2101 Northgate Dr, Irving, TX 75062 · Dallas County · (972) 255-4460
120 certified beds, about 59 residents a day · For profit - Corporation · Medicare and Medicaid since 2003
CMS Care Compare ratings, data as of September 1, 2026 · CCN 675967 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on March 12, 2026, inspectors cited 4 health deficiencies (the Texas average is 9.4, the national average 9.2).
Of 65 health citations since September 2023, 1 was rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $49,730 in the last three years; the largest was $49,730, and the latest is dated March 28, 2025.
Nurses and nurse aides worked 3.19 hours per resident per day, against 3.39 across Texas and 3.86 nationally. Registered nurses accounted for 0.40 of those hours.
66.1% of nursing staff left within the year CMS measured (Texas average 55.3%).
CMS links it to The Ensign Group, an affiliated group of 344 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 65 health citations on file.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the residents' environment remained free of hazards as was possible for three of eight residents (Residents #2, #3 and #6) reviewed for accident hazards. The facility failed to ensure that Resident #2 did not have a container of Sani-wipes germicidal wipes on her shelf and a Hoyer-lift stored in her room on 07/15/2026. The facility failed to ensure that Resident #3 did not have Febreze aerosol spray can, Sani-wipes germicidal wipes and Febreze fabric freshener spray bottle in her room on 07/15/26. The facility failed to ensure that Resident #6 did not have disinfectant spray can in her room on 07/15/26. These deficient practices placed the residents at risk for accidental injury, exposure to hazardous chemicals and misuse of facility equipment.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable environment for residents' staff and the public for 1 of 4 hall shower rooms (300 Hall shower room) and 2 of 8 (Residents #1 and #4) reviewed for environment. The facility failed to ensure that the shower room in 300 hall was clean and in sanitary condition on 07/15/26. The facility failed to ensure that the trash can in Resident #1's room had trash liners 07/15/26. The facility failed to ensure that the trash can in Resident #4's room had trash liners 07/15/26. This failure could place residents at risk for diminished quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for one of eight residents (Resident #4) reviewed for quality of care. The facility failed to ensure that Resident #4's non-pressure wound left buttock and stage 4 pressure wound of right lateral ankle were cleansed in accord with best practice on 07/15/26. These failures could place the residents at risk of worsening pressure and non-pressure injuries and could result in a decline in health.
Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure parental fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive care plan and the resident's goals and preferences for 1 (Resident #5) of 4 residents reviewed for PICC lines (Peripherally Inserted Central Catheter). The facility failed to change the PICC line intravenous catheter (an intravenous catheter that is suitable for long term infusion therapy) dressing on Resident #5 for more than 7 days. These failures placed the residents at risk of infection or dislodgement.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 2 of 8 residents reviewed for pressure injuries. (Residents #2 and #4) The Facility failed to ensure that Resident #2 buttocks and sacral were covered with dressing as ordered on 06/02/26. The facility failed to ensure that an order for wound care was in place for Resident #2 who had a non-pressure ulcer to the left buttocks and sacrum (triangular area at base of spine). The facility failed to ensure that Resident #4's sacral wound was covered with dressing as ordered on 06/03/26. These failure can place the residents at risk for worsening or pressure and non-pressure injuries and could result in a decline in health.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 2 out of 8 residents (Resident #2 and #3) reviewed for enteral feeding. The facility failed to ensure that Resident #3 was provided with her G-Tube (a medical device inserted through the abdominal wall directly into the stomach. It provides a direct route to deliver nutrition (fluids) feeding on 06/02/26 as ordered by her physician. The facility failed to ensure that Resident #2 had continuous feeding via G-Tube from 12:00 A.M to 10:00 P.M. as ordered on 06/02/26 as ordered by his physician. This failure could place 14 residents who had feeding tubes at risk for dehydration, weight loss, and/or metabolic abnormalities.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 8 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's Humidifier bottle was not empty when Oxygen concentrator was in use by Resident #1. The facility failed to ensure Resident #1's nasal cannula storage bag was changed weekly as ordered. These failures could place the residents at risk of respiratory infection and not having their respiratory needs met.
Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for each resident for (Resident #1) of 6 residents reviewed for Comprehensive Care Plans. The facility failed to ensure Resident #1 had sufficient comprehensive care plan to reflect his negative pressure wound treatment device and monitoring care needs. This failure could place residents at risk of their needs not being met.
