Cycle 1
Health 2025-04-02 · Fire 2025-04-02
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Duncanville, TX
The Laurenwood Nursing And Rehabilitation
3-star overall rating with 4-star inspections with $38,522 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
330 W Camp Wisdom Rd, Duncanville, TX
(972) 298-3398
Overall
3 / 5
CMS overall stars
Health inspections
4 / 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
103
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Paramount Healthcare
Operator or chain grouping
Approved since
1999-08-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 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
0.23
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
1.78
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.97
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.71
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
3.01
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
62%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,690
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.03
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.17
Performance 58.90% · Measure score 1.17 · Achievement 1.17 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.04
Baseline 3.42 hours · Performance 3.37 hours · Measure score 1.04 · Achievement 1.04 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.13% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 7.5% · Lower 95% interval 6.27% |
| Discharge to community | 62.55% |
50.57%
12 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 58.54% · Lower 95% interval 49.31% |
| Medicare spending per beneficiary | 1.53 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 97.22% |
95.27%
2 pts better
|
Numerator 35 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 1 · Denominator 36 · Adjusted rate 2.08% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 75 |
| Staff flu vaccination coverage | 16.67% |
42%
25.3 pts worse
|
Numerator 22 · Denominator 132 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| 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 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
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 | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 5.1% · Q3 1.8% · Q4 0.0% · 4Q avg 2.3% · 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 | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 7.4% |
18.9%
11.5 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 7.1% · Q3 4.0% · Q4 6.2% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.2% |
10.8%
6.6 pts better
|
16.7%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.2% · Q3 7.5% · Q4 5.0% · 4Q avg 4.2% · 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 | 31.0% |
15.4%
15.6 pts worse
|
16.3%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.3% |
16.1%
13.2 pts worse
|
14.9%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 38.1% · Q3 31.6% · Q4 19.0% · 4Q avg 29.3% · 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 | 21.9% |
15.0%
6.9 pts worse
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 25.8% · Q3 21.4% · Q4 21.0% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
4.2%
3.3 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · 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 | 12.9% |
12.0%
0.9 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 13.0% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.5%
1 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 4.1% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
88.0%
10.6 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.4% |
25.9%
8.5 pts worse
|
23.9%
10.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.4% · Observed 30.4% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-01-10 · Fire 2023-01-10
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-02
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-05-17
E · Potential for more than minimal harm
2025-04-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-17
E · Potential for more than minimal harm
2025-04-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-17
F · Potential for more than minimal harm
2024-02-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-02-26
F · Potential for more than minimal harm
2024-02-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-02-26
F · Potential for more than minimal harm
2024-02-22
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 2024-03-08
F · Potential for more than minimal harm
2024-02-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-07
F · Potential for more than minimal harm
2024-02-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-11
F · Potential for more than minimal harm
2024-02-22
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-03-14
E · Potential for more than minimal harm
2024-02-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-06
D · Potential for more than minimal harm
2024-02-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-02-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-06
E · Potential for more than minimal harm
2023-01-10
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 2023-02-05
E · Potential for more than minimal harm
2023-01-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-05
E · Potential for more than minimal harm
2023-01-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-05
D · Potential for more than minimal harm
2023-01-10
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-02-05
D · Potential for more than minimal harm
2023-01-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-09
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 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-02
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 2025-05-26
E · Potential for more than minimal harm
2025-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-26
D · Potential for more than minimal harm
2025-04-02
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 2025-05-26
D · Potential for more than minimal harm
2025-04-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-26
D · Potential for more than minimal harm
2025-04-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-26
J · Immediate jeopardy
2025-01-27
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 2025-01-13
D · Potential for more than minimal harm
2025-01-27
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 2025-01-28
J · Immediate jeopardy
2024-12-30
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 2024-05-15
J · Immediate jeopardy
2024-12-30
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 2024-07-02
D · Potential for more than minimal harm
2024-12-30
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 2025-01-27
D · Potential for more than minimal harm
2024-04-24
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 2024-05-23
D · Potential for more than minimal harm
2024-04-24
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 2024-05-23
D · Potential for more than minimal harm
2024-04-24
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-02-22
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 2024-02-23
E · Potential for more than minimal harm
2023-09-06
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 2023-09-07
E · Potential for more than minimal harm
2023-01-10
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 2023-02-05
D · Potential for more than minimal harm
2023-01-10
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 2023-02-05
D · Potential for more than minimal harm
2023-01-10
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 2023-02-05
Penalties and ownership
What sits behind the stars
$14,508
2025-01-27
Fine
Fine · fine $14,508
Fine
$9,113
2024-12-30
Fine
Fine · fine $9,113
Fine
$14,901
2024-12-30
Fine
Fine · fine $14,901
Fine
Ownership
Hamilton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Dkp Investments, LLC
Operational/Managerial Control · Organization
Dkp Investments, LLC
5% Or Greater Mortgage Interest · Organization
Duncanville Nursing, Ltd
Operational/Managerial Control · Organization
Golden, Lauren
Operational/Managerial Control · Individual
Hooper, Grady
Corporate Officer · Individual
Miller, Marquisha
Operational/Managerial Control · Individual
Pln Ltd.
5% Or Greater Mortgage Interest · Organization
Port Au Prince LLC
5% Or Greater Mortgage Interest · Organization
Prince, Danny
Operational/Managerial Control · Individual
Prince, Danny
5% Or Greater Mortgage Interest · Individual
Nearby options
Other facilities in reach
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Duncanville Healthcare and Rehabilitation Center
Duncanville, TX
1-star overall rating with 1-star inspections with $116,171 in total fines with 17 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
The Lennwood Nursing And Rehabilitation
Dallas, TX
1-star overall rating with 2-star inspections with $29,969 in total fines with 5 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#3
Williamsburg Village Healthcare Campus
Desoto, TX
2-star overall rating with 2-star inspections with abuse icon flag with $85,161 in total fines with 25 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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