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
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing
LPN hours / resident day
0.87
Licensed practical nurse staffing
Aide hours / resident day
1.95
Nurse aide staffing
Weekend hours
2.88
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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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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