Dallas, TX

The Lennwood Nursing And Rehabilitation

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

8017 W Virginia Dr, Dallas, TX

(972) 709-1112

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 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

124

Certified beds

Average residents

61

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Paramount Healthcare

Operator or chain grouping

Approved since

2000-03-09

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

0.39

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.85

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.86

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.10

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.24

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.66

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

0.41

CMS adjusted RN staffing hours

Adjusted total hours

3.24

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

73%

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

13,163

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

7.82

Composite VBP score used to determine payment impact.

Payment multiplier

0.9807

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

2.35

Baseline 8.55% · Performance 7.54% · Measure score 2.35 · Achievement 0.99 · Improvement 2.35

Total nurse turnover

0

Performance 70.00% · 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 3.02 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.73%
10.72%
1 pts better
No Different than the National Rate · Eligible stays 44 · Observed rate 6.82% · Lower 95% interval 6.58%
Discharge to community 59.3%
50.57%
8.7 pts better
No Different than the National Rate · Eligible stays 33 · Observed rate 57.58% · Lower 95% interval 43.81%
Medicare spending per beneficiary 1.23
1.02
0.2 pts worse
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 47 · Denominator 47
Falls with major injury 4.26%
0.77%
3.5 pts worse
Numerator 2 · Denominator 47
Discharge self-care score 52%
53.69%
1.7 pts worse
Numerator 13 · Denominator 25
Discharge mobility score 32%
50.94%
18.9 pts worse
Numerator 8 · Denominator 25
Pressure ulcers or injuries, new or worsened 0%
2.29%
2.3 pts better
Numerator 0 · Denominator 47 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization 7.54%
7.12%
0.4 pts worse
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 4.09%
Staff COVID-19 vaccination coverage 0%
8.2%
8.2 pts worse
Numerator 0 · Denominator 96
Staff flu vaccination coverage 22.88%
42%
19.1 pts worse
Numerator 35 · Denominator 153
Discharge function score 40%
56.45%
16.5 pts worse
Numerator 10 · Denominator 25
Transfer of health information to provider 95.45%
95.95%
0.5 pts worse
Numerator 21 · Denominator 22
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 8.7%
25.2%
16.5 pts worse
Numerator 2 · Denominator 23

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.7
2.1
0.4 pts better
1.9
0.2 pts better
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.1
2.1
About the same
1.8
0.3 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 99.2%
97.1%
2.1 pts better
93.4%
5.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.2%
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 1.2%
3.3%
2.1 pts better
3.3%
2.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 1.8% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 0.4%
2.7%
2.3 pts better
11.4%
11 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents who lose too much weight 0.9%
3.3%
2.4 pts better
5.4%
4.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 2.0% · Q4 0.0% · 4Q avg 0.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 6.0%
18.9%
12.9 pts better
19.6%
13.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 5.1% · Q3 8.0% · Q4 7.8% · 4Q avg 6.0%
Percentage of long-stay residents who received an antipsychotic medication 7.6%
10.8%
3.2 pts better
16.7%
9.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.0% · Q3 9.5% · Q4 7.3% · 4Q avg 7.6% · 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 ability to walk independently worsened 22.0%
15.4%
6.6 pts worse
16.3%
5.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q2 40.5% · 4Q avg 22.0% · 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 13.5% · Q2 16.4% · Q3 4.1% · Q4 8.5% · 4Q avg 10.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 3.5%
0.5%
3 pts worse
1.0%
2.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.7% · Q3 4.3% · Q4 3.1% · 4Q avg 3.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.4%
0.8%
0.4 pts better
1.7%
1.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 13.8%
15.0%
1.2 pts better
19.8%
6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 11.5% · Q3 13.6% · Q4 20.9% · 4Q avg 13.8%
Percentage of long-stay residents with pressure ulcers 2.9%
4.2%
1.3 pts better
5.1%
2.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 5.4% · Q3 2.0% · Q4 2.1% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 99.2%
89.7%
9.5 pts better
81.7%
17.5 pts better
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 98.3% · Q4 100.0% · 4Q avg 99.2%
Percentage of short-stay residents who had an outpatient emergency department visit 18.2%
12.0%
6.2 pts worse
12.0%
6.2 pts worse
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 20.8% · Expected 12.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
1.5%
1.5 pts better
1.6%
1.6 pts better
Short 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 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 27.1%
25.9%
1.2 pts worse
23.9%
3.2 pts worse
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 29.2% · Expected 25.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-29 · Fire 2024-08-29

5 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

19 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Cycle 2 Health 2023-07-12 · Fire 2023-07-12

12 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2022-04-28 · Fire 2022-04-28

