01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-29 | 4 | 2025-05-29 | 4 |
| Cycle 2 | 2024-04-18 | 5 | 2024-04-18 | 14 |
| Cycle 3 | 2023-03-02 | 6 | 2023-03-02 | 3 |
CMS CCN 6758112026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Victoria Gardens Of Frisco
10700 Rolater Dr. · Frisco, TX 75035 · Collin County
Certified beds118CMS provider file
Recent citation rows36current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
36 rows in the current release
2 rows carry G–L scope/severity codes; 2 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-14 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2026-02-05 · complaint2025-12-08 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2025-12-10 · complaint2025-05-29 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Past Non-Compliance · 2025-03-17 · complaint2025-05-29 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-06-182025-05-29 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-06-192025-05-29 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-06-192025-05-29 · FIREK0741Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2025-06-192025-05-29 · FIREK0923Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2025-06-192025-02-25 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2025-02-22 · complaint2024-10-23 · HEALTHF0604Severity J · isolated immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Correction field: Past Non-Compliance · 2024-09-09 · complaint2024-06-13 · HEALTHF0805Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Correction field: Deficient, Provider has date of correction · 2024-07-08 · complaint2024-04-18 · FIREE0006Severity E · pattern; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2024-06-012024-04-18 · FIREE0007Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address patient/client population and determine types of services needed.
Correction field: Deficient, Provider has date of correction · 2024-06-012024-04-18 · FIREE0009Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Correction field: Deficient, Provider has date of correction · 2024-06-012024-04-18 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2024-06-012024-04-18 · FIREE0037Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Correction field: Deficient, Provider has date of correction · 2024-06-012024-04-18 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-05-252024-04-18 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-05-25 · complaint2024-04-18 · HEALTHF0925Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has date of correction · 2024-05-252024-04-18 · FIREK0222Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Correction field: Deficient, Provider has date of correction · 2024-05-172024-04-18 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-05-292024-04-18 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-06-012024-04-18 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-06-012024-04-18 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-05-2303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-02-25 | Fine | $9,113 | 0 |
| 2024-10-23 | Fine | $14,433 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- BAUDER FAMILY INVESTMENTS, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST33% · since 04/01/2024
- BOULWARE ST JAMES LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST33% · since 04/01/2024
- STEVEN BOULWARE FAMILY INVESTMENTS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST33% · since 04/01/2024
- BAUDER, KELLYIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST8% · since 04/01/2024
- BAUDER, MADISONIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST8% · since 04/01/2024
- BAUDER, PARKERIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST8% · since 04/01/2024
- BOULWARE, THOMASIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST8% · since 04/01/2024
- WALKER, KATIEIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST8% · since 04/01/2024
- BOULWARE, DOUGLASIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/01/2024
- BOULWARE, SANDRAIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 04/01/2024
- BAUDER, WILLIAMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2024
- BOULWARE, STEVENIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2024
- MILLER, BOBBIEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/01/2024
- BRIDGEPOINTE FINANICAL SERVICES, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2024
- INNOVATIVE NURSE CONSULTING, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2024
- PRIORITY MANAGEMENT GROUP, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2024
- PROGRESSIVE REHAB SOLUTIONS, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2024
- AHMED, MD JEWELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.32per resident day
RN hours0.41per resident day
Weekend nurse hours2.86per resident day
Staff turnover46.3%CMS reported field
06 / LOCAL RECORDS
Open the Frisco ledger →