Cycle 1
Health 2025-05-22 · Fire 2025-05-22
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Allen, TX
The Belmont At Twin Creeks
4-star overall rating with 4-star inspections with $8,278 in total fines with 6 recent health deficiencies
999 Raintree Circle, Allen, TX
(972) 390-8088
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
112
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cantex Continuing Care
Operator or chain grouping
Approved since
2009-09-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 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
0.97
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.73
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.48
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
0.75
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,999
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.05% · Performance 23.82% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.62
Baseline 4.97% · Performance 6.16% · Measure score 5.62 · Achievement 5.62 · Improvement 0
Total nurse turnover
5.52
Baseline 100.00% · Performance 54.80% · Measure score 5.52 · Achievement 2.17 · Improvement 5.52
Adjusted total nurse staffing
1.30
Baseline 3.33 hours · Performance 3.45 hours · Measure score 1.30 · Achievement 1.30 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.18% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 255 · Observed rate 12.94% · Lower 95% interval 9.46% |
| Discharge to community | 53.95% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 239 · Observed rate 49.37% · Lower 95% interval 48.64% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.04% |
95.27%
1.8 pts better
|
Numerator 131 · Denominator 135 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 135 |
| Discharge self-care score | 51.58% |
53.69%
2.1 pts worse
|
Numerator 49 · Denominator 95 |
| Discharge mobility score | 42.11% |
50.94%
8.8 pts worse
|
Numerator 40 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 0.74% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 135 · Adjusted rate 0.77% |
| Healthcare-associated infections requiring hospitalization | 6.16% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 165 · Observed rate 5.45% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 108 |
| Staff flu vaccination coverage | 13.25% |
42%
28.8 pts worse
|
Numerator 22 · Denominator 166 |
| Discharge function score | 53.68% |
56.45%
2.8 pts worse
|
Numerator 51 · Denominator 95 |
| Transfer of health information to provider | 97.3% |
95.95%
1.3 pts better
|
Numerator 36 · Denominator 37 |
| Transfer of health information to patient | 93.15% |
96.28%
3.1 pts worse
|
Numerator 68 · Denominator 73 |
| Resident COVID-19 vaccinations up to date | 71.01% |
25.2%
45.8 pts better
|
Numerator 49 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 2.2 · 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 | 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 | 3.2% |
3.3%
0.1 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.6% · Q3 3.3% · Q4 4.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.3%
0.5 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 5.6% · Q4 3.8% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.2% |
18.9%
4.3 pts worse
|
19.6%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 18.5% · Q3 27.8% · Q4 25.9% · 4Q avg 23.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
10.8%
4.2 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.5% · Q3 4.8% · Q4 9.3% · 4Q avg 6.6% · 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 | 5.0% |
15.4%
10.4 pts better
|
16.3%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 3.9% · Q4 11.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.3% |
16.1%
8.8 pts better
|
14.9%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 13.5% · Q3 1.9% · Q4 8.2% · 4Q avg 7.3% · 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 | 7.7% |
15.0%
7.3 pts better
|
19.8%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 8.6% · Q3 4.7% · Q4 9.0% · 4Q avg 7.7% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
4.2%
3.2 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 16.1% · Q3 4.0% · Q4 0.0% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
89.7%
10.2 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.6% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.4% |
12.0%
0.6 pts better
|
12.0%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.4% · Observed 11.7% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.5% · Q4 0.0% · 4Q avg 0.3% · 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 | 24.4% |
25.9%
1.5 pts better
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 25.5% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-22 · Fire 2024-03-22
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-07 · Fire 2023-02-07
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
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
2024-03-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-03-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-03-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-03-22
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 2024-04-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-22
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-22
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 2025-05-30
D · Potential for more than minimal harm
2025-05-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-25
G · Actual harm
2025-01-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-27
E · Potential for more than minimal harm
2025-01-30
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-30
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 2025-01-31
D · Potential for more than minimal harm
2024-08-23
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-08-24
D · Potential for more than minimal harm
2024-07-06
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 2024-06-22
D · Potential for more than minimal harm
2024-04-13
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 2024-05-12
D · Potential for more than minimal harm
2024-04-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-12
F · Potential for more than minimal harm
2024-03-22
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 2024-03-23
E · Potential for more than minimal harm
2024-03-22
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-03-22
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 2024-03-23
D · Potential for more than minimal harm
2024-03-22
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-03-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-03-22
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 2024-03-23
D · Potential for more than minimal harm
2024-03-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-03-23
E · Potential for more than minimal harm
2023-06-16
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 2023-06-17
D · Potential for more than minimal harm
2023-02-07
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 2023-02-09
Penalties and ownership
What sits behind the stars
$8,278
2025-01-30
Fine
Fine · fine $8,278
Fine
Ownership
Dallas County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Amiri, Rachel
Operational/Managerial Control · Individual
Belmont Care Center Ltd Co
Operational/Managerial Control · Organization
Castaneda, Edmundo
Corporate Officer · Individual
Cerise, Frederick
Corporate Officer · Individual
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#2
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4-star overall rating with 4-star inspections with 6 recent health deficiencies
#3
The Park In Plano
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2-star overall rating with 3-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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