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-12-11

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 2025-12-12

E · Potential for more than minimal harm 2025-12-11

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-12-12

D · Potential for more than minimal harm 2025-12-11

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-12-12

D · Potential for more than minimal harm 2025-12-11

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-12-12

F · Potential for more than minimal harm 2024-08-29

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2024-09-27

F · Potential for more than minimal harm 2024-08-29

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-09-18

F · Potential for more than minimal harm 2024-08-29

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-09-18

F · Potential for more than minimal harm 2024-08-29

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2024-09-18

F · Potential for more than minimal harm 2024-08-29

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2024-09-18

F · Potential for more than minimal harm 2024-08-29

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-09-20

F · Potential for more than minimal harm 2024-08-29

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-09-23

F · Potential for more than minimal harm 2024-08-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-09-23

F · Potential for more than minimal harm 2024-08-29

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-09-23

F · Potential for more than minimal harm 2024-08-29

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-09-23

F · Potential for more than minimal harm 2024-08-29

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-09-27

E · Potential for more than minimal harm 2024-08-29

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-09-18

E · Potential for more than minimal harm 2024-08-29

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-09-18

E · Potential for more than minimal harm 2024-08-29

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-09-18

E · Potential for more than minimal harm 2024-08-29

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-09-18

F · Potential for more than minimal harm 2023-07-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-08-03

D · Potential for more than minimal harm 2023-07-12

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 2023-07-18

D · Potential for more than minimal harm 2023-07-12

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-07-17

F · Potential for more than minimal harm 2022-04-28

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2022-06-03

F · Potential for more than minimal harm 2022-04-28

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 2022-06-03

F · Potential for more than minimal harm 2022-04-28

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-06-03

F · Potential for more than minimal harm 2022-04-28

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-06-03

F · Potential for more than minimal harm 2022-04-28

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-06-03

F · Potential for more than minimal harm 2022-04-28

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-06-03

E · Potential for more than minimal harm 2022-04-28

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 2022-06-03

E · Potential for more than minimal harm 2022-04-28

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-06-03

E · Potential for more than minimal harm 2022-04-28

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2022-06-03

Inspection history

Recent health citations

J · Immediate jeopardy 2025-05-07

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 2025-04-01

D · Potential for more than minimal harm 2025-05-07

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 2025-05-30

D · Potential for more than minimal harm 2025-03-01

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 2024-10-17

E · Potential for more than minimal harm 2025-02-07

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-03-10

E · Potential for more than minimal harm 2025-02-07

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 2025-03-10

E · Potential for more than minimal harm 2025-02-07

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 2025-03-10

E · Potential for more than minimal harm 2025-02-07

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 2025-03-10

E · Potential for more than minimal harm 2025-02-07

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2025-03-10

E · Potential for more than minimal harm 2024-08-29

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-08-29

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-23

K · Immediate jeopardy 2024-07-01

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 2024-07-26

K · Immediate jeopardy 2024-07-01

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-07-26

E · Potential for more than minimal harm 2024-07-01

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 2024-07-26

D · Potential for more than minimal harm 2024-07-01

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 2024-07-26

E · Potential for more than minimal harm 2024-03-20

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-04-09

E · Potential for more than minimal harm 2024-03-20

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 2024-04-09

D · Potential for more than minimal harm 2024-01-04

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2024-01-05

D · Potential for more than minimal harm 2023-07-12

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 2023-07-13

D · Potential for more than minimal harm 2022-04-28

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 2022-05-27

D · Potential for more than minimal harm 2022-04-28

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2022-05-27

D · Potential for more than minimal harm 2022-04-28

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2022-05-27

D · Potential for more than minimal harm 2022-04-28

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 2022-05-27

D · Potential for more than minimal harm 2022-04-28

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-05-27

C · Minimal harm 2022-04-28

F727 · Nursing and Physician Services Deficiencies

Health

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Corrected 2022-05-27

Penalties and ownership

What sits behind the stars

$9,113 2025-05-07

Fine

Fine · fine $9,113

Fine

$20,856 2024-07-01

Fine

Fine · fine $20,856

Fine

Ownership

Hamilton County Hospital District

5% Or Greater Direct Ownership Interest · Organization

100% 55 facilities 2023-04-01
D K Lancaster Land Co LP

Operational/Managerial Control · Organization

0% 1 facilities 2023-04-01
Dkp Investments, LLC

Operational/Managerial Control · Organization

0% 10 facilities 2023-04-01
Dkp Investments, LLC

5% Or Greater Mortgage Interest · Organization

0% 10 facilities 2023-04-01
Golden, Lauren

Operational/Managerial Control · Individual

0% 8 facilities 2023-04-01
Hooper, Grady

Corporate Officer · Individual

0% 61 facilities 2023-04-01
Llld Associates, LP

5% Or Greater Mortgage Interest · Organization

0% 2 facilities 2023-04-01
Port Au Prince LLC

5% Or Greater Mortgage Interest · Organization

0% 4 facilities 2023-04-01
Prince, Danny

Operational/Managerial Control · Individual

0% 12 facilities 2023-04-01

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#3

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Overall
3 / 5
Health
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Staffing
1 / 5
Fines
$8,514

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