Federal inspection record · CMS data as of October 1, 2026
The Eden of Las Colinas
2101 Northgate Dr, Irving, TX · (972) 255-4460
- Certified beds
- 120
- Residents per day
- 67
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- May 21, 2003
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
-
Staffing
★★★★★no change (already 1)
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
The Eden of Las Colinas carries 207.25 inspection points. That is fewer than 9% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
66 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
K
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Everything else, by area of care
Quality of Life and Care26E
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
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.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Ensure the activities program is directed by a qualified professional.
- D
Provide enough food/fluids to maintain a resident's health.
- D
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.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Resident Rights14E
- E
Reasonably accommodate the needs and preferences of each resident.
- E
Reasonably accommodate the needs and preferences of each resident.
- E
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.
- E
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- D
Keep residents' personal and medical records private and confidential.
- E
Reasonably accommodate the needs and preferences of each resident.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- E
Reasonably accommodate the needs and preferences of each resident.
- E
Keep residents' personal and medical records private and confidential.
- E
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.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- E
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.
- D
Reasonably accommodate the needs and preferences of each resident.
Resident Assessment and Care Planning7E
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pharmacy Service5E
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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.
- D
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.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Nutrition and Dietary5F
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control4E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation2E
- E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Environmental1E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Nursing and Physician Services1E
- E
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.
Inspection history
2026-03-12
29 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (13 deficiencies)
2024-12-18
21 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2023-11-09
16 health deficiencies · 4 fire-safety deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 10 min of nursing staff time a day, 24 min of it from a registered nurse.
This home
3 h 10 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 63% of nursing staff and 50% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$49,730 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-03-28 | Fine | $49,730 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine5.9 pts worse | 90.5% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine0.2 pts worse | 96.8% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2.7 pts better | 0.5% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.3 pts better | 0.0% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.9 pts better | 1.0% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.1 pts worse | 17.9% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication0.9 pts better | 8.9% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened1.7 pts worse | 14.6% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased16.2 pts worse | 32.0% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.3 pts better | 0.5% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence4 pts worse | 16.5% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.8 pts worse | 6.5% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine28 pts worse | 60.7% | 88.7% | 82.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.4 pts better | 0.0% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine2.5 pts better | 87.9% | 85.4% | 80.1% |
·
Who owns and runs it
15 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Barnes, Marcus | Managing Control - Governing Body · Individual | 0% | 1 facilities |
| Barnes, Marcus | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Barnes, Marcus | Adp Of The SNF · Individual | 0% | 1 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Coil, Ryan | Managing Control - Governing Body · Individual | 0% | 4 facilities |
| Coil, Ryan | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Coil, Ryan | Adp Of The SNF · Individual | 0% | 4 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Hooper, Grady | Corporate Officer · Individual | 0% | 61 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Standard Bearer Healthcare Op, LP | Adp Of The SNF · Organization | 0% | 78 facilities |
| Sweet Bay Healthcare LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Sweet Bay Healthcare LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| The Ensign Group Inc | Adp Of The SNF · Organization | 0% | 135 facilities |
| Valley Ranch Health Holdings LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
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Fire safety
8 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke3F
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Install corridor and hallway doors that block smoke.
Egress3E
- E
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.
- E
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.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Gas, Vacuum, and Electrical Systems1F
- F
Have generator or other power source capable of supplying service within 10 seconds.
Services1E
- E
Have properly installed electrical wiring and gas equipment.
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