Inspectors wroteBased on interview and record review the facility failed to ensure and maintain medical records on each resident that are complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for wound care. The facility failed to enter a verbal provider order for a Negative Pressure Wound Treatment device (NPWT) ordered during her rounds at the facility on 03/19/2026. Subsequently, no consistent documentation of care, monitoring, or treatment was documented on Resident #1's EMR between 03/19/2026 - 03/24/2026. This failure could affect residents that require a change in their treatments to ensure they receive accurate orders from providers which could lead to lack of care, infection, and not following provider orders. Findings Included: [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systemically organized in accordance with accepted professional standards for 1 of 3 residents (Resident #1) reviewed for clinical records regarding wound care. The facility failed to ensure nursing staff documented that physician ordered wound care was provided to Resident #1 for 2 pressure ulcers on 03/03/26, 03/06/26, 03/07/26, 03/08/26, 03/09/26, 03/10/26, 03/11/26, 03/31/26, 04/01/26, 04/03/26, 04/06/26, 04/07/26, and 04/11/26. This failure could place residents at risk for incomplete and inaccurately documented medical records that included their progress treatment, services, and interventions.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #1, #2, #3, and #4) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1, #2, #3, and #4's room was in a position accessible to the resident on 03/31/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for seven of twelve Resident rooms (room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7), and two of four halls (300 and 400) observed for cleanliness. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7 on the 300 and 400 halls were thoroughly cleaned and sanitized. The facility failed to ensure the handrails on the 300 and 400 halls were thoroughly cleaned and sanitized. These failures could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 5 residents (Resident #5, #6 and #7) of five residents reviewed for respiratory care. The facility failed to ensure Resident #5's Nasal cannula connected to the oxygen concentrator and Nebulizer mask connected to the nebulizer machine were properly stored on 03/31/2026. The facility failed to ensure Resident #6's nasal cannula connected to the oxygen concentrator was properly stored and oxygen humidifier bottle left on nightstand was 1/4 full, cracked and dated 03/15/26 on 03/31/2026. [...]
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 10 of 10 residents (Residents #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) reviewed for pharmacy services. 1. The Facility failed to administered Residents #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17's medications greater than one hour after the scheduled administration time. 2. The Facility failed to check Resident #10's blood pressure before dispensing medication for administered. 3. The Facility failed to keep Med pass nutritional supplement refrigerated or on ice before serving as directed by manufacture and facility protocol. 4. [...]
Inspectors wroteBased on observations, interviews, 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 1 of 10 residents (Resident #9) reviewed medication administration, and for residents residing on two of four halls (Hall 100 and 200) reviewed for infection control The facility failed to ensure personal items were not stored on the medication carts located on the 100 and 200 halls on 03/31/2026. The facility failed to have staff sanitize hands after going from dirty to clean task before donning clean gloves and entered the resident room to administer medication. These failures could place residents at risk for infection.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 23 residents (Resident #9) reviewed for hazards. The facility failed to ensure Resident #9 did not have a can disinfectant spray and a bottle of hand cleaner spray in his room on 03/31/26. This failure could prevent the residents from having an environment that was free from hazards.
Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed with the resident and the resident's representative for 3 (Resident #3, Resident #7 and Resident #39) of 5 residents reviewed for comprehensive care plans. The facility failed to ensure that Resident #3, Resident #7 and Resident #39 or the resident's representative were invited to and participated in the resident's care plan meeting. This failure placed residents at risk for loss of independence, psychosocial well-being and the opportunity for them to participate in the planning of their care.
Inspectors wroteBased on observation, interview, and record review, based on the comprehensive assessment of a resident, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #45) of three residents reviewed for quality of care. The facility failed to ensure skin integrity changes were documented for Resident #45. This failure placed residents at risk for skin integrity changes occurring with no monitoring in place.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #2) of three residents reviewed for Foley catheters. The facility failed to ensure LVN A performed catheter care for Resident #2 per facility policy. This failure placed residents with Foley catheters at increased risk of infection.
Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility's walk-in refrigerator were labeled and dated. These failures could affect residents who received their meals from the facility's only kitchen by placing them at risk for food-borne illness, and food contamination.
