Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- TexasAbove 87% of peers1,167 rated homes · average 2.8★
- Ellis CountyAbove 78% of peers10 rated homes · average 3.0★
- United StatesAbove 80% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point5★+2.2 vs TX avg
- StaffingCan add or remove a star2★−0.1 vs TX avg
- Quality measuresCan add or remove a star3★−0.8 vs TX avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles5★Top 10%TX avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 37% of peersTX avg2.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 15% of peersTX avg3.8★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff4.04hrsTop 10%TX avg3.40Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.21hrsAbove only 9% of peersTX avg0.44Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better53%Above only 42% of peersTX avg51%RN turnover70%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$20,131Above 51% of peersTX avg$55,368Fines · denials5 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthDec 2023 – Aug 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Aug 15, 2024Cycle 2worst E · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Sep 29, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Sep 29, 2024
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined4.04hrs
- Registered nursesRN hours only0.21hrs
- Licensed practical nursesLPN hours1.13hrs
- Nurse aidesCNA hours2.70hrs
- Weekend nursingAll staff on Saturdays and Sundays3.65hrs
- Texas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better53%Above only 42% of peersTX avg 51%
- RN turnoverRegistered nurses only70%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy121 certified beds · ~102 residents a day84%Above 82% of peersTX avg 67%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $20,131In fines
- 5Fines
- 0Payment denials
- $55,368TX avg in fines
Actions on record
- Feb 12, 2024Civil money penalty$3,798
- Jan 22, 2024Civil money penalty$9,116
- Jan 8, 2024Civil money penalty$2,279
- Jan 2, 2024Civil money penalty$1,764
- Dec 11, 2023Civil money penalty$3,174
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Gracen Hawley
- Russell Hawley
- Steven Arze
- Gracen Hawley
- Bcp Investments LLC
- Broadmore Health Realty Ltd
- Cl Healthcare LLC
- Ellis Mid Healthcare LLC
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 745039 · 110 DYLAN WAY, MIDLOTHIAN, TX, 76065.
- Percentiles compare this facility with every rated nursing home in Texas and Ellis County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
