Cycle 1
Health 2025-03-13 · Fire 2025-03-13
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Electrical (1 deficiency)
Richardson, TX
The Reserve At Richardson
3-star overall rating with 3-star inspections with $29,835 in total fines with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1610 Richardson Dr, Richardson, TX
(972) 600-8219
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
129
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hamilton County Hospital District
Operator or chain grouping
Approved since
2018-06-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 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
Staffing
Hours and turnover
RN hours / resident day
0.23
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.00
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
1.15
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.79
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
0.23
CMS adjusted RN staffing hours
Adjusted total hours
3.16
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,828
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9915
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6
Baseline 23.52% · Performance 19.30% · Measure score 6 · Achievement 4.61 · Improvement 6
Healthcare-associated infections
5.16
Baseline 6.24% · Performance 6.29% · Measure score 5.16 · Achievement 5.16 · Improvement 0
Total nurse turnover
4.21
Performance 46.48% · Measure score 4.21 · Achievement 4.21 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.80 hours · Performance 2.87 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.37% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 6.52% · Lower 95% interval 6.27% |
| Discharge to community | 51.22% |
50.57%
0.6 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 43.84% · Lower 95% interval 40.03% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 66 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 63.89% |
53.69%
10.2 pts better
|
Numerator 23 · Denominator 36 |
| Discharge mobility score | 58.33% |
50.94%
7.4 pts better
|
Numerator 21 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 1.52% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 66 · Adjusted rate 0.88% |
| Healthcare-associated infections requiring hospitalization | 6.29% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 5.08% · Lower 95% interval 3.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 78 |
| Staff flu vaccination coverage | 35.63% |
42%
6.4 pts worse
|
Numerator 57 · Denominator 160 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 24 · Denominator 36 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 22% |
25.2%
3.2 pts worse
|
Numerator 11 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.7 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.1%
2.5 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 3.4% |
2.7%
0.7 pts worse
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
3.3%
2.1 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 2.4% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.9% |
18.9%
5 pts worse
|
19.6%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 20.0% · Q3 20.8% · Q4 28.9% · 4Q avg 23.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.5% |
10.8%
5.3 pts better
|
16.7%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 8.1% · Q3 2.7% · Q4 5.6% · 4Q avg 5.5% · 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 | 17.8% |
15.4%
2.4 pts worse
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.1% |
16.1%
4 pts worse
|
14.9%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 23.5% · Q3 19.0% · Q4 20.0% · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.5%
1.6 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
0.8%
1.1 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 0.0% · Q4 3.9% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.6% |
15.0%
0.6 pts worse
|
19.8%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 3.1% · Q3 11.9% · Q4 21.4% · 4Q avg 15.6% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
4.2%
1.9 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 3.1% · Q3 9.2% · Q4 4.5% · 4Q avg 6.1% · 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 | 15.5% |
12.0%
3.5 pts worse
|
12.0%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 16.1% · 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 4.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · 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 | 33.4% |
25.9%
7.5 pts worse
|
23.9%
9.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.4% · Observed 35.5% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-13
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-03-14
F · Potential for more than minimal harm
2024-02-15
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-03-08
F · Potential for more than minimal harm
2024-02-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-02-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-02-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-08
E · Potential for more than minimal harm
2024-02-15
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-15
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
D · Potential for more than minimal harm
2023-01-12
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-02-10
D · Potential for more than minimal harm
2023-01-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-02-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-12-09
D · Potential for more than minimal harm
2025-12-02
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 2025-12-09
E · Potential for more than minimal harm
2025-06-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-18
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 2025-07-10
D · Potential for more than minimal harm
2025-06-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-03-13
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 2025-04-04
E · Potential for more than minimal harm
2025-03-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-13
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 2025-04-04
D · Potential for more than minimal harm
2025-03-13
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 2025-04-04
D · Potential for more than minimal harm
2025-03-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-13
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 2025-04-04
D · Potential for more than minimal harm
2025-03-13
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 2025-04-04
D · Potential for more than minimal harm
2025-03-13
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 2025-04-04
D · Potential for more than minimal harm
2025-03-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
J · Immediate jeopardy
2025-03-10
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 2025-02-02
E · Potential for more than minimal harm
2024-02-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-15
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 2024-03-08
D · Potential for more than minimal harm
2024-02-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-15
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 2024-03-08
D · Potential for more than minimal harm
2024-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-08
G · Actual harm
2023-04-12
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 2023-05-05
D · Potential for more than minimal harm
2023-03-09
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-01-12
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 2023-02-09
D · Potential for more than minimal harm
2023-01-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-01-12
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 2023-02-09
D · Potential for more than minimal harm
2023-01-12
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 2023-02-09
D · Potential for more than minimal harm
2023-01-12
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-02-09
Penalties and ownership
What sits behind the stars
$21,645
2025-03-10
Fine
Fine · fine $21,645
Fine
$8,190
2023-04-12
Fine
Fine · fine $8,190
Fine
Ownership
Hamilton County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Dkp Investments, LLC
Operational/Managerial Control · Organization
Go Operations 6 LLC
Operational/Managerial Control · Organization
Golden, Lauren
Operational/Managerial Control · Individual
Golden, Shawn
Operational/Managerial Control · Individual
Hooper, Grady
Corporate Officer · Individual
Hurst, Roy
Operational/Managerial Control · Individual
Prince, Danny
Operational/Managerial Control · Individual
Slm Investments LLC
Operational/Managerial Control · Organization
Nearby options
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#2
Richardson Nursing And Rehabilitation
Richardson, TX
1-star overall rating with 2-star inspections with $36,140 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Cottonwood Creek Healthcare Community
Richardson, TX
5-star overall rating with 4-star inspections with $7,443 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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