Inspectors wroteBased on observation, interview, and record review the facility failed to respect the residents right to personal privacy, for 1 of 4 residents (Resident #1) reviewed for privacy for medical treatment. LVN P conducted Resident #1's blood sugar test in the hall and not in a private setting. This deficient practice could place residents at risk of not feeling as if they were being treated with dignity, privacy, and respect.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #2, Resident #3, and Resident #4) of twelve residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light in Resident #2, Resident #3, and Resident #4's rooms were in a position that was accessible to the resident on 09/30/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.
Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #2) of eight residents reviewed for resident rights. The facility failed to treat Resident #2 with dignity and promote enhancement of his quality of life when the resident was not provided a privacy bag for his catheter bag (collects urine from the urinary bladder) on 09/30/2025. This failure could place residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life.
Inspectors wroteBased observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #2) two residents reviewed for catheter care. The facility failed to ensure that RN D placed orders for Resident #2's catheter when the resident was admitted back to the facility on [DATE]. This failure could place residents with catheter at risk of no continuity of catheter care.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #5) of five residents reviewed for respiratory care. The facility failed to ensure Resident #5's breathing mask was stored properly when not in use on 08/12/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.
Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Resident #1) of ten residents reviewed for medication storage. The facility failed to ensure Resident #1's skin protectant (medicated cream used to prevent skin irritation) was not left inside the resident's room on 09/30/2025. This failure could place residents at risk of misuse of medications that could lead to overdosing and adverse reactions.
Inspectors wroteBased 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 (Resident #2) of eight residents reviewed for infection control. The facility failed to ensure CNA C wore a gown while providing incontinent care to Resident #2, who had a catheter (flexible tube inserted into the bladder to remove the urine) and had an order for enhanced barrier protection, on 09/30/2025. This failure could place residents at risk of cross-contamination and development of infections.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents. The facility failed to ensure Resident #1, assessed as high fall risk, had a floor mat in place while in bed upon observation on 08/07/2025 at 10:53 AM and 11:43 AM. This failure could place residents at risk of injury, resulting in a decreased quality of life.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #1, Resident #2, and Resident #3) of six residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #1, Resident #2, and Resident #3's rooms was in a position that was accessible to the residents on 05/14/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms 3 of 6 residents (Residents #1, #5, and #6) reviewed for physical restraints. The facility failed to ensure Residents #1, #5, and #6 had physician orders for the scoop mattresses on their beds. This failure could prevent the residents from having an environment that was free from physical restraints.
Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained as free of accident hazards as was possible for 1 of 6 residents (Resident #4) reviewed for accident prevention. The facility failed to ensure Resident #4 had a fall mat placed alongside her bed while she was lying in it on 05/14/25. This failure could prevent the residents from having an environment that was free and clear of accident hazards.
Inspectors wroteBased on interview and record review, the facility failed to ensure the 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 #1) of 6 residents reviewed for quality of care. -The facility failed to follow the Infectious Disease NP recommendation given on [DATE] to transfer Resident #1 to the hospital after the resident exhibited s/sx of an infection that included increased confusion, lethargy, hypotension (low blood pressure), and lab work that was positive for leukocytosis (elevated white blood cells). [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received food that accommodates resident allergies, intolerances, and preferences for 2 residents (Resident #3 and Resident #4) of six residents reviewed for food preferences. -The facility failed to ensure Resident #3 and Resident #4 had nutritious and palatable meal substitutes to meet their intolerances and/or preferences. This failure could place residents at risk of not having their daily nutritional needs met, placing them at risk for weight loss and a diminished quality of life.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 2 residents (Resident #1 and Resident #2) of five residents reviewed for pressure ulcers. 1. The facility failed to document wound care treatments as ordered by the physician in February 2025 to Resident #1's right heel for 7 occurrences and to Resident #1's coccyx (tailbone) for 4 occurrences. 2. The facility failed to document wound care treatments as ordered by the physician in February 2025 to Resident #2's right heel for 7 occurrences and to Resident #2's sacrum (bone at base of spine)/coccyx for 11 occurrences. [...]
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's left and right-sided vents were free from dust. 2. The facility failed to ensure food items in the refrigerator and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator and dry storage that were not properly labeled or past the 'best by', discard by or expiration dates. 4. The facility failed to have Dietary staff change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. 5. [...]
Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for 8 consecutive hours 7 days a week for all four quarters reviewed for RN coverage. The facility did not have RN coverage for eight consecutive hours on 42 days during the review period. This failure could place residents at risk of lack of nursing oversight and higher level of care needed.
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 for mobility for 1 of 5 residents reviewed for activities of daily living (Resident #1). The facility did not provide for assistance with activities of daily living by addressing the mobility/transfer needs of Resident #1. The failure could place residents requiring assistance to transfer at risk for developing wounds, infections, generalized deterioration, and loss of functional abilities.
Inspectors wroteBased on observation, interview, and record review, the facility in accordance with professional standards and practices, failed to maintain medical records on each resident that are complete and accurately documented, for 1 of 5 residents reviewed for documentation (Resident #1). The facility did not accurately document refusal of transfers by Resident #1. The failure could place residents at risk for not receiving resident-centered plans of care.
Inspectors wroteBased on observation, interview, and record review, the facility failed to secure confidential and personal medical records for four (Resident #6, Resident #7, Resident #8, and Resident #9) of four resident reviewed for Privacy and Confidentiality. 1. The facility failed to ensure LVN B would not leave Resident #6's information about her death unattended and visible on top of the nurse's cart on 200 Hall. 2. The facility failed to ensure LVN B would not leave Resident #7's schedule for Norco unattended and visible on top of the nurse's cart on 200 Hall. 3. The facility failed to ensure LVN B would not leave Resident #8's schedule for Baclofen unattended and visible on top of the nurse's cart on 200 Hall. 4. The facility failed to ensure LVN B would not leave Resident #9's vital signs and code status unattended and visible on top of the nurse's cart on 200 Hall. [...]
Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 5 (room [ROOM NUMBER], #2, #3, #4, and #5) of 5 resident rooms and the handrails reviewed for cleanliness and sanitization. *The facility failed to ensure that Resident Rooms #1, #2, #3, #4, and #5 were thoroughly cleaned and sanitized. *The facility failed to clean and sanitize the handrails, utilized by residents throughout the facility. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four (Resident #3, Resident #4, Resident #5, and Resident #10) of eight residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #3's humidifier had water in it. 2. The facility failed to ensure that Resident #4's breathing mask and nasal cannula (flexible tube used to deliver oxygen to the nose through two prong) were properly stored when not in use. 3. The facility failed to ensure that Resident #5's nasal cannula connected to the portable tank behind the wheelchair was properly stored when not in use. 4. [...]
Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure the ice machine and the ice scoop, located in the kitchen area, was cleaned. 2. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the stored date. These failures could place residents at risk for cross contamination and other air-borne illnesses.
Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #1 and Resident #2) of ten residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Resident #1 and Resident #2. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.
Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #4) of 4 residents reviewed for (ADLs) care provided to dependent residents. 1. The facility failed to ensure Resident #4 received scheduled bed baths from October 1, 2024 - October 30, 2024. This failure placed the resident at risk of not receiving necessary services to maintain good personal hygiene, skin breakdown, and decreased self- esteem.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement interventions that are consistent with current professional standards of practice for 1 (Resident #11) of 9 residents reviewed for environmental hazards. Resident #11's mattress was raised up on one side using wedges and a pillow. Improper placement of the resident's mattress could put residents at risk for injury or entrapment.
Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 (Resident #10) of 9 residents reviewed for medications at the bedside. A box containing vials of nebulizer (machine that turns liquid medication into a mist and breathed directly into the lungs) medication was left unattended and unsecured on the nightstand at Resident #10's bedside. This failure could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects.
Inspectors wroteBased observations, interviews, 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 one (Resident #3) of eight residents observed for Infection Control. The facility failed to ensure that CNA C changed her gloves and performed hand hygiene while providing incontinent care to Resident #3. This failure could place the residents at risk of cross-contamination and development of infections.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for one (Resident #1) of three residents reviewed for abuse. The Administrator failed to report an incident to the State Survey Agency when Resident #1 alleged PTA A had physically abused him on 10/24/24. This failure could place the residents in the facility at risk of not receiving timely reporting of incidents involving allegations of abuse which could result in undetected abuse and misappropriation or theft and emotional distress.
