 in total fines with 21 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
14655 Preston Rd, Dallas, TX
(972) 726-7575
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
195
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Life Care Services
Operator or chain grouping
Approved since
1998-06-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 4 health / 4 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
0.51
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.79
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
0.48
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.87
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,350
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.20
Baseline 23.00% · Performance 22.58% · Measure score 0.20 · Achievement 0 · Improvement 0.20
Healthcare-associated infections
2.14
Baseline 5.29% · Performance 7.20% · Measure score 2.14 · Achievement 2.14 · Improvement 0
Total nurse turnover
1.80
Baseline 54.63% · Performance 56.30% · Measure score 1.80 · Achievement 1.80 · Improvement 0
Adjusted total nurse staffing
2.72
Baseline 3.81 hours · Performance 3.85 hours · Measure score 2.72 · Achievement 2.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 17.67% |
10.72%
7 pts worse
|
Worse than the National Rate · Eligible stays 438 · Observed rate 20.78% · Lower 95% interval 15.49% |
| Discharge to community | 59.24% |
50.57%
8.7 pts better
|
Better than the National Rate · Eligible stays 347 · Observed rate 51.87% · Lower 95% interval 54.35% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 180 · Denominator 180 |
| Falls with major injury | 2.22% |
0.77%
1.5 pts worse
|
Numerator 4 · Denominator 180 |
| Discharge self-care score | 52.5% |
53.69%
1.2 pts worse
|
Numerator 84 · Denominator 160 |
| Discharge mobility score | 29.38% |
50.94%
21.6 pts worse
|
Numerator 47 · Denominator 160 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 3 · Denominator 180 · Adjusted rate 1.57% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 232 · Observed rate 7.33% · Lower 95% interval 5.11% |
| Staff COVID-19 vaccination coverage | 1.11% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 90 |
| Staff flu vaccination coverage | 52.81% |
42%
10.8 pts better
|
Numerator 47 · Denominator 89 |
| Discharge function score | 40.63% |
56.45%
15.8 pts worse
|
Numerator 65 · Denominator 160 |
| Transfer of health information to provider | 91.67% |
95.95%
4.3 pts worse
|
Numerator 22 · Denominator 24 |
| Transfer of health information to patient | 94.81% |
96.28%
1.5 pts worse
|
Numerator 128 · Denominator 135 |
| Resident COVID-19 vaccinations up to date | 2.3% |
25.2%
22.9 pts worse
|
Numerator 2 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · 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 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 61.8% |
97.1%
35.3 pts worse
|
93.4%
31.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.2% · Q2 68.6% · Q3 56.8% · Q4 51.5% · 4Q avg 61.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.8% |
97.9%
10.1 pts worse
|
95.5%
7.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.9% · Q3 0.0% · Q4 6.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
2.7%
3.3 pts worse
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 9.1% · Q3 3.1% · Q4 6.2% · 4Q avg 6.0% |
| 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 | 16.4% |
18.9%
2.5 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 18.2% · Q3 14.3% · Q4 12.5% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
10.8%
3.4 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 10.0% · Q3 7.7% · Q4 7.7% · 4Q avg 7.4% · 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 | 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 | 9.2% |
16.1%
6.9 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 12.0% · Q3 3.7% · Q4 0.0% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.5%
1.7 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 0.0% · Q3 2.0% · Q4 2.3% · 4Q avg 2.2% · 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 | 1.6% |
15.0%
13.4 pts better
|
19.8%
18.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 1.6% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
4.2%
1.4 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.5% · Q3 5.4% · Q4 3.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 44.9% |
89.7%
44.8 pts worse
|
81.7%
36.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 59.0% · Q2 46.2% · Q3 38.6% · Q4 34.9% · 4Q avg 44.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
12.0%
2.4 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 10.5% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 37.9% |
88.0%
50.1 pts worse
|
79.7%
41.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 37.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
25.9%
0.9 pts better
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 29.1% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-10-12 · Fire 2022-10-12
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-15
E · Potential for more than minimal harm
2025-02-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-15
F · Potential for more than minimal harm
2023-12-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-21
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-21
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 2023-12-22
F · Potential for more than minimal harm
2023-12-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-12-21
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 2024-02-01
E · Potential for more than minimal harm
2023-12-21
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-12-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-19
F · Potential for more than minimal harm
2022-10-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-10-12
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-10-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-10-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-14
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Not marked corrected
D · Potential for more than minimal harm
2026-01-14
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
E · Potential for more than minimal harm
2025-12-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-12-09
E · Potential for more than minimal harm
2025-12-03
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-12-06
E · Potential for more than minimal harm
2025-12-03
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 2025-12-06
D · Potential for more than minimal harm
2025-12-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-06
D · Potential for more than minimal harm
2025-11-25
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 2025-11-26
D · Potential for more than minimal harm
2025-11-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-25
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-26
E · Potential for more than minimal harm
2025-08-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-13
E · Potential for more than minimal harm
2025-08-12
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-08-13
E · Potential for more than minimal harm
2025-05-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-05-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-05-09
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 2025-05-10
E · Potential for more than minimal harm
2025-02-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-02-13
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 2025-02-21
D · Potential for more than minimal harm
2025-02-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-02-13
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 2025-02-21
D · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-21
E · Potential for more than minimal harm
2024-06-06
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 2024-06-07
E · Potential for more than minimal harm
2024-05-29
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 2024-05-30
G · Actual harm
2023-12-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-12-21
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 2024-01-15
E · Potential for more than minimal harm
2023-12-21
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 2024-01-15
D · Potential for more than minimal harm
2023-12-21
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-12-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-06-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-19
E · Potential for more than minimal harm
2022-10-12
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 2022-10-13
D · Potential for more than minimal harm
2022-10-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-10-12
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 2022-10-13
D · Potential for more than minimal harm
2022-10-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-10-13
Penalties and ownership
What sits behind the stars
$38,436
2023-12-21
Fine
Fine · fine $38,436
Fine
$0
2023-12-21
Payment Denial
Payment Denial · denial start 2024-01-25 · 7 days
7 day denial
Ownership
Mustang SNF Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Lmof V Mustang Aiv LLC
5% Or Greater Indirect Ownership Interest · Organization
Javelin Group Funding I, LP
5% Or Greater Indirect Ownership Interest · Organization
Eden, Kevin
Operational/Managerial Control · Individual
Garcia, Jennifer
Operational/Managerial Control · Individual
Naul, Alan
Operational/Managerial Control · Individual
Village Senior Care LLC
Operational/Managerial Control · Organization
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