Cycle 1
Health 2025-07-03 · Fire 2025-07-03
14 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Irving, TX
The Villages on MacArthur
3-star overall rating with 2-star inspections with abuse icon flag with $25,259 in total fines with 14 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
3443 N MacArthur Blvd, Irving, TX
(469) 586-4424
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
124
Certified beds
Average residents
113
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Stonegate Senior Living
Operator or chain grouping
Approved since
2014-02-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
24 facilities
Chain averages 2 overall / 2 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
0.47
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.88
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
3.35
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,324
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9980
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.87
Baseline 19.15% · Performance 19.64% · Measure score 3.87 · Achievement 3.87 · Improvement 0
Healthcare-associated infections
10
Baseline 5.26% · Performance 4.84% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
3.12
Baseline 52.63% · Performance 50.93% · Measure score 3.12 · Achievement 3.12 · Improvement 0.11
Adjusted total nurse staffing
0.96
Baseline 3.03 hours · Performance 3.35 hours · Measure score 0.96 · Achievement 0.96 · Improvement 0.67
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 175 · Observed rate 10.86% · Lower 95% interval 7.42% |
| Discharge to community | 58.87% |
50.57%
8.3 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 51.48% · Lower 95% interval 48.91% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.33% |
95.27%
4.1 pts better
|
Numerator 149 · Denominator 150 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 150 |
| Discharge self-care score | 52.58% |
53.69%
1.1 pts worse
|
Numerator 51 · Denominator 97 |
| Discharge mobility score | 38.14% |
50.94%
12.8 pts worse
|
Numerator 37 · Denominator 97 |
| Pressure ulcers or injuries, new or worsened | 0.67% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 150 · Adjusted rate 0.65% |
| Healthcare-associated infections requiring hospitalization | 4.84% |
7.12%
2.3 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 0.99% · Lower 95% interval 2.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 165 |
| Staff flu vaccination coverage | 86.93% |
42%
44.9 pts better
|
Numerator 133 · Denominator 153 |
| Discharge function score | 43.3% |
56.45%
13.2 pts worse
|
Numerator 42 · Denominator 97 |
| Transfer of health information to provider | 91.3% |
95.95%
4.7 pts worse
|
Numerator 63 · Denominator 69 |
| Transfer of health information to patient | 71.43% |
96.28%
24.8 pts worse
|
Numerator 45 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 2.15% |
25.2%
23.1 pts worse
|
Numerator 2 · Denominator 93 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.1
1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.8 · Expected 3.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.1
1.5 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.7 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
97.1%
1.9 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.7% · Q4 97.3% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
97.9%
2.8 pts worse
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.3%
1.7 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 4.1% · 4Q avg 1.6% · 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 6.1% · Q2 0.0% · Q3 5.8% · Q4 1.4% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
3.3%
3 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.8% · Q3 3.0% · Q4 4.5% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
18.9%
0.5 pts worse
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 21.4% · Q3 20.6% · Q4 16.7% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
10.8%
1.2 pts worse
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 9.7% · Q3 12.9% · Q4 15.3% · 4Q avg 12.0% · 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 | 15.8% |
15.4%
0.4 pts worse
|
16.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 25.1% · Q4 25.8% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
16.1%
6.5 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 8.6% · Q3 6.7% · Q4 18.0% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.5% · 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 | 9.8% |
15.0%
5.2 pts better
|
19.8%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 11.6% · Q3 8.0% · Q4 11.0% · 4Q avg 9.8% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.2%
0.9 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.4% · Q3 3.3% · Q4 3.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.3% |
89.7%
0.6 pts better
|
81.7%
8.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.4% · Q2 89.4% · Q3 93.0% · Q4 91.3% · 4Q avg 90.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
12.0%
2.5 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 10.1% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.8% · Q3 0.6% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.4% |
88.0%
2.4 pts better
|
79.7%
10.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
25.9%
7.3 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 21.6% · Expected 27.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2024-06-06
11 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-04-27 · Fire 2023-04-27
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-03
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-07-03
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-07-03
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-07-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-07-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-22
F · Potential for more than minimal harm
2025-07-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-22
E · Potential for more than minimal harm
2025-07-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-22
E · Potential for more than minimal harm
2025-07-03
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 2025-07-22
E · Potential for more than minimal harm
2025-07-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-22
E · Potential for more than minimal harm
2025-07-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-07-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-22
F · Potential for more than minimal harm
2024-06-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-01-05
G · Actual harm
2025-07-03
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 2025-03-03
F · Potential for more than minimal harm
2025-07-03
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-07-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-07-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-07-03
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
2025-07-03
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-07-03
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-08-06
D · Potential for more than minimal harm
2025-07-03
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 2025-07-10
D · Potential for more than minimal harm
2025-07-03
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 2025-07-10
D · Potential for more than minimal harm
2025-07-03
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
2025-07-03
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 2025-07-10
D · Potential for more than minimal harm
2025-07-03
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
2025-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-10
J · Immediate jeopardy
2025-02-21
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
2025-02-21
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-03-14
D · Potential for more than minimal harm
2024-09-13
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 2024-09-20
E · Potential for more than minimal harm
2024-09-06
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 2024-09-13
E · Potential for more than minimal harm
2024-06-06
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 2024-06-14
E · Potential for more than minimal harm
2024-06-06
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 2024-06-14
E · Potential for more than minimal harm
2024-06-06
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 2024-06-14
E · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-06-06
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-06-06
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 2024-06-14
D · Potential for more than minimal harm
2024-06-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-01-10
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 2024-02-02
E · Potential for more than minimal harm
2023-04-27
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 2023-05-05
D · Potential for more than minimal harm
2023-04-27
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-27
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 2023-05-05
D · Potential for more than minimal harm
2023-03-06
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-03-06
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-03-06
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-03-06
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-03-06
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 2023-03-10
D · Potential for more than minimal harm
2023-03-06
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-03-06
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-03-10
Penalties and ownership
What sits behind the stars
$11,190
2025-07-03
Fine
Fine · fine $11,190
Fine
$14,069
2025-02-21
Fine
Fine · fine $14,069
Fine
Ownership
South Limestone Hospital District
5% Or Greater Direct Ownership Interest · Organization
Olvera, Noel
Operational/Managerial Control · Individual
Pf Irving SNF Ops, LLC
Operational/Managerial Control · Organization
Price, Larry
Corporate Officer · Individual
Stonegate Senior Living, LP
Operational/Managerial Control · Organization
Umb Bank Na
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Northgate Plaza
Irving, TX
1-star overall rating with 1-star inspections with $55,697 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Ashford Hall
Irving, TX
1-star overall rating with 1-star inspections with abuse icon flag with $285,320 in total fines with 7 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Las Brisas Rehabilitation And Wellness Center
Irving, TX
3-star overall rating with 3-star inspections with $18,274 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out