419 S Cockrell Hill Rd, Duncanville, TX 75116 · Dallas County · (972) 708-8800
124 certified beds, about 74 residents a day · For profit - Corporation · Medicare and Medicaid since 2008
CMS Care Compare ratings, data as of September 1, 2026 · CCN 676178 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on August 14, 2025, inspectors cited 7 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 58 health citations since May 2023, 5 were rated as actual harm or immediate jeopardy to residents (4 immediate jeopardy).
CMS lists 3 fines totaling $26,118 in the last three years; the largest was $17,345, and the latest is dated May 20, 2025.
Nurses and nurse aides worked 3.95 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.30 of those hours.
56.3% of nursing staff left within the year CMS measured (Texas average 55.3%).
CMS links it to Nexion Health, an affiliated group of 51 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 58 health citations on file.
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 or 4 CNAs (CNA A) reviewed for CNA certification. The facility failed to ensure CNA A's certification was current before allowing her to care for residents. CNA A worked in the facility providing resident care, on a full-time basis, with an expired certification for 8 days between [DATE], and [DATE]. This failure could result in residents being provided care by staff who were not currently qualified per state laws.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment, received the appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of 6 residents reviewed for incontinent care. The facility failed to ensure Resident #1 was assisted with incontinence care and toileting in a timely manner on 05/20/26. This failure could place residents at risk of skin breakdown, infection and a diminished quality of life by not receiving care and services to meet their toileting needs. Record review of Resident #1's annual MDS assessment, dated 01/10/26, reflected a [AGE] year-old-male admitted to the facility on [DATE]. [...]
Inspectors wroteBased on interviews and record reviews, the facility failed to send a copy of the residents' discharge notice to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 1 of 3 residents (Resident #1) reviewed for discharge planning. The facility failed to send a copy of the discharge notice to the facility's Ombudsman when Resident #1 received a discharge notice on 03/19/26 and 04/22/2026. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #2) reviewed for ADL care. The facility failed to provide Resident #2 assistance with timely incontinence care for at least 5 hours. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs and described the services that were to be furnished to attain, or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that:The facility failed to include interventions for ADLs in Resident #1's care plan. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #1) of 6 residents reviewed for ADLs. The facility failed to ensure Resident#1 had his fingernails trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 8 residents (Resident #1) observed for infection control. The facility failed to ensure CNA A performed hand hygiene, and proper use of gloves, while providing incontinent care to Resident # 1 on 03/25/2026. These failures could place residents at risk for development of infection.
Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 4 of 10 residents (Resident #1, Resident #4, and Resident #5 and Resident #6 ) reviewed for rights. The facility failed to ensure the staff in the main dining room served Resident #4, and Resident #5, at the same time Resident #1 was served his lunch meal. The facility failed to ensure CNA B made up Resident #6's bed in her room before lunch as she had requested. These failures could place residents at risk of feeling like their dignity was being invaded or the facility was not their home.
Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five (MA A) staff members reviewed for infection control procedures. Medication Aide A failed to perform hand hygiene after direct contact with residents while serving meals in the main dining room. This failure could place residents at risk for healthcare associated cross contamination and infections.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that resident who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #1) of five residents. The facility failed to change Resident #1 colostomy bag upon request. These failures placed residents at risk of embarrassment, at risk of loss of dignity and a decrease in quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 6 residents (Resident #1) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #1 tied the call light cord around his neck. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.
Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for three (one medication cart for Hall 400 and one medication cart for Hall 200, one medication cart for Hall 300) of seven medication carts reviewed for medication storage. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys, when LVN A's one medication cart for Hall 400 were left unlocked and unattended by LVN A. The facility failed to ensure medication supplies were all stored in locked compartments and permit only authorized personnel to have keys when LVN B's two medication carts for Hall 200 and one medication carts for Hall 300 were left unlocked and unattended by LVN B. [...]
