Cycle 1
Health 2025-04-10 · Fire 2025-04-10
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Frisco, TX
Stonemere Rehabilitation Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies
11855 Lebanon Road, Frisco, TX
(469) 269-1000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
136
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Paramount Healthcare
Operator or chain grouping
Approved since
2014-02-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 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
0.40
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,546
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.83
Baseline 21.53% · Performance 19.66% · Measure score 3.83 · Achievement 3.83 · Improvement 3.66
Healthcare-associated infections
3.74
Baseline 8.74% · Performance 7.15% · Measure score 3.74 · Achievement 2.28 · Improvement 3.74
Total nurse turnover
1.93
Performance 55.79% · Measure score 1.93 · Achievement 1.93 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.04
Baseline 3.30 hours · Performance 3.37 hours · Measure score 1.04 · Achievement 1.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.72% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 371 · Observed rate 11.59% · Lower 95% interval 9.42% |
| Discharge to community | 59% |
50.57%
8.4 pts better
|
Better than the National Rate · Eligible stays 361 · Observed rate 54.02% · Lower 95% interval 53.01% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.54% |
95.27%
4.3 pts better
|
Numerator 217 · Denominator 218 |
| Falls with major injury | 0.46% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 218 |
| Discharge self-care score | 63.8% |
53.69%
10.1 pts better
|
Numerator 104 · Denominator 163 |
| Discharge mobility score | 52.76% |
50.94%
1.8 pts better
|
Numerator 86 · Denominator 163 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 218 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 228 · Observed rate 7.46% · Lower 95% interval 5.22% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 119 |
| Staff flu vaccination coverage | 14.39% |
42%
27.6 pts worse
|
Numerator 19 · Denominator 132 |
| Discharge function score | 52.76% |
56.45%
3.7 pts worse
|
Numerator 86 · Denominator 163 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 56 · Denominator 56 |
| Transfer of health information to patient | 95.33% |
96.28%
1 pts worse
|
Numerator 143 · Denominator 150 |
| Resident COVID-19 vaccinations up to date | 0.93% |
25.2%
24.3 pts worse
|
Numerator 1 · Denominator 108 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.4 · 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 | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 0.0% · Q4 2.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 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 | 22.9% |
18.9%
4 pts worse
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 17.8% · Q3 19.5% · Q4 25.6% · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.0% |
10.8%
1.8 pts better
|
16.7%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.5% · Q3 10.3% · Q4 7.9% · 4Q avg 9.0% · 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 | 34.2% |
15.4%
18.8 pts worse
|
16.3%
17.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
16.1%
7.5 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 18.4% · Q3 37.1% · Q4 35.5% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.5%
1.5 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.4% · Q3 0.0% · Q4 2.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
0.8%
1.2 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.0% · Q3 0.0% · Q4 2.1% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.8% |
15.0%
8.8 pts worse
|
19.8%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 26.7% · Q3 25.5% · Q4 15.7% · 4Q avg 23.8% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.2%
1.1 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.0% · Q3 7.9% · Q4 4.8% · 4Q avg 5.3% · 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 · Q1 100.0% · 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 | 6.0% |
12.0%
6 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.8% · Expected 10.8% · 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 0.5% · Q3 0.4% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
88.0%
10.3 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
25.9%
3.4 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 21.5% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-03-07
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 2024-04-01
D · Potential for more than minimal harm
2024-03-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-01
F · Potential for more than minimal harm
2023-01-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-19
D · Potential for more than minimal harm
2023-01-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-19
D · Potential for more than minimal harm
2023-01-26
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 2023-02-19
D · Potential for more than minimal harm
2023-01-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-04-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-04-10
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 2025-05-02
D · Potential for more than minimal harm
2025-04-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-02
D · Potential for more than minimal harm
2024-05-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-03-07
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 2024-03-29
E · Potential for more than minimal harm
2024-03-07
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 2024-03-29
E · Potential for more than minimal harm
2024-03-07
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 2024-03-29
E · Potential for more than minimal harm
2024-03-07
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 2024-03-29
E · Potential for more than minimal harm
2024-03-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-07
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-03-29
E · Potential for more than minimal harm
2023-01-26
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-01-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-24
D · Potential for more than minimal harm
2023-01-26
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 2023-02-24
D · Potential for more than minimal harm
2023-01-26
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-02-24
Penalties and ownership
What sits behind the stars
Ownership
Hamilton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Dkp Investments, LLC
Operational/Managerial Control · Organization
Hodge, Christopher
Operational/Managerial Control · Individual
Hooper, Grady
Corporate Officer · Individual
Lebanon Road Real Estates, LLC
5% Or Greater Mortgage Interest · Organization
Prince, Danny
Operational/Managerial Control · Individual
Stonemere Rehabilitation Center LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Victoria Gardens Of Frisco
Frisco, TX
4-star overall rating with 4-star inspections with $23,546 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
The Legacy At Willow Bend
Plano, TX
5-star overall rating with 4-star inspections with 6 recent health deficiencies
#3
Baybrooke Village Care And Rehab Center
Mckinney, TX
4-star overall rating with 3-star inspections with $15,642 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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