Cycle 1
Health 2025-09-25 · Fire 2025-09-25
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Dallas, TX
The Legacy Midtown Park
5-star overall rating with 5-star inspections with $27,523 in total fines with 3 recent health deficiencies
8280 Manderville Lane, Dallas, TX
(972) 468-6207
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
50
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2020-07-31
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
0.72
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.35
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
3.94
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
6.00
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
5.54
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
5.69
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,576
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9893
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.36% · Performance 21.68% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.59
Baseline 4.46% · Performance 7.36% · Measure score 1.59 · Achievement 1.59 · Improvement 0
Total nurse turnover
5.42
Baseline 63.49% · Performance 41.54% · Measure score 5.42 · Achievement 5.42 · Improvement 5.18
Adjusted total nurse staffing
7.26
Baseline 6.81 hours · Performance 5.14 hours · Measure score 7.26 · Achievement 7.26 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.26% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 354 · Observed rate 11.86% · Lower 95% interval 10.11% |
| Discharge to community | 64.01% |
50.57%
13.4 pts better
|
Better than the National Rate · Eligible stays 334 · Observed rate 59.88% · Lower 95% interval 58.91% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99% |
95.27%
3.7 pts better
|
Numerator 198 · Denominator 200 |
| Falls with major injury | 0.5% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 200 |
| Discharge self-care score | 57.76% |
53.69%
4.1 pts better
|
Numerator 67 · Denominator 116 |
| Discharge mobility score | 62.07% |
50.94%
11.1 pts better
|
Numerator 72 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 10 · Denominator 200 · Adjusted rate 5.3% |
| Healthcare-associated infections requiring hospitalization | 7.36% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 208 · Observed rate 7.21% · Lower 95% interval 4.7% |
| Staff COVID-19 vaccination coverage | 2.94% |
8.2%
5.3 pts worse
|
Numerator 1 · Denominator 34 |
| Staff flu vaccination coverage | 1.9% |
42%
40.1 pts worse
|
Numerator 2 · Denominator 105 |
| Discharge function score | 64.66% |
56.45%
8.2 pts better
|
Numerator 75 · Denominator 116 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 49 · Denominator 49 |
| Transfer of health information to patient | 98.41% |
96.28%
2.1 pts better
|
Numerator 124 · Denominator 126 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 104 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.3 |
2.1
2.2 pts worse
|
1.9
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 4.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.1
1.7 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
97.1%
2 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.3% |
97.9%
4.6 pts worse
|
95.5%
2.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.3%
2.4 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.7% |
2.7%
4 pts worse
|
11.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 14.3% · Q3 0.0% · Q4 4.5% · 4Q avg 6.7% |
| Percentage of long-stay residents who lose too much weight | 18.3% |
3.3%
15 pts worse
|
5.4%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
18.9%
2.2 pts worse
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q4 20.0% · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
10.8%
2.2 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · 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 need for help with daily activities has increased | 22.0% |
16.1%
5.9 pts worse
|
14.9%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
0.8%
1.2 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 4.8% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
15.0%
15.9 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.7% · Q2 26.2% · Q4 17.5% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.2%
0.4 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.7% · Q3 5.5% · Q4 2.4% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
89.7%
5 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 94.4% · Q3 98.5% · Q4 94.5% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
12.0%
4.1 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.9% · Observed 8.3% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.5%
0.2 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 2.0% · Q4 1.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.5% |
88.0%
3.5 pts better
|
79.7%
11.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
25.9%
0.5 pts better
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 27.8% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-20 · Fire 2023-07-20
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-07-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-08
D · Potential for more than minimal harm
2023-07-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-22
D · Potential for more than minimal harm
2025-11-19
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 2025-11-20
D · Potential for more than minimal harm
2025-09-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-30
E · Potential for more than minimal harm
2024-08-29
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 2024-10-09
E · Potential for more than minimal harm
2023-07-20
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 2023-07-24
D · Potential for more than minimal harm
2023-07-20
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 2023-07-24
Penalties and ownership
What sits behind the stars
$4,587
2023-11-20
Fine
Fine · fine $4,587
Fine
$4,587
2023-11-13
Fine
Fine · fine $4,587
Fine
$4,587
2023-11-06
Fine
Fine · fine $4,587
Fine
$13,762
2023-10-17
Fine
Fine · fine $13,762
Fine
Ownership
The Legacy Midtown Park Inc
5% Or Greater Direct Ownership Interest · Organization
Scott, Bridgette
Operational/Managerial Control · Individual
Snorton, Scott
Corporate Officer · Individual
The Legacy Senior Communities Inc
Operational/Managerial Control · Organization
Walshe, Bridgette
Corporate Director · Individual
Nearby options
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#2
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#3
The Highlands Guest Care Center
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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
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