Inspectors wroteBased on interview and record review, the facility failed to promptly notify the physician of laboratory results in accordance with facility policy and procedures for notification for 1 of 5 residents (Resident #306) reviewed for laboratory services. The facility failed to send Resident #306's weekly labs to the infectious disease doctor while the resident resided at the facility from 11/27/24 to 12/20/24. This deficient practice placed the residents at high risk of not receiving treatment, and/or developing complications.
Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve foods in accordance with the professional standards for food service safety in the facility's kitchen. 1. The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service.2. The facility failed to ensure stored canned goods, had an uncompromised seal, free from dents.3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. These failures could place residents at risk for food-borne illness and cross contamination. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #74, #46,#5, #73, and #29) of eight residents observed for infection control in that: CNA C failed to wear a gown, change her soiled gloves and wash hands during incontinent care to Resident #74. LVN D failed to clean off the overbed table prior to and after usage, while replacing tubing on Resident #46' G-tube. LVN E failed to disinfect the blood pressure cuff, in between vital sign checks for Resident #5, and Resident #73. LVN E failed to disinfect the glucometer (machine used to check blood sugar) in between usage on Resident # 29 and Resident #5. [...]
Inspectors wroteBased on record reviews and interviews the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move, for 1 of 5 residents (Resident #8) reviewed for notifying the LTC Ombudsman of the residents' discharge. Resident #8 was discharged on 07/01/2025 without a notice to the LTC state ombudsman. This failure could place residents at risk of not knowing their rights or receiving the services of the state LTC Ombudsman.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs residents for one (Resident #5) of three residents reviewed for medication review. LVN E failed to ensure Keppra (a medication given to prevent seizures) was administered to Resident #5 appropriately. LVN E did not hold the G-tube feeding an hour before and one hour after the medication was given. This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Nurse Staffing Information was posted daily for one of one building. The facility did not post and maintain the required staffing information on August 12, 2025. This failure could place residents and visitors at risk of not knowing how many nursing staff were on duty and the actual hours worked per shift daily.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 7 residents (Resident #1) reviewed for cardio-pulmonary resuscitation. RN E failed initiate CPR when FM C told him Resident #1 was unresponsive on [DATE]. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on [DATE] at 4:04 PM at exit. The noncompliance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the investigation began. This failure could place residents at risk of not receiving life-saving measures, medical complications, distress, and up to and including death.
Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing staff were licensed for 1 of 4 staff (RN E) reviewed for competencies. The facility failed to ensure RN E was permitted to practice as a licensed vocational nurse. RN E registered nurse license was expired, the facility failed to ensure RN E was permitted to practice as a registered nurse. Confirmed through board of nursing RN E's nurse license was expired.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe and decent living environment for one (Dining Hall) of one dining halls reviewed for decent living environment. The facility failed to ensure ten dinner trays from 05/05/25 were removed from the dining hall before breakfast on 05/06/25. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment.
Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food stored in the refrigerator, freezer, and pantry were labeled, dated, and sealed. 2. The facility failed to ensure there were no dented canned goods in the pantry. 3. The facility failed to ensure there were no spoiled foods in the refrigerator or freezer. These failures could place residents at risk for food contamination and food-borne illness.
Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #3) of four resident reviewed for misappropriation. The facility failed to ensure Resident #3 was free from exploitation when Resident #3 reported that $611.00 was taken from her. This failure could place the residents at risk of unresolved and unreported allegations of misappropriation.
Inspectors wroteBased on interview and record review, the facility in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to report immediately to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with Texas law no later than two hours after the allegation is made, for 1 of 5 residents reviewed for abuse and neglect (Resident #1): The Administrator, who is the Abuse Coordinator, failed to immediately report (within 2 hours) an allegation of abuse that Resident #2 hit the arm of Resident #1. This failure could place residents at increased risk for abuse and neglect. Findings Include: [...]
Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one (Resident #5) of five residents reviewed for accidents. The facility failed to update interventions for falls or accidents on Resident #5's care plan from 10/31/24 to 12/03/24. Resident #5 had two falls on 11/10/24 and 11/23/24, no interventions were entered on Resident #5's care plan. This failure could place residents at risk of not addressing individualized needs and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for three (Resident #1, Resident #2, and Resident #3) of seven residents reviewed for pharmaceutical services. 1. LVN A failed to follow physician orders for administering medications (Carafate, amlodipine, aspirin, folic acid, losartan, pantoprazole DR, vitamin D3, finasteride, multivitamin, Potassium ER, and sertraline) by mouth to Resident #1 and administered the medications via Resident #1's gastrostomy tube (abdominal feeding tube). 2. LVN A failed to ensure proper placement of Resident #1's gastrostomy tube prior to administering medications. 3. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four residents (Resident #1, #2, #3, and #4) reviewed for infection control procedures. The facility failed to ensure CNA A performed hand hygiene after direct contact with Residents #1, #2, #3, and #4 while serving meals on Hall 300. This failure could place residents at risk for healthcare associated cross contamination and infections.
Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed. The facility failed to send Resident #1 to the hospital when he requested to be transported to the hospital. This failure could place residents at risk of a change in condition and not receiving proper treatment and care in a timely manner.
Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safety. 1. The facility failed to ensure the ice machine chute guard was clean. 2. The facility failed to ensure food items in the refrigerators, freezer and dry storage room were labeled with the item description (handwritten or manufacturer's label), had the received by date, the opened date and or the consume by or expiration by dates (if opened, 72 hours per the facility's policy or the manufacturer's expiration date); stored in accordance with the professional standards for food service. 3. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #19) of 5 residents reviewed for ADLs. On 07/08/24 at 9:47 AM the facility failed to ensure Resident #1 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #19) reviewed for quality of care when: A. On 07/08/24 at 9:47 AM CNA J failed to note that Resident #19 had superficial scratches to his forehead that had been observed earlier that day. B. On 07/08/24 at 1:47 PM LVN H failed to assess he superficial scratches to Resident #19's forehead after being notified about the superficial scratches. This failure placed facility residents at risk for worsening stasis and venous ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood) severe pain, and loss of limbs.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 (Resident #28) of 3 reviewed for storage of drugs, in that: LVN A failed to lock unattended medication cart outside of a resident room. The facility failed to ensure Resident #28's medications were stored properly prior to administration by LVN A. This failure could place residents at risk of medication misuse and diversion.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure Food and drink that is palatable, attractive, and appetizing temperature for 1 (Residents #14) of 6 residents reviewed for food and nutrition. The facility failed to serve the resident food that was the appropriate temperature and fully cooked. This failure could place residents at risk for decreased quality of life.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferencesfor 1 (Residents #14) of 6 residents reviewed for resident rights. The facility failed to facility's failure to provide lactose free milk to Resident #14. The resident had an allergy to milk products and the facility failed to keep the product in the facility. The facility failed to serve the resident food that was the appropriate temperature and fully cooked. This failure could place residents at risk for decreased quality of life.
Inspectors wroteBased on interviews and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #19) of 5 residents reviewed for accuracy and completeness of clinical records. The facility failed to accurately document Resident #19 ' s superficial scratches on his forehead in his medical records. A. On 07/08/24 at 9:47 AM CNA J failed to note that Resident #19 had superficial scratches to his forehead that had been observed earlier that day. B. On 07/08/24 at 1:47 PM LVN H failed to assess he superficial scratches to Resident #19's forehead after being notified about the superficial scratches. C. [...]
