Cycle 1
Health 2024-10-03 · Fire 2024-10-03
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Southlake, TX
The Carlyle at Stonebridge Park
3-star overall rating with 2-star inspections with $125,895 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
170 Stonebridge Lane, Southlake, TX
(817) 431-5778
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cantex Continuing Care
Operator or chain grouping
Approved since
2010-03-31
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.74
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.31
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.40
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
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,835
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.23% · Performance 22.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.80
Baseline 7.99% · Performance 7.01% · Measure score 2.80 · Achievement 2.77 · Improvement 2.80
Total nurse turnover
0
Performance 71.77% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.27
Baseline 3.56 hours · Performance 3.44 hours · Measure score 1.27 · Achievement 1.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.3% |
10.72%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 138 · Observed rate 17.39% · Lower 95% interval 9.63% |
| Discharge to community | 50.41% |
50.57%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 45% · Lower 95% interval 40.99% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 72 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 68.75% |
53.69%
15.1 pts better
|
Numerator 33 · Denominator 48 |
| Discharge mobility score | 39.58% |
50.94%
11.4 pts worse
|
Numerator 19 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 72 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.01% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 7.04% · Lower 95% interval 4.23% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 101 |
| Staff flu vaccination coverage | 6.06% |
42%
35.9 pts worse
|
Numerator 10 · Denominator 165 |
| Discharge function score | 70.83% |
56.45%
14.4 pts better
|
Numerator 34 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 8.33% |
25.2%
16.9 pts worse
|
Numerator 3 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 2.0% · Q4 1.7% · 4Q avg 1.9% · 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 | 1.6% |
3.3%
1.7 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 2.2% · Q4 1.9% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
18.9%
2.9 pts worse
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 25.5% · Q3 21.7% · Q4 18.5% · 4Q avg 21.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
10.8%
2.5 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 8.3% · Q3 5.9% · Q4 7.7% · 4Q avg 8.3% · 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 | 3.6% |
15.4%
11.8 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q4 8.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.8% |
16.1%
11.3 pts better
|
14.9%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.1% · Q3 2.3% · Q4 5.9% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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 | 6.8% |
15.0%
8.2 pts better
|
19.8%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 10.2% · Q4 10.4% · 4Q avg 6.8% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
4.2%
2.3 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 9.9% · Q3 5.9% · Q4 7.6% · 4Q avg 6.5% · 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 99.5% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
12.0%
3.8 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 8.7% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.5% · 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 | 26.2% |
25.9%
0.3 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 30.4% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-20 · Fire 2023-09-20
14 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-07-28 · Fire 2022-07-28
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-10-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-10-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-10-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-10-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-10-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-05
F · Potential for more than minimal harm
2023-09-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-09-20
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 2023-09-21
D · Potential for more than minimal harm
2022-07-28
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-08-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-01
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 2025-12-02
J · Immediate jeopardy
2025-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-23
E · Potential for more than minimal harm
2025-06-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-24
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 2025-05-25
D · Potential for more than minimal harm
2025-01-21
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-01-22
E · Potential for more than minimal harm
2024-10-03
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 2024-11-05
E · Potential for more than minimal harm
2024-10-03
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 2024-11-05
D · Potential for more than minimal harm
2024-10-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-10-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-08-08
D · Potential for more than minimal harm
2024-09-05
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 2024-10-26
D · Potential for more than minimal harm
2024-05-22
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 2024-03-27
D · Potential for more than minimal harm
2024-05-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-03-14
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 2024-03-15
D · Potential for more than minimal harm
2024-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-15
D · Potential for more than minimal harm
2023-12-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-22
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 2023-11-25
J · Immediate jeopardy
2023-10-19
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-10-19
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 2023-10-23
E · Potential for more than minimal harm
2023-09-20
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-09-20
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 2023-09-21
E · Potential for more than minimal harm
2023-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-09-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-09-20
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 2023-09-21
D · Potential for more than minimal harm
2023-09-20
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-09-21
C · Minimal harm
2023-09-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-09-21
C · Minimal harm
2023-09-20
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-03-22
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 2023-03-23
E · Potential for more than minimal harm
2022-07-28
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 2022-07-29
D · Potential for more than minimal harm
2022-07-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-07-29
Penalties and ownership
What sits behind the stars
$113,246
2025-08-22
Fine
Fine · fine $113,246
Fine
$12,649
2023-09-20
Fine
Fine · fine $12,649
Fine
Ownership
Dallas County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Carlyle Health Care Center Ltd Co
Operational/Managerial Control · Organization
Castaneda, Edmundo
Corporate Officer · Individual
Cerise, Frederick
Corporate Officer · Individual
Washington, Michael
Operational/Managerial Control · Individual
Nearby options
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Discovery Village At Southlake
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4-star overall rating with 4-star inspections with $12,649 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Keller Oaks Healthcare Center
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3-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Bear Creek Nursing And Rehabilitation
Grapevine, TX
2-star overall rating with 1-star inspections with $142,612 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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