Inspectors wroteBased on interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for pharmacy services. 1. The facility failed to document that Resident #1 was given albuterol sulfate (for asthma ) on 09/08/2024,and buspirone HCL (for anxiety) on 09/06/2024 2. The facility failed to document that Resident #2 was given atorvastatin calcium (for hyperlipidemia), on 09/12/2024 duloxetine oral (for depression) on 09/12/2024, melatonin (for insomnia) on 09/12/2024, sennosides-docusate sodium (for constipation)on 09/12/2024, and carboxymethyl cellulose (for dry eyes on 09/12/2024,09/13/2024,09/16/2024. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive assessment and quarterly review assessments for one (Resident #1) of four residents were reviewed for comprehensive care plans. The facility failed to ensure the interdisciplinary team revised and reviewed the plan of care for Resident #1 with interventions following elopement attempts on 07/24/24,08/22/24 and 09/12/24. This failure could affect residents by placing them at risk for not having their individual needs met.
Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for elopement. The facility failed to provide Resident #1 with adequate supervision to prevent her from leaving the building on 07/26/2024, 08/22/2024, and 09/12/2024. This failure placed residents at risk for harm and serious injury.
Inspectors wroteBased on interviews and record review, the facility failed to immediately inform the resident's representative(s) of a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of three resident reviewed for resident rights. The facility failed to ensure the WCN notified the resident's representative on 01/03/24 that Resident #1 had a change of condition in clinical status (exposed hardware [screw] in the left lower extremity wound). This deficient practice placed residents at high risk or the likelihood of, serious injury, harm, impairment, or death by not having their needs met, or receiving treatment in a timely manner in accordance with professional standards of practice.
Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 15 of 23 resident rooms (Resident # #1, 3, 11, 20, 21, 27, 29, 33, 35, 38, 40, 42, 45, 48, and 50) for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms were thoroughly clean and sanitized, and handrails were cleaned and serviced. These failures could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.
Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 6 residents (Residents #11, #29, and #42) reviewed for ADLs care provided to dependent residents. The facility failed to ensure Residents #11, #29, and #42 received showers consistently based on records reviewed for October 2023 This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Record review of Resident #11's Face Sheet, dated 11/08/23, revealed he was a 68 -year-old male initially admitted on [DATE] and readmitted on [DATE]. [...]
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 staff reviewed for activity professional qualifications The facility failed to ensure the activities at the facility was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. These failures could place the residents at risk of not receiving and effective activities program developed and implemented for their physical and mental well-being.
Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to cover and date food stored in the refrigerator and freezer that should no longer be consumed. 2. The FSM failed to wear hair restraint inside the kitchen area. These failures could affect Residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #53) of six residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #53's rooms was in a position that was accessible to the resident. This failure could place the resident at risk of being unable to obtain assistance and ask fo help in the event of an emergency.
Inspectors wroteBased on observation, interview, and record review the facility failed develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 1 of 4 (Residents # 62) Residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident # 62's use of side rails. This failure could place resident at risk of not having a plan developed to address care needs.
Inspectors wroteBased on interview and record review, the facility failed to ensure that resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents (Resident #29) reviewed for nutrition and hydration. The facility failed to assess Residents #29's weight on a weekly basis per facility's policy regarding 'Nutrition Status Management, and the resident experienced a 7.5% weight loss in a 90-day period. This failure could place resident at risk of experiencing a decline in health due to malnutrition.
Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that 2 (Resident #53 and Resident #66) of 4 residents who were fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding. The facility failed to ensure Resident #53's dressing on the g-tube insertion site was changed everyday The facility failed to ensure Resident #66's syringe was changed as per facility' policy. These failures could place the residents at risk for nutritional problems.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a Resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 3 Residents (#270 and 51) reviewed for respiratory care, in that: Resident #270 did not have physician orders for oxygen administration and humidity bottle was not label or dated. Resident #51's oxygen concentrator humidifier was labeled but was not dated and failed to include the mode of administration in the order for Resident #51's oxygen administration.
Inspectors wroteBased on observations, interviews and record review, the facility failed to assess and obtain consent for bed for one of one resident (Resident #62) reviewed for bed rails in that: 1. Resident #62 was not assessed, did not have a consent, and did not have an order on the electronic medical record for the use of bedrails or side bars. 2. Resident #62 did not have any care plan documentation for the use of bed rails or side bars This deficient practice could affect Residents who utilized some type of bedrail in the facility and could put the Residents at risk for potential injuries.