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #6) of 5 residents reviewed for quality of care in that:. 1) Resident #6 was observed to have moisture-related skin breakdown and chafing which had not been addressed by the nursing staff; and 2) The facility failed to conduct weekly skin assessments and ensure Resident #6 was accurately assessed and treated for her skin breakdown. This failure placed residents at risk of having unidentified skin conditions leading to delays in treatment and worsening of conditions.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was provided equal access to care regardless of diagnoses, severity of condition, or payor source for two (Residents #1 and Resident #2) of seven residents reviewed for resident rights. 1) The facility failed to ensure Resident #1 was rescheduled for his colonoscopy (a procedure that uses a flexible tube with a camera to view the inside of the intestines) consultation when his appointment was cancelled on [DATE] due to a lapse in his Medicaid coverage. 2) The facility failed to ensure Resident #2 was scheduled for a timely Obstetrics and Gynecology (OBGYN--physician who cares for pregnant women and women's reproductive organs) consultation as recommended by her emergency room provider on [DATE] due to difficulties locating one within her Medicaid plan. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 01 of 01 kitchen reviewed for food and nutrition services. The facility did not check the temperature of the breakfast eggs on the holding table on 02/23/24 at 7:00 AM. The facility did not check and document the temperatures of breakfast, lunch, and dinner meals on 02/23/24. These failures could place residents who ate food from the kitchen at risk of foodborne illness.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 (Resident #1 and Resident #2) of 7 residents reviewed for resident rights. 1) The facility failed to ensure Resident #1 was rescheduled for his colonoscopy consultation when his was cancelled on [DATE] due to a lapse in his Medicaid coverage. No attempts were made by the facility staff to ascertain whether the Resident #1 had other payor sources available to him to proceed with his consultation. The Administrator was unaware Resident #1 was waiting for his Medicaid to be restored to proceed with his consultation. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 2 (Resident #5 and Resident #7) of 10 residents reviewed for accommodation of needs. The facility failed to ensure Resident #5's and Resident #7's call light was placed within their reach. This failure could place dependent residents at risk of unmet needs.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 2 (Resident #3 and Resident #5) of 5 residents reviewed for ADLs in that: Residents #3 was observed soaked in urine and feces in her bed. The urine had soaked through to her mattress. Resident #5 was observed laying in a soaked incontinence brief in her bed. The urine had soaked through to her pajamas and sheets. This failure could put residents at risk of impaired skin integrity, and decreased feelings of self-worth and dignity.
Inspectors wroteBased on observation, interview and record review the facility failed to establish a system of records, receipts, and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and account for all controlled drugs for one resident (Resident #4) of one resident reviewed for destruction of narcotic pain patches in that: LVN G failed to document the removal and destruction of Resident #4's fentanyl pain patch in a manner to prevent the misappropriation of, or accidental or intentional exposure to, narcotic medications. This failure could place residents at risk of not receiving medications due to drug diversion and could place residents or staff at risk for intentional or accidental exposure to used narcotic pain patches still containing active medication.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide each resident with a diet that met his or her daily nutritional and special dietary needs for one (Resident #8) of 5 residents reviewed for diet needs. The facility failed to provide Resident #8 with a NAS diet as ordered by the physician. This failure could place residents with special dietary needs at risk of disease exacerbation and/or inadequate nutrition.
Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident, that meet professional standards of quality care for 1 (Resident #1) of 3 residents reviewed for care plans in that: The facility failed to ensure Resident #1 had a baseline care plan created within 48 hours after admission with goals and interventions. This deficient practice could affect residents who are newly admitted and could result in decreased quality of care.
Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one of four (Medication Cart #1) medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.
Inspectors wroteBased on interview and record review the facility failed to consult with the resident's physician and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for notification of changes. The facility failed to notify and consult with the Resident #1's physician and notify the resident's representative when Resident #1 was coughing up blood on 01/06/24 and her blood sugar level dropped to 52 mg/dl on 01/07/24. Resident #1 was hospitalized on [DATE] and expired on 01/08/24. An Immediate Jeopardy (IJ) was identified on 01/11/24 at 2:25 PM. While the IJ was removed on 01/12/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. [...]
Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from deprivation of goods for 1 of 5 residents (Resident #1) reviewed for abuse. 1. The facility failed to provide Resident #1 with goods necessary to avoid physical harm, when the nurses did not report to the resident's MD/NP change of conditions including her coughing up blood on 01/06/24, her blood sugar reaching a level of 52 mg/dl on 01/07/24. 2. LVN B failed to take Resident #1's vitals when her BS dropped to 52 mg/dl. Resident #1 was found approximately 40 minutes later unresponsive with no pulse, which led to her being hospitalized on [DATE]. Resident #1 expired on 01/08/24. An Immediate Jeopardy (IJ) was identified on 01/11/24 at 2:25 PM. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility nurses failed to identify and report to Resident #1's MD/NP change of conditions, including her coughing up blood on 01/06/24 and her blood sugar reaching a level of 52 mg/dl on 01/07/24, which led to her not being provided with needed care and services. Resident #1 was hospitalized on [DATE] and expired on 01/08/24. An Immediate Jeopardy (IJ) was identified on 01/11/24 at 2:25 PM. While the IJ was removed on 01/12/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs were provided for 2 (Resident #1 and Resident #2) of 5 residents reviewed for accommodation of needs. The facility failed to ensure Resident #1's and Resident #2's call light was placed within his reach. This failure could place dependent residents at risk of injuries and unmet needs.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 (Rooms #108, #113 and #308) of 6 bedrooms reviewed for environment, in that: - The facility failed to ensure room [ROOM NUMBER]'s in-wall night light had a cover, exposing metal fixtures and a light bulb. - The facility failed to ensure the air condition units in Rooms #113 and #308 were free of damage and debris. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.
Inspectors wroteBased on observation, record review and interview, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 of 11 dietary support staff (DA B, DA C, DA D, and DA E) reviewed for competencies: The facility failed to ensure DA B, DA C, DA D, and DA E had a current Food Handling Certificate while working in the facility kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff.
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: - The facility failed to ensure food items stored in dry storage were labeled and dated. - The facility failed to ensure foods stored in the walk in cooler were stored in a sanitary manner. - The facility failed to ensure foods stored in the walk-in cooler were labeled and dated. - The facility failed to ensure cooler temperatures were monitored and recorded since 09/18/23 through 09/19/23 and 09/24/23 through 09/27/23. - The facility failed to ensure personal food items were not stored in the walk-in freezer. - The facility failed to ensure food stored in the walk-in cooler were not stored past the use by date. [...]
Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 (DM) of 1 reviewed for competencies: The facility failed to ensure the DM met the requirements for a certified dietary manager. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for one of six residents (Resident #1) reviewed for environment. 1. The facility failed to ensure Resident #1 had a sheet covering her bed. 2. The facility failed to ensure Resident #1 had a clean floor free of stains. These failures could place residents at risk of living in conditions that were not safe and decent.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the medications for one of one (Nurse Station #1) reviewed for medication storage. The facility failed to ensure medication was on a locked cart or in a medication storage area and not in an unlocked, open area. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.
Inspectors wroteBased on observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 3. The facility failed to ensure only paper towels were placed in the handwashing sink garbage receptacle instead of gloves, product boxes and other forms of trash. 4. The facility failed to secure closed food items that were previously opened and stored in the dry storage room, refrigerator and freezer. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #82, Resident #83, and Resident #240) of 6 residents reviewed for infection control. The facility failed to ensure the Med Aide disinfected the blood pressure cuff in between blood pressure checks for Resident #82, Resident #83, and Resident #240. The facility failed to ensure the Med Aide used hand hygiene before and after contact with Resident #82, Resident #83, and Resident #240. These failure could place residents at-risk of cross contamination which could result in infections or illness.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice for one (Resident #47) of six residents reviewed for nursing services. The facility failed to obtain a physician's order for Resident #47's dialysis treatment, AV shunt monitoring (permanent venous access site for dialysis to remove excess fluid), and AV shunt pressure dressing monitoring and change, after he was admitted to facility from the hospital on [DATE]. This failure could place residents at risk of not receiving dialysis treatment as ordered by their physician.
