Cycle 1
Health 2025-05-29 · Fire 2025-05-29
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Frisco, TX
Victoria Gardens Of Frisco
4-star overall rating with 4-star inspections with $23,546 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
10700 Rolater Dr, Frisco, TX
(972) 712-8652
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
118
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Priority Management
Operator or chain grouping
Approved since
1999-11-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 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
0.40
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.88
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.14
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,775
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.48
Baseline 23.61% · Performance 20.34% · Measure score 4.48 · Achievement 2.36 · Improvement 4.48
Healthcare-associated infections
6
Baseline 9.71% · Performance 6.65% · Measure score 6 · Achievement 3.97 · Improvement 6
Total nurse turnover
1.49
Baseline 62.16% · Performance 57.58% · Measure score 1.49 · Achievement 1.49 · Improvement 0.73
Adjusted total nurse staffing
0.73
Baseline 3.36 hours · Performance 3.29 hours · Measure score 0.73 · Achievement 0.73 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.2% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 9.43% · Lower 95% interval 6.49% |
| Discharge to community | 54.16% |
50.57%
3.6 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 42.86% · Lower 95% interval 38.68% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 92.59% |
95.27%
2.7 pts worse
|
Numerator 25 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 11.11% |
8.2%
2.9 pts better
|
Numerator 11 · Denominator 99 |
| Staff flu vaccination coverage | 44.25% |
42%
2.2 pts better
|
Numerator 50 · Denominator 113 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
97.1%
3.2 pts worse
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 92.9% · Q3 97.1% · Q4 100.0% · 4Q avg 93.9% |
| 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 | 5.0% |
3.3%
1.7 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.1% · Q3 4.4% · Q4 2.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
2.7%
2.5 pts worse
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.0% · Q3 4.6% · Q4 9.9% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.3%
0.5 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.6% · Q3 2.0% · Q4 1.8% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.4% |
18.9%
4.5 pts worse
|
19.6%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 17.7% · Q3 25.4% · Q4 31.7% · 4Q avg 23.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.7% |
10.8%
6.1 pts better
|
16.7%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.9% · Q3 4.5% · Q4 7.3% · 4Q avg 4.7% · 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 | 12.8% |
15.4%
2.6 pts better
|
16.3%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 14.0% · Q3 9.7% · Q4 4.9% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
16.1%
3.4 pts better
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 18.6% · Q3 7.5% · Q4 7.5% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.5%
0.2 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.6% |
15.0%
1.6 pts worse
|
19.8%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 15.2% · Q3 9.3% · Q4 25.9% · 4Q avg 16.6% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.2%
0.8 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.6% · Q3 2.4% · Q4 0.9% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.8% |
89.7%
1.1 pts better
|
81.7%
9.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 70.4% · Q2 92.0% · Q3 100.0% · Q4 100.0% · 4Q avg 90.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.1% |
12.0%
9.9 pts better
|
12.0%
9.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.1% · Observed 2.4% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 7.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.2% |
88.0%
0.8 pts worse
|
79.7%
7.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
25.9%
1 pts better
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 23.8% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-18 · Fire 2024-04-18
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Cycle 3
Health 2023-03-02 · Fire 2023-03-02
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-19
F · Potential for more than minimal harm
2025-05-29
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 2025-06-19
E · Potential for more than minimal harm
2025-05-29
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 2025-06-19
E · Potential for more than minimal harm
2025-05-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-19
F · Potential for more than minimal harm
2024-04-18
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-18
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-18
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-18
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-18
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 2024-05-17
F · Potential for more than minimal harm
2024-04-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-01
E · Potential for more than minimal harm
2024-04-18
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-06-01
E · Potential for more than minimal harm
2024-04-18
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 2024-05-29
E · Potential for more than minimal harm
2024-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-04-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-01
E · Potential for more than minimal harm
2023-03-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-07
E · Potential for more than minimal harm
2023-03-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-03-02
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 2023-03-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-02-05
E · Potential for more than minimal harm
2025-12-08
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 2025-12-10
E · Potential for more than minimal harm
2025-05-29
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 2025-06-18
D · Potential for more than minimal harm
2025-05-29
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 2025-03-17
J · Immediate jeopardy
2025-02-25
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 2025-02-22
J · Immediate jeopardy
2024-10-23
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 2024-09-09
D · Potential for more than minimal harm
2024-06-13
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-07-08
E · Potential for more than minimal harm
2024-04-18
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 2024-05-25
E · Potential for more than minimal harm
2024-04-18
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 2024-05-25
E · Potential for more than minimal harm
2024-04-18
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-05-25
E · Potential for more than minimal harm
2024-03-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-12
D · Potential for more than minimal harm
2023-12-16
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-12-16
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-12-29
D · Potential for more than minimal harm
2023-04-20
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 2023-05-19
D · Potential for more than minimal harm
2023-04-20
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 2023-05-19
D · Potential for more than minimal harm
2023-04-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-03-02
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 2023-03-10
D · Potential for more than minimal harm
2023-03-02
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 2023-03-10
Penalties and ownership
What sits behind the stars
$9,113
2025-02-25
Fine
Fine · fine $9,113
Fine
$14,433
2024-10-23
Fine
Fine · fine $14,433
Fine
Ownership
Boulware, Steven
5% Or Greater Indirect Ownership Interest · Individual
Bauder Family Investments, LLC
5% Or Greater Direct Ownership Interest · Organization
Boulware St James LLC
5% Or Greater Direct Ownership Interest · Organization
Steven Boulware Family Investments LLC
5% Or Greater Direct Ownership Interest · Organization
Bauder, Kelly
5% Or Greater Indirect Ownership Interest · Individual
Bauder, Madison
5% Or Greater Indirect Ownership Interest · Individual
Bauder, Parker
5% Or Greater Indirect Ownership Interest · Individual
Bauder, William
5% Or Greater Indirect Ownership Interest · Individual
Boulware, Thomas
5% Or Greater Indirect Ownership Interest · Individual
Walker, Katie
5% Or Greater Indirect Ownership Interest · Individual
Ahmed, Md Jewel
Operational/Managerial Control · Individual
Bauder, William
Operational/Managerial Control · Individual
Bauder, William
Corporate Officer · Individual
Boulware, Steven
Corporate Officer · Individual
Bridgepointe Finanical Services, LLC
Operational/Managerial Control · Organization
Innovative Nurse Consulting, LLC
Operational/Managerial Control · Organization
Miller, Bobbie
Corporate Officer · Individual
Priority Management Group, LLC
Operational/Managerial Control · Organization
Progressive Rehab Solutions, LLC
Operational/Managerial Control · Organization
Washington, Michael
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Stonemere Rehabilitation Center
Frisco, TX
4-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Baybrooke Village Care And Rehab Center
Mckinney, TX
4-star overall rating with 3-star inspections with $15,642 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Legacy At Willow Bend
Plano, TX
5-star overall rating with 4-star inspections with 6 recent health deficiencies
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