Cycle 1
Health 2025-06-26 · Fire 2025-06-26
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Plano, TX
The Healthcare Resort Of Plano
3-star overall rating with 3-star inspections with $16,438 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3325 West Plano Parkway, Plano, TX
(972) 379-0000
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
60
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2016-05-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.72
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.44
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.15
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.59
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.40
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,062
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.16% · Performance 22.77% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.22
Baseline 6.76% · Performance 6.57% · Measure score 4.22 · Achievement 4.22 · Improvement 0.54
Total nurse turnover
0
Baseline 67.16% · Performance 69.05% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.04
Baseline 3.48 hours · Performance 3.94 hours · Measure score 3.04 · Achievement 3.04 · Improvement 1.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.95% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 305 · Observed rate 12.13% · Lower 95% interval 9.66% |
| Discharge to community | 53.53% |
50.57%
3 pts better
|
No Different than the National Rate · Eligible stays 315 · Observed rate 47.94% · Lower 95% interval 46.85% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 179 · Denominator 179 |
| Falls with major injury | 0.56% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 179 |
| Discharge self-care score | 61.76% |
53.69%
8.1 pts better
|
Numerator 42 · Denominator 68 |
| Discharge mobility score | 32.35% |
50.94%
18.6 pts worse
|
Numerator 22 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 179 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.57% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 209 · Observed rate 6.22% · Lower 95% interval 4.38% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 169 |
| Staff flu vaccination coverage | 30.14% |
42%
11.9 pts worse
|
Numerator 63 · Denominator 209 |
| Discharge function score | 47.06% |
56.45%
9.4 pts worse
|
Numerator 32 · Denominator 68 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 71 · Denominator 71 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 94 · Denominator 94 |
| Resident COVID-19 vaccinations up to date | 4% |
25.2%
21.2 pts worse
|
Numerator 3 · Denominator 75 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
97.1%
1.5 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 98.6% |
| 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 | 2.7% |
3.3%
0.6 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
2.7%
1.1 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
3.3%
4.4 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
18.9%
1.8 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
10.8%
1.5 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.3% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.3% |
15.4%
11.9 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.2% |
16.1%
14.1 pts worse
|
14.9%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.2% · 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 · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
0.8%
0.7 pts worse
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 40.6% |
15.0%
25.6 pts worse
|
19.8%
20.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 40.6% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.2%
4.2 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
89.7%
5.1 pts better
|
81.7%
13.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 99.4% · Q3 95.8% · Q4 84.4% · 4Q avg 94.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
12.0%
5.8 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 6.9% · Expected 12.5% · 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 0.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
88.0%
10.5 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.7% |
25.9%
3.8 pts worse
|
23.9%
5.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.7% · Observed 32.3% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-02-23 · Fire 2023-02-23
13 health deficiencies
Top issue: Pharmacy Service (4 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
2025-06-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-27
C · Minimal harm
2025-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-26
F · Potential for more than minimal harm
2024-05-16
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-05-20
F · Potential for more than minimal harm
2024-05-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-05-16
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-05-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-06-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-31
E · Potential for more than minimal harm
2025-06-26
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 2025-07-31
E · Potential for more than minimal harm
2025-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-26
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 2025-07-31
D · Potential for more than minimal harm
2025-06-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-07-31
E · Potential for more than minimal harm
2024-10-09
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 2024-10-31
J · Immediate jeopardy
2024-09-10
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 2024-05-31
E · Potential for more than minimal harm
2024-05-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-17
E · Potential for more than minimal harm
2024-05-16
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 2024-06-17
E · Potential for more than minimal harm
2024-05-16
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 2024-06-17
E · Potential for more than minimal harm
2024-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-17
D · Potential for more than minimal harm
2024-05-16
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 2024-06-17
G · Actual harm
2023-11-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-09-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-04-18
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 2023-04-30
D · Potential for more than minimal harm
2023-04-18
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 2023-05-31
E · Potential for more than minimal harm
2023-02-23
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-03-02
E · Potential for more than minimal harm
2023-02-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-23
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-23
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 2023-03-31
D · Potential for more than minimal harm
2023-02-23
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 2023-03-02
D · Potential for more than minimal harm
2023-02-23
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 2023-03-02
D · Potential for more than minimal harm
2023-02-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-31
C · Minimal harm
2023-02-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-03-02
Penalties and ownership
What sits behind the stars
$8,995
2024-09-10
Fine
Fine · fine $8,995
Fine
$7,443
2023-11-16
Fine
Fine · fine $7,443
Fine
$0
2023-11-16
Payment Denial
Payment Denial · denial start 2023-12-20 · 12 days
12 day denial
Ownership
Ashton, Andrew
Corporate Officer · Individual
Burnam, Soon
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Niccum, Kevin
Operational/Managerial Control · Individual
Park, Ken
Operational/Managerial Control · Individual
Sato, Ami
Corporate Officer · Individual
Wilson, Edward
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Continuing Care At Highland Springs
Dallas, TX
3-star overall rating with 2-star inspections with $45,705 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Landmark of Plano Rehabilitation and Nursing Cente
Plano, TX
1-star overall rating with 1-star inspections with abuse icon flag with $79,867 in total fines with 25 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Plano
Plano, TX
4-star overall rating with 3-star inspections with $8,281 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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