Skyline Nursing Center
3326 Burgoyne St, Dallas, TX 75233 · Dallas County · 204 certified beds · avg 170 residents/day · certified since Mar 26, 1986
Abuse citation flag (CMS)
Part of chain: OPCO SKILLED MANAGEMENT (66 facilities, chain avg rating 2.3★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Sep 27, 2023 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 29, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Sep 27, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 29, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Sep 27, 2023 · F-0607 · triggered by a complaint
The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 29, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Sep 27, 2023 · F-0742 · triggered by a complaint
The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Why it matters: Residents with mental health needs who go untreated can suffer worsening symptoms, distress, and isolation.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 29, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Sep 27, 2023 · F-0624 · triggered by a complaint
The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly.
Why it matters: An unprepared discharge can send a resident somewhere unsafe or without the care arrangements they need.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 29, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (39)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 14, 2026 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 14, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 14, 2026 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 14, 2026 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Apr 14, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| May 4, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 29, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 29, 2025 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jan 29, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jan 29, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jan 29, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jan 29, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 27, 2024 | E · Potential for harm, repeated | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Nov 18, 2023 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Nov 18, 2023 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 27, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Sep 27, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Sep 27, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Sep 27, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint |
| Sep 27, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. · from a complaint |
| Sep 27, 2023 | E · Potential for harm, repeated | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Sep 27, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 1, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 20 | 5 | K ▲ |
| 2024 | 1 | 0 | E |
| 2025 | 9 | 0 | F |
| 2026 | 9 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.62 | 3.46 | 3.95 | bottom 5% in Texas; bottom 5% in the U.S. |
| Registered Nurse hours | 0.38 | 0.44 | 0.69 | bottom 47% in Texas; bottom 19% in the U.S. |
| Weekend total nurse staffing | 2.35 | 3.04 | 3.50 | bottom 8% in Texas; bottom 6% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.46 | 0.34 | 0.48 | top 18% in Texas; top 38% in the U.S. |
| Total nursing staff turnover (%) | 50.0 | 55.3 | 45.8 | top 44% in Texas; bottom 38% in the U.S. |
| RN turnover (%) | 43.8 | 54.6 | 42.9 | top 37% in Texas; bottom 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.05, RN 0.44, weekend 2.74. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Nocona Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 12/01/2015 |
| 3326 Burgoyne Street TX, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| Brown, Deandre | Individual | ADP of the SNF | NOT APPLICABLE | 04/05/2018 |
| Continuum Rehab Group LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| Dallas Sky Realty, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| Dallas Texas Healthcare LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2015 |
| First Texas Propco, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| Garetz, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2015 |
| Gibraltar Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| Gurwitz, Solomon | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/28/2025 |
| Hagins, Elizabeth | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/28/2025 |
| Harvest Realty LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| Kaplan, Esther | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/03/2025 |
| Kaplan, Mordechai | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/10/2025 |
| Meekins, Greg | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2015 |
| Mindle, Adam | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/03/2025 |
| Montgomery Sky Trust | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| Opco Ca Skilled Mgmt INC. | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| Opco Texas Skilled Mgmt LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/01/2015 |
| Roberts, David | Individual | ADP of the SNF | NOT APPLICABLE | 10/23/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
- "What does your discharge planning process look like, and how are families involved before a move?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| The Villa at Mountain View | 2.0 mi | Dallas, TX | ★★☆☆☆ | 2/5 | |
| The Renaissance at Kessler Park | 3.2 mi | Dallas, TX | ★★★☆☆ | 4/5 | |
| The Laurenwood Nursing and Rehabilitation | 4.0 mi | Duncanville, TX | ★★★★☆ | 3/5 | |
| The Lennwood Nursing and Rehabilitation | 4.2 mi | Dallas, TX | ★☆☆☆☆ | 2/5 | |
| Duncanville Healthcare and Rehabilitation Center | 4.3 mi | Duncanville, TX | ★☆☆☆☆ | 1/5 | |
| Williamsburg Village Healthcare Campus | 4.7 mi | Desoto, TX | ★★☆☆☆ | 1/5 | SFF |
| The Villages of Dallas | 4.8 mi | Dallas, TX | ★★★☆☆ | 2/5 | |
| Lakewest Rehabilitation and Skilled Care | 5.3 mi | Dallas, TX | ★☆☆☆☆ | 1/5 | abuse |
| Southern Oaks Therapy and Living Center | 5.7 mi | Dallas, TX | ★★★☆☆ | 3/5 | |
| Five Points Nursing and Rehabilitation | 5.8 mi | Desoto, TX | ★★☆☆☆ | 3/5 | |
| Ventana by Buckner | 7.0 mi | Dallas, TX | ★★★★★ | 4/5 | |
| Desoto Nursing & Rehabilitation Center | 7.2 mi | Desoto, TX | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 455653.