Cycle 1
Health 2025-07-31 · Fire 2025-07-31
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Dallas, TX
The Hillcrest Of North Dallas
1-star overall rating with 1-star inspections with $236,449 in total fines with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
18648 Hillcrest Rd, Dallas, TX
(972) 517-7771
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
120
Certified beds
Average residents
111
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
2012-06-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 2 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.52
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.88
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.57
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.17
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
2.77
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
87%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,380
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.1
Composite VBP score used to determine payment impact.
Payment multiplier
0.9875
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.72
Baseline 19.86% · Performance 19.71% · Measure score 3.72 · Achievement 3.72 · Improvement 0.02
Healthcare-associated infections
7.14
Baseline 6.91% · Performance 5.70% · Measure score 7.14 · Achievement 7.14 · Improvement 5.82
Total nurse turnover
1.54
Baseline 78.48% · Performance 67.54% · Measure score 1.54 · Achievement 0 · Improvement 1.54
Adjusted total nurse staffing
0.84
Baseline 3.30 hours · Performance 3.32 hours · Measure score 0.84 · Achievement 0.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.06% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 13.04% · Lower 95% interval 6.97% |
| Discharge to community | 33.37% |
50.57%
17.2 pts worse
|
Worse than the National Rate · Eligible stays 37 · Observed rate 18.92% · Lower 95% interval 22.49% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 86% |
95.27%
9.3 pts worse
|
Numerator 43 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 36.67% |
53.69%
17 pts worse
|
Numerator 11 · Denominator 30 |
| Discharge mobility score | 23.33% |
50.94%
27.6 pts worse
|
Numerator 7 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 50 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.7% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 0% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 194 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 10 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 3.57% |
25.2%
21.6 pts worse
|
Numerator 1 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.7 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
97.1%
2.1 pts worse
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 91.1% · Q3 94.4% · Q4 95.9% · 4Q avg 95.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.9% |
97.9%
8 pts worse
|
95.5%
5.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.3%
2.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
2.7%
1.8 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 1.1% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
3.3%
3.5 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 15.5% · Q3 3.8% · Q4 1.1% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
18.9%
1 pts worse
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 18.3% · Q3 19.0% · Q4 20.0% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
10.8%
2.5 pts worse
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 15.2% · Q3 16.1% · Q4 16.9% · 4Q avg 13.3% · 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 | 9.6% |
15.4%
5.8 pts better
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 12.2% · Q3 3.4% · Q4 6.8% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.8% |
16.1%
5.3 pts better
|
14.9%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 14.3% · Q3 4.0% · Q4 6.1% · 4Q avg 10.8% · 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 | 21.8% |
15.0%
6.8 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 14.1% · Q3 15.5% · Q4 25.7% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
4.2%
2.7 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.6% · Q3 0.0% · Q4 1.8% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.9% |
89.7%
6.8 pts worse
|
81.7%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 78.2% · Q2 78.0% · Q3 84.0% · Q4 92.5% · 4Q avg 82.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
12.0%
3.6 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 9.1% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.3% |
88.0%
10.7 pts worse
|
79.7%
2.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
25.9%
3.2 pts better
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 22.7% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-31 · Fire 2024-05-31
21 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-03-17 · Fire 2023-03-17
8 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-31
E · Potential for more than minimal harm
2024-05-31
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 2024-06-21
F · Potential for more than minimal harm
2023-03-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-03-17
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-01
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 2025-12-02
E · Potential for more than minimal harm
2025-07-31
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-31
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 2025-08-01
E · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-07-31
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-31
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 2025-08-01
D · Potential for more than minimal harm
2025-07-31
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 2025-08-01
D · Potential for more than minimal harm
2025-07-31
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 2025-08-01
D · Potential for more than minimal harm
2025-07-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-07-31
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-03
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 2025-06-04
E · 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 2025-05-23
E · Potential for more than minimal harm
2025-05-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-05-01
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 2025-05-02
D · Potential for more than minimal harm
2025-04-04
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-04-10
D · Potential for more than minimal harm
2024-12-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-08
E · Potential for more than minimal harm
2024-12-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-03
G · Actual harm
2024-09-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-08-30
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 2024-08-31
E · Potential for more than minimal harm
2024-08-30
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 2024-08-31
D · Potential for more than minimal harm
2024-08-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-31
K · Immediate jeopardy
2024-08-12
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 2024-08-13
K · Immediate jeopardy
2024-08-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-08-13
K · Immediate jeopardy
2024-08-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-13
K · Immediate jeopardy
2024-08-12
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 2024-08-13
D · Potential for more than minimal harm
2024-08-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-08-03
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 2024-08-17
J · Immediate jeopardy
2024-06-14
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 2024-06-15
D · Potential for more than minimal harm
2024-06-10
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 2024-06-26
E · Potential for more than minimal harm
2024-05-31
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-06-20
E · Potential for more than minimal harm
2024-05-31
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 2024-06-20
D · Potential for more than minimal harm
2024-05-31
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 2024-06-20
D · Potential for more than minimal harm
2024-05-31
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 2024-06-20
D · Potential for more than minimal harm
2024-03-28
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 2024-03-29
D · Potential for more than minimal harm
2024-03-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-28
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 2024-03-29
D · Potential for more than minimal harm
2024-02-28
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 2024-02-29
D · Potential for more than minimal harm
2024-02-28
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 2024-02-29
E · Potential for more than minimal harm
2023-10-16
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 2023-10-17
E · Potential for more than minimal harm
2023-03-17
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 2023-04-06
D · Potential for more than minimal harm
2023-03-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-03-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-03-17
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 2023-04-06
D · Potential for more than minimal harm
2023-03-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-06
Penalties and ownership
What sits behind the stars
$12,202
2024-08-03
Fine
Fine · fine $12,202
Fine
$199,833
2024-08-03
Fine
Fine · fine $199,833
Fine
$0
2024-08-03
Payment Denial
Payment Denial · denial start 2024-09-13 · 4 days
4 day denial
$9,017
2024-05-31
Fine
Fine · fine $9,017
Fine
$15,397
2023-03-17
Fine
Fine · fine $15,397
Fine
Ownership
Dallas County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Bradley, Shannan
Corporate Officer · Individual
Castaneda, Edmundo
Corporate Officer · Individual
Cerise, Frederick
Corporate Officer · Individual
Garetz, David
Operational/Managerial Control · Individual
Hansen Hunter LLC
Operational/Managerial Control · Organization
Hillcrest Of North Dallas LLC
Operational/Managerial Control · Organization
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