5 fire safety citations on file: 1 on August 14, 2025, 1 on July 10, 2024, 3 on May 24, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| May 20, 2025 | Fine | $17,345 |
| February 7, 2024 | Fine | $1,668 |
| January 12, 2024 | Fine | $7,105 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Texas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.95 | 3.39 | 3.86 |
| Registered nurses | 0.30 | 0.43 | 0.69 |
| All nursing staff on weekends | 3.58 | 2.98 | 3.42 |
| Nurse aides | 2.66 | ||
| Licensed practical nurses | 0.99 | ||
| Nursing staff turnover (share who left in a year) | 56.3% | 55.3% | 45.8% |
| Registered nurse turnover | 60.0% | 54.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.91 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.10 on weekdays and 3.58 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.64 in April to June 2025 to 3.95 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.95 | 0.30 | 4.10 | 3.58 | 0.2% | 0 of 90 | 74 |
| Oct to Dec 2025 | 4.11 | 0.36 | 4.31 | 3.61 | 0.0% | 0 of 92 | 79 |
| Jul to Sep 2025 | 3.69 | 0.27 | 3.87 | 3.24 | 0.0% | 0 of 92 | 81 |
| Apr to Jun 2025 | 3.64 | 0.32 | 3.83 | 3.15 | 0.0% | 1 of 91 | 82 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Texas, Jan to Mar 2026 | 3.33 | 0.40 | 3.50 | 2.93 | 2.2% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Texas, all employers | |||
| CNAs (nursing assistants) | $18.03 | $16.97 to $20.71 | 88,680 |
| LPNs and LVNs | $29.92 | $27.46 to $32.89 | 57,560 |
| Registered nurses | $46.14 | $38.06 to $50.53 | 271,380 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Texas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 15.9 | 15.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.3 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.0 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.2 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 12.1 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.3 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 6.0 | 9.6 | 15.4 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Duncanville Healthcare and Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (44.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
44.4% this home
No different from the national rate
US median of homes 51.5% · Texas: 116 better, 50 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 36 eligible stays.
10.9% this home
No different from the national rate
US median of homes 10.7% · Texas: 0 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 53 eligible stays.
7.3% this home
No different from the national rate
US median of homes 7.1% · Texas: 4 better, 11 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 27 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas57.3% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 10 residents counted.
0.0% this home
Median of homes: Texas0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 22 residents counted.
0.0% this home
Median of homes: Texas1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 22 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Texas98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 4 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: DALLAS COUNTY HOSPITAL DISTRICT. CMS links this home to Nexion Health, a group of 51 nursing homes averaging 2.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Dallas County Hospital District | 5% or greater direct ownership interest | Organization | 100% | 02/21/2015 |
| Nexion Health Leasing, Inc. | 5% or greater indirect ownership interest | Organization | 08/08/2001 | |
| Nexion Health, Inc. | 5% or greater indirect ownership interest | Organization | 08/08/2001 | |
| Callies, Marilyn | W-2 managing employee | Individual | 08/31/2022 | |
| Taylor, Kiara | W-2 managing employee | Individual | 09/20/2021 | |
| Callies, Marilyn | Corporate officer | Individual | 02/11/2013 | |
| Cerise, Frederick | Corporate officer | Individual | 03/24/2014 | |
| Pierce, Daniel | Corporate officer | Individual | 03/16/2021 | |
| Dallas County Hospital District | Operational/managerial control | Organization | 02/21/2015 | |
| Nexion Health at Duncanville Inc | Operational/managerial control | Organization | 02/21/2015 | |
| Nexion Health Leasing, Inc. | Operational/managerial control | Organization | 08/08/2001 | |
| Nexion Health, Inc. | Operational/managerial control | Organization | 08/08/2001 | |
| Cerise, Frederick | Operational/managerial control | Individual | 02/21/2015 | |
| Kirley, Francis | Operational/managerial control | Individual | 02/21/2015 | |
| Lee, Brian | Operational/managerial control | Individual | 02/21/2015 | |
| Riner, Meera | Operational/managerial control | Individual | 02/21/2015 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Texas. NursingHomeClear cannot take or act on complaints.