Dallas, TX

The Villages Of Dallas

4-star overall rating with 3-star inspections with $31,303 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

550 E Ann Arbor Ave, Dallas, TX

(214) 376-1701

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

160

Certified beds

Average residents

104

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

1996-05-08

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

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

0.28

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

1.39

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.65

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

4.31

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.66

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.70

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.32

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.39

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.29

CMS adjusted RN staffing hours

Adjusted total hours

4.50

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

64%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

63%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,787

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

Performance score

28.78

Composite VBP score used to determine payment impact.

Payment multiplier

0.9851

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.63

Baseline 19.73% · Performance 19.28% · Measure score 4.63 · Achievement 4.63 · Improvement 1.15

Healthcare-associated infections

Baseline 5.53% · Performance 7.81% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

1.72

Baseline 66.67% · Performance 57.38% · Measure score 1.72 · Achievement 1.54 · Improvement 1.72

Adjusted total nurse staffing

5.15

Baseline 3.24 hours · Performance 4.54 hours · Measure score 5.15 · Achievement 5.15 · Improvement 4.64

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.62%	10.72% 1.1 pts better	No Different than the National Rate · Eligible stays 111 · Observed rate 8.11% · Lower 95% interval 6.31%
Discharge to community	59.27%	50.57% 8.7 pts better	No Different than the National Rate · Eligible stays 91 · Observed rate 49.45% · Lower 95% interval 47.75%
Medicare spending per beneficiary	1.18	1.02 0.2 pts worse
Drug regimen review with follow-up	95.89%	95.27% 0.6 pts better	Numerator 70 · Denominator 73
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 73
Discharge self-care score	33.33%	53.69% 20.4 pts worse	Numerator 14 · Denominator 42
Discharge mobility score	38.1%	50.94% 12.8 pts worse	Numerator 16 · Denominator 42
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 73 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.81%	7.12% 0.7 pts worse	No Different than the National Rate · Eligible stays 58 · Observed rate 10.34% · Lower 95% interval 4.35%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 174
Staff flu vaccination coverage	6.64%	42% 35.4 pts worse	Numerator 19 · Denominator 286
Discharge function score	52.38%	56.45% 4.1 pts worse	Numerator 22 · Denominator 42
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 26 · Denominator 26
Resident COVID-19 vaccinations up to date	3.03%	25.2% 22.2 pts worse	Numerator 1 · Denominator 33

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.2	2.1 0.1 pts worse	1.9 0.3 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.9	2.1 1.2 pts better	1.8 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.9%	97.1% 1.8 pts better	93.4% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 97.8% · Q3 100.0% · Q4 98.8% · 4Q avg 98.9%
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	1.7%	3.3% 1.6 pts better	3.3% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.2% · Q3 1.2% · Q4 0.0% · 4Q avg 1.7% · 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	0.6%	3.3% 2.7 pts better	5.4% 4.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.2% · 4Q avg 0.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	12.0%	18.9% 6.9 pts better	19.6% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 12.9% · Q3 10.4% · Q4 10.7% · 4Q avg 12.0%
Percentage of long-stay residents who received an antipsychotic medication	4.1%	10.8% 6.7 pts better	16.7% 12.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 3.4% · Q3 3.3% · Q4 4.8% · 4Q avg 4.1% · 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	8.4%	15.4% 7 pts better	16.3% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 8.6% · Q3 9.2% · Q4 12.5% · 4Q avg 8.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	15.8%	16.1% 0.3 pts better	14.9% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 17.2% · Q3 13.3% · Q4 11.8% · 4Q avg 15.8% · 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	19.6%	15.0% 4.6 pts worse	19.8% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 16.0% · Q3 12.3% · Q4 18.9% · 4Q avg 19.6%
Percentage of long-stay residents with pressure ulcers	3.2%	4.2% 1 pts better	5.1% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.2% · Q3 2.6% · Q4 3.1% · 4Q avg 3.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	88.9%	89.7% 0.8 pts worse	81.7% 7.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 91.1% · Q2 92.5% · Q3 88.9% · Q4 83.0% · 4Q avg 88.9%
Percentage of short-stay residents who had an outpatient emergency department visit	14.0%	12.0% 2 pts worse	12.0% 2 pts worse	Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 13.2% · Expected 10.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.5%	1.5% About the same	1.6% 0.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 1.4% · Q4 1.6% · 4Q avg 1.5% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	86.0%	88.0% 2 pts worse	79.7% 6.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 86.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	18.5%	25.9% 7.4 pts better	23.9% 5.4 pts better	Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 17.0% · Expected 21.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-06 · Fire 2025-02-06

8 health deficiencies

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

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-12-21 · Fire 2023-12-21

20 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2022-10-14 · Fire 2022-10-14

7 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-06

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2025-03-07

E · Potential for more than minimal harm 2025-02-06

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-03-04

E · Potential for more than minimal harm 2022-10-14

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-11-03

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-09

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-09-13

D · Potential for more than minimal harm 2025-09-09

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2025-09-13

D · Potential for more than minimal harm 2025-03-14

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 2025-03-31

D · Potential for more than minimal harm 2025-03-14

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 2025-03-31

E · Potential for more than minimal harm 2025-02-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-08

D · Potential for more than minimal harm 2025-02-06

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-02-08

D · Potential for more than minimal harm 2025-02-06

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 2025-02-08

D · Potential for more than minimal harm 2025-02-06

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 2025-02-08

J · Immediate jeopardy 2024-10-02

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 2024-10-03

E · Potential for more than minimal harm 2024-10-02

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-10-03

E · Potential for more than minimal harm 2024-10-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-30

D · Potential for more than minimal harm 2024-10-02

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-10-03

D · Potential for more than minimal harm 2024-10-02

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 2024-10-03

E · Potential for more than minimal harm 2024-06-14

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-06-17

D · Potential for more than minimal harm 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 2024-06-17

K · Immediate jeopardy 2024-06-10

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 2024-06-06

J · Immediate jeopardy 2024-06-10

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 2024-06-06

E · Potential for more than minimal harm 2023-12-21

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-12-29

E · Potential for more than minimal harm 2023-12-21

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-12-29

E · Potential for more than minimal harm 2023-12-21

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-12-29

E · Potential for more than minimal harm 2023-12-21

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 2023-12-29

E · Potential for more than minimal harm 2023-12-21

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 2023-12-29