Cycle 1
Health 2025-12-30 · Fire 2025-12-30
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Dallas, TX
The Highlands Guest Care Center
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $53,825 in total fines with 7 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
9009 Forest Ln, Dallas, TX
(972) 783-1771
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-01-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.39
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.63
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
7,513
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.76
Baseline 20.64% · Performance 17.84% · Measure score 7.76 · Achievement 7.76 · Improvement 7.26
Healthcare-associated infections
4.06
Baseline 8.95% · Performance 7.14% · Measure score 4.06 · Achievement 2.31 · Improvement 4.06
Total nurse turnover
0
Performance 65.15% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.61 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.25% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 10.71% · Lower 95% interval 6.83% |
| Discharge to community | 38.33% |
50.57%
12.2 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 21.43% · Lower 95% interval 25.05% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 93.55% |
95.27%
1.7 pts worse
|
Numerator 29 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 30.43% |
53.69%
23.3 pts worse
|
Numerator 7 · Denominator 23 |
| Discharge mobility score | 17.39% |
50.94%
33.5 pts worse
|
Numerator 4 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.14% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 30 · Observed rate 10% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 5.49% |
8.2%
2.7 pts worse
|
Numerator 5 · Denominator 91 |
| Staff flu vaccination coverage | 15.56% |
42%
26.4 pts worse
|
Numerator 14 · Denominator 90 |
| Discharge function score | 21.74% |
56.45%
34.7 pts worse
|
Numerator 5 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 45% |
25.2%
19.8 pts better
|
Numerator 9 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.6 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.8 · 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 | 0.6% |
3.3%
2.7 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
2.7%
2 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.3% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
3.3%
2.9 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
18.9%
3.2 pts better
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 19.2% · Q3 15.1% · Q4 15.5% · 4Q avg 15.7% |
| 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 6.4% · Q2 7.5% · Q3 12.8% · Q4 9.6% · 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 | 10.2% |
15.4%
5.2 pts better
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 4.4% · Q3 10.2% · Q4 11.2% · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
16.1%
6.7 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 8.1% · Q3 10.9% · Q4 9.8% · 4Q avg 9.4% · 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 | 12.3% |
15.0%
2.7 pts better
|
19.8%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 14.8% · Q3 13.4% · Q4 6.0% · 4Q avg 12.3% |
| Percentage of long-stay residents with pressure ulcers | 9.8% |
4.2%
5.6 pts worse
|
5.1%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 11.0% · Q3 8.4% · Q4 8.4% · 4Q avg 9.8% · 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 | 7.6% |
12.0%
4.4 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 8.3% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · 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 | 20.1% |
25.9%
5.8 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 22.2% · Expected 26.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-10 · Fire 2024-10-10
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-08-24 · Fire 2023-08-24
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-30
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-30
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-30
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-30
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2026-01-30
F · Potential for more than minimal harm
2025-12-30
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2026-01-30
F · Potential for more than minimal harm
2025-12-30
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2026-01-30
F · Potential for more than minimal harm
2025-12-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-30
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-30
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2026-02-13
F · Potential for more than minimal harm
2025-12-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-13
E · Potential for more than minimal harm
2025-12-30
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 2026-02-13
E · Potential for more than minimal harm
2025-12-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-13
E · Potential for more than minimal harm
2024-10-10
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 2024-11-15
E · Potential for more than minimal harm
2024-10-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-10
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 2024-11-15
E · Potential for more than minimal harm
2024-10-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-15
E · Potential for more than minimal harm
2023-08-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-23
D · Potential for more than minimal harm
2023-08-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-10
C · Minimal harm
2025-12-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2026-01-10
K · Immediate jeopardy
2025-04-14
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 2025-04-16
K · Immediate jeopardy
2025-04-14
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 2025-04-16
K · Immediate jeopardy
2025-04-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-16
K · Immediate jeopardy
2025-04-14
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-04-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-02-19
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 2025-03-28
E · Potential for more than minimal harm
2025-02-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-10-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-08
E · Potential for more than minimal harm
2023-08-24
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 2023-10-02
E · Potential for more than minimal harm
2023-08-24
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 2023-10-02
E · Potential for more than minimal harm
2023-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-24
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 2023-10-02
D · Potential for more than minimal harm
2023-08-24
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 2023-10-02
D · Potential for more than minimal harm
2023-08-24
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-10-02
E · Potential for more than minimal harm
2023-08-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-11
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 2023-09-15
E · Potential for more than minimal harm
2023-08-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-15
Penalties and ownership
What sits behind the stars
$53,825
2025-04-14
Fine
Fine · fine $53,825
Fine
Ownership
Nocona Hospital District
5% Or Greater Direct Ownership Interest · Organization
Gamble, Denny
Operational/Managerial Control · Individual
Gamvest Texas LLC
5% Or Greater Mortgage Interest · Organization
Gordy, Otis
Operational/Managerial Control · Individual
Meekins, Greg
Corporate Director · Individual
The Highlands Guest Care Center LLC
Operational/Managerial Control · Organization
Nearby options
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4-star overall rating with 4-star inspections with $46,255 in total fines with 6 recent health deficiencies
#2
The Legacy Midtown Park
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5-star overall rating with 5-star inspections with $27,523 in total fines with 3 recent health deficiencies
#3
The Meadows Health and Rehabilitation Center
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1-star overall rating with 1-star inspections with $35,731 in total fines with 15 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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