Inspectors wroteBased on, interviews and record reviews the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in §483.70(g) for 1 of 6 residents (Resident #48) reviewed for pharmacy services. The facility failed to ensure Resident #48 had received his insulin medications as scheduled and as ordered by his physician. This failure could place residents at risk of health complications.
Inspectors wroteBased 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 1 (Resident #56) of 10 residents observed for infection control. The facility failed to ensure Resident #56's nebulizer (a medical equipment that can help deliver medication directly to the lungs) mask was not on top of the table when not in use. This failure could place the resident at risk of cross-contamination and development of infection.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences for one (Resident #205) of 5 residents reviewed for food preferences. The facility failed to honor Resident #1's dislike of pork products and gravy, and served him ham with gravy. This failure could place residents at risk for malnutrition and poor quality of life.
8 fire safety citations on file: 2 on March 12, 2026, 2 on December 18, 2024, 4 on November 9, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| March 28, 2025 | Fine | $49,730 |
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) | 3.19 | 3.39 | 3.86 |
| Registered nurses | 0.40 | 0.43 | 0.69 |
| All nursing staff on weekends | 2.63 | 2.98 | 3.42 |
| Nurse aides | 1.88 | ||
| Licensed practical nurses | 0.92 | ||
| Nursing staff turnover (share who left in a year) | 66.1% | 55.3% | 45.8% |
| Registered nurse turnover | 50.0% | 54.6% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.04 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 3.42 on weekdays and 2.63 on weekends, 23% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 4.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.12 in April to June 2025 to 3.19 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 | 3.19 | 0.40 | 3.42 | 2.63 | 4.7% | 2 of 90 | 59 |
| Oct to Dec 2025 | 2.94 | 0.40 | 3.14 | 2.41 | 4.0% | 5 of 92 | 60 |
| Jul to Sep 2025 | 2.99 | 0.45 | 3.18 | 2.49 | 8.9% | 1 of 92 | 58 |
| Apr to Jun 2025 | 3.12 | 0.67 | 3.36 | 2.52 | 12.6% | 0 of 91 | 60 |
| 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.
Trains nurse aides: this home runs a state-approved CNA program (state list: HHSC Approved NATCEP Providers, as of October 6, 2026). A nursing home cannot charge aides it employs, or has offered a job, for state-approved training (42 CFR 483.152(c)). See The Eden of Las Colinas CNA training on CareerFunded, our sister site for career training.
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. If you work here, your report helps start one.
| 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 | 33.7 | 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 | 0.5 | 0.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.0 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.9 | 1.5 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 17.7 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.4 | 3.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.2 | 9.6 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 21.9 | 25.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 28.4 | 12.3 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for The Eden of Las Colinas's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (55.9% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
55.9% 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. 27 eligible stays.
10.5% 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. 44 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.
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. 24 eligible stays.
69.6% this home
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. 23 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. 27 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. 27 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. 12 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: HAMILTON COUNTY HOSPITAL DISTRICT. CMS links this home to The Ensign Group, a group of 344 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Barnes, Marcus | Managing control - governing body | Individual | 07/01/2022 | |
| Coil, Ryan | Managing control - governing body | Individual | 06/23/2025 | |
| Burnam, Soon | Corporate officer | Individual | 07/01/2022 | |
| Hooper, Grady | Corporate officer | Individual | 12/01/2015 | |
| Keetch, Chad | Corporate officer | Individual | 03/01/2011 | |
| Sweet Bay Healthcare LLC | Operational/managerial control | Organization | 07/01/2022 | |
| Barnes, Marcus | Operational/managerial control | Individual | 07/01/2022 | |
| Coil, Ryan | Operational/managerial control | Individual | 06/23/2025 | |
| Ensign Services Inc | Adp of the SNF | Organization | 04/19/2022 | |
| Standard Bearer Healthcare Op, LP | Adp of the SNF | Organization | 07/01/2022 | |
| Sweet Bay Healthcare LLC | Adp of the SNF | Organization | 10/30/2025 | |
| The Ensign Group Inc | Adp of the SNF | Organization | 07/01/2022 | |
| Valley Ranch Health Holdings LLC | Adp of the SNF | Organization | 07/01/2022 | |
| Barnes, Marcus | Adp of the SNF | Individual | 07/01/2022 | |
| Coil, Ryan | Adp of the SNF | Individual | 06/23/2025 |
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.