Deficiency Index

The Eden of Las Colinas

Irving, Texas · CCN 675967

54 surveys since 2010, 16 of them producing a finding at harm level or worse.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
167
Surveys
54
Harm or worse
16
Immediate jeopardy
9
The record, 2010–2026
’10’15’20’25’26
No harm recordedHarm or worseNot surveyed
Immediate jeopardy9

Findings at the most serious level CMS records.

Beyond CMS’s monthly file33/54

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
120
Ownership
For profit - Corporation
Chain
THE ENSIGN GROUP
County
Dallas
Medicare-certified since
2003

CMS ratings

Overall
1
Health inspection
1
Staffing
1
Quality measures
4

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded more weighted findings than most of its peer group.

Weighted by harm level, against 377 for-profit facilities of 100–127 beds in Texas.

Last survey on record

Jul 15, 2026

117 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day3.193.25
Registered-nurse hours per resident day0.40—
Annual nurse turnover66.1%54.0%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

Fines
$49,730 across 1 penalty

Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K11.3%L—
Actual harmG11.3%H—I—
No harm, potential for more than minimalD4660.5%E2735.5%F11.3%
No harm, potential for minimalA—B—C—
CMS’s current file: 76 of the 167 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F6896×

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • F5585×

    Reasonably accommodate the needs and preferences of each resident.

  • F6955×

    Provide safe and appropriate respiratory care for a resident when needed.

  • F8125×

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • F6774×

    Provide care and assistance to perform activities of daily living for any resident who is unable.

In the surveyor’s words

From the most serious findings on record at The Eden of Las Colinas, in the surveyor’s own words.

  • Immediate jeopardy, patternF684Mar 28, 2025

    Based 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). […]

  • Actual harm, isolatedF697Aug 4, 2023

    Based on interview and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for pain management. The facility failed to ensure Resident #1 received scheduled doses of her pain medications. This failure could affect residents by placing them at risk of not receiving pain medications as ordered resulting in a high level of pain, and loss of quality of life. […]

  • Actual harm, isolatedF689Jun 4, 2021

    Based on observation, interview, record review, and policy review, the facility failed to assess fall risk and develop and implement a care plan with appropriate resident specific interventions to ensure one resident (Resident (R) 21) out of a total sample of 27 residents was free from accidents. R21 sustained harm when she experienced a fall causing a fractured nose. Findings include: Review of the facility's Safety and Supervision of Residents policy, dated July 2017, revealed, . The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents . […]

  • No harm, potential for more than minimal, widespreadF812Dec 18, 2024

    Based 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. […]

  • No harm, potential for more than minimal, widespreadF812Jul 8, 2021

    Based 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 kitchen; in that: 1) The facility failed to ensure foods were protected from possible contamination during processing and storage (puree processing, refrigerator storage). 2) Dietary staff (A) failed to use good hygienic practices during dietary duties (bare hand contact with food contact surfaces), and 3) Food contact and non-food contact equipment was soiled (cutting boards, drink guns, exteriors of equipment, carts). […]

Read 36 findings in full →The most serious and the most recent: 36 of 167 on record.

Every survey on record

FindingsAt actual harm or above

  • Aug 18, 2026Complaint2 findings
  • Jul 15, 2026Complaint4 findings
  • Jun 3, 2026Complaint3 findings
  • May 8, 2026Complaint2 findings
  • Apr 14, 2026Complaint1 finding
  • Mar 31, 2026Complaint6 findings
  • Mar 12, 2026Standard4 findings
  • Feb 13, 2026Complaint1 finding
Show the 46 earlier surveys
  • Nov 25, 2025Complaint6 findings
  • Aug 7, 2025Complaint1 finding
  • May 14, 2025Complaint3 findings
  • Mar 28, 2025Complaint3 findings · 1 harm
  • Dec 18, 2024Standard4 findings
  • Oct 31, 2024Complaint9 findings
  • Oct 28, 2024Complaint1 finding
  • Sep 19, 2024Complaint3 findings
  • Jan 19, 2024Complaint1 finding
  • Nov 9, 2023Standard and complaint12 findings
  • Sep 7, 2023Complaint1 finding
  • Aug 22, 2023Complaint1 finding
  • Aug 4, 2023Complaint2 findings · 1 harm
  • Jun 16, 2023Complaint2 findings
  • Apr 13, 2023Complaint2 findings
  • Feb 26, 2023Complaint4 findings
  • Dec 29, 2022Complaint1 finding
  • Oct 20, 2022Complaint1 finding
  • Sep 28, 2022Standard8 findings
  • Jun 1, 2022Complaint2 findings
  • Apr 6, 2022Complaint1 finding
  • Feb 16, 2022Complaint1 finding
  • Jan 6, 2022Infection control2 findings
  • Nov 30, 2021Infection control1 finding
  • Jul 8, 2021Standard5 findings
  • Jun 4, 2021Complaint2 findings · 1 harm
  • Sep 4, 2020Infection control1 finding
  • Aug 28, 2020Complaint1 finding · 1 harm
  • Jul 15, 2020Complaint1 finding
  • Aug 30, 2019Standard5 findings
  • Jul 13, 2018Standard2 findings
  • May 21, 2018Complaint7 findings
  • Feb 1, 2018Complaint1 finding
  • May 26, 2017Standard and complaint8 findings · 5 harm
  • May 19, 2016Standard2 findings
  • Jun 17, 2015Complaint2 findings
  • May 14, 2015Standard and complaint3 findings
  • Nov 20, 2013—1 finding
  • Apr 26, 2013—4 findings
  • Jan 24, 2013—6 findings
  • May 11, 2012—2 findings · 1 harm
  • Apr 13, 2012—4 findings
  • Sep 30, 2011—2 findings · 2 harm
  • Jun 13, 2011—5 findings · 2 harm
  • Mar 5, 2011—7 findings · 2 harm
  • Nov 18, 2010—1 finding

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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