Cycle 1
Health 2025-07-22 · Fire 2025-07-22
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Dallas, TX
Traymore Nursing Center
4-star overall rating with 4-star inspections with $15,733 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
4315 Hopkins Ave, Dallas, TX
(214) 358-3131
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
103
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Foursquare Healthcare
Operator or chain grouping
Approved since
1998-06-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 4 health / 1 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
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
2.81
CMS adjusted total nurse staffing hours
Case-mix index
1.78
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,363
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.64% · Performance 21.40% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.52
Baseline 9.88% · Performance 6.94% · Measure score 5.52 · Achievement 2.98 · Improvement 5.52
Total nurse turnover
2.74
Baseline 75.42% · Performance 59.04% · Measure score 2.74 · Achievement 1.14 · Improvement 2.74
Adjusted total nurse staffing
0
Baseline 2.42 hours · Performance 2.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 11.67% · Lower 95% interval 7.06% |
| Discharge to community | 46.26% |
50.57%
4.3 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 33.33% · Lower 95% interval 30.87% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 15.25% |
95.27%
80 pts worse
|
Numerator 9 · Denominator 59 |
| Falls with major injury | 1.69% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 59 |
| Discharge self-care score | 48% |
53.69%
5.7 pts worse
|
Numerator 12 · Denominator 25 |
| Discharge mobility score | 56% |
50.94%
5.1 pts better
|
Numerator 14 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 59 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 9.62% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 25 · Denominator 25 |
| Staff flu vaccination coverage | 7.76% |
42%
34.2 pts worse
|
Numerator 9 · Denominator 116 |
| Discharge function score | 76% |
56.45%
19.5 pts better
|
Numerator 19 · Denominator 25 |
| Transfer of health information to provider | 14.81% |
95.95%
81.1 pts worse
|
Numerator 4 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 6.2 · Expected 4.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.5 · Expected 2.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
97.1%
2.6 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
97.9%
0.1 pts worse
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 0.0% · Q4 3.3% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 52.6% |
2.7%
49.9 pts worse
|
11.4%
41.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 90.0% · Q3 31.9% · Q4 21.9% · 4Q avg 52.6% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 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 received an antianxiety or hypnotic medication | 16.4% |
18.9%
2.5 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 15.9% · Q3 17.7% · Q4 17.5% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
10.8%
7.7 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 1.7% · Q3 3.6% · Q4 1.8% · 4Q avg 3.1% · 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 | 14.0% |
15.4%
1.4 pts better
|
16.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
16.1%
1.6 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 9.2% · Q3 21.9% · Q4 12.5% · 4Q avg 14.5% · 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 | 2.4% |
0.8%
1.6 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 2.5% · Q4 5.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.6% |
15.0%
5.6 pts worse
|
19.8%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 28.2% · Q3 22.5% · Q4 13.3% · 4Q avg 20.6% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.2%
1.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 3.3% · Q4 2.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
89.7%
6.5 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 94.8% · Q3 97.2% · Q4 96.1% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.2% |
12.0%
8.8 pts better
|
12.0%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.2% · Observed 3.4% · Expected 11.8% · 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 | 72.3% |
88.0%
15.7 pts worse
|
79.7%
7.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
25.9%
0.1 pts worse
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 33.9% · Expected 31.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-20 · Fire 2024-06-20
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-22
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-07-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-15
F · Potential for more than minimal harm
2025-07-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-07-22
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 2025-09-15
E · Potential for more than minimal harm
2025-07-22
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 2025-09-15
E · Potential for more than minimal harm
2025-07-22
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-09-15
C · Minimal harm
2025-07-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-15
F · Potential for more than minimal harm
2024-06-20
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-04
C · Minimal harm
2023-05-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-22
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 2025-08-15
K · Immediate jeopardy
2025-05-31
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-05-30
D · Potential for more than minimal harm
2024-08-23
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 2024-08-26
D · Potential for more than minimal harm
2024-06-20
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-06-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-21
G · Actual harm
2024-01-24
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 2024-01-25
E · Potential for more than minimal harm
2023-05-11
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 2023-06-10
E · Potential for more than minimal harm
2023-05-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-10
Penalties and ownership
What sits behind the stars
$15,733
2025-05-31
Fine
Fine · fine $15,733
Fine
Ownership
Nocona Hospital District
5% Or Greater Direct Ownership Interest · Organization
Lewis, Shane
Operational/Managerial Control · Individual
Meekins, Greg
Corporate Director · Individual
Uptown Fs LLC
Operational/Managerial Control · Organization
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#3
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