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Bluebonnet Rehab At Ennis

2300 South Oak Grove Rd, Ennis, TX 75119 · For profit - Limited Liability company · 136 certified beds · (972) 875-8643 Medicare & Medicaid certified

Call the home — (972) 875-8643 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 17 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
601 S Clay St · (972) 232-7047 · Call to confirm hours
Pharmacy
601 S Clay St Ste 108 · (469) 901-7100 · Call to confirm hours
Grocery
500 S Kaufman St · (972) 875-0349 · Call to confirm hours
Park
Knighthurst St · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.9%15.8%15.4%worse
Long-stay residents who lose too much weight3.3%3.0%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.3%0.9%worse than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection1.2%0.8%2.0%worse than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms3.7%2.4%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury1.9%3.3%3.3%better
Long-stay residents whose ability to walk worsened17.8%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication17.8%18.0%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers3.2%3.8%4.7%better
Long-stay residents with worsening bladder/bowel control3.7%13.4%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.5%9.6%17.1%better
Short-stay residents who newly got an antipsychotic medication2.7%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine97.7%88.0%79.4%better
Short-stay residents rehospitalized after admission23.9%25.7%22.6%typical
Short-stay residents with an outpatient ER visit6.8%12.3%12.0%better
Long-stay hospitalizations per 1,000 resident days1.752.171.67typical
Long-stay outpatient ER visits per 1,000 resident days1.342.061.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

42.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 55 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.3%U.S. median 51.5%
Got home and stayed home
13.4%U.S. median 10.7%
Went back to hospital
48.6%U.S. median 56.6%
Met the expected recovery
0.28U.S. median 0.31
Therapy hours / resident / day
0.17hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 48.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.28 therapist hours per resident per day in 2026Q1 — more than 43% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.3%CMS range 32.8–53.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF13.4%CMS range 9.6–17.110.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.6%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge40.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge45.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified95.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.9%CMS range 4.6–14.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.341.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.32
RN hours/ resident / day
0.83
LPN hours/ resident / day
2.48
Aide hours/ resident / day
3.63
Total nurse hours/ resident / day
0.33
RN hoursweekends
56.9%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 136 beds and averages 72.7 residents a day — about 53% occupied, or roughly 63 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.63 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.34 hrs/resident/day on weekends vs 3.75 on weekdays — 11% thinner on weekends. RN hours go from 0.31 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

4
deficiencies at the latest standard inspection (2026-04-23)
4
at the previous standard inspection (2025-02-26)

Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.

  • Potential for harm · Fcited before2026-04-23 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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 for one of one kitchen reviewed for sanitation. 1.The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning the juice machine dispenser, cleaning the inside of the microwave, storing the ice scoop in an ice scoop receptacle that was free from food debris buildup, cleaning the refrigerator unit shelving to ensure they are free of mold). 2.The facility failed to ensure cleaning logs were being completed. 3.The facility failed to ensure all items were covered and stored properly. 4.The facility failed to label and date all food items in the kitchen. These failures could place residents at risk of foodborne illness. Observation on 04/21/2026 at 9:10 a.m., of kitchen refrigerator #1 revealed: -gallon bag of shredded cheese unsealed with a date of 4/1/26 and used by date of 8/16/26. -gallon of sweet pickle relish undated-gallon of ranch dressing undated-gallon of tartar sauce…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-23 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and records review, the facility failed to ensure that medical records maintained on each resident were accurately documented for three (3) of seven (7) residents, (Resident #8, Resident #19, and Resident #62) reviewed for accurate clinical records, in that: The facility failed to ensure Resident #8, Resident #19, and Resident #62's EMRs contained orders upon admission to the secured unit that included corresponding clinical criteria for admission to the secured unit. This deficient practice could result in errors in care and treatment and violate resident rights.Resident #8 Review of Resident #8's face sheet dated 4/22/2026, reflected an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included: alcoholic cirrhosis of liver, (permanent scarring of the liver due to alcohol), sepsis (infection of the blood stream), aphasia (language disorder), depression, anxiety disorder, and high blood pressure. Review of Resident #8's census reflected they he was admitted on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 residents (Resident #86) reviewed for dignity with meal assistance. The facility failed to ensure MA D did not stand while she assisted Resident #86 with eating. This failure could place residents at risk of loss of dignity.Findings include: Record review of Resident #86's face sheet, dated 04/23/26, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #86's diagnoses included senile degeneration of the brain (a progressive decline in cognitive function that occurs with aging), dementia (a general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), atherosclerotic heart disease of native coronary artery (coronary artery…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-23 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service for 1 (Resident #74) of 6 residents reviewed for personal privacy. The facility did not deliver unopened mail for Resident #74. This failure could affect residents' personal privacy and could result in decreased quality of life. Findings included: Record review of Resident #74's face sheet, dated 05/03/21, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a readmit date of 12/11/25. Resident #74's diagnoses chronic obstructive pulmonary disease (a lung disease characterized by chronic respiratory symptoms and airflow limitation), diabetes (a group…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accident hazards and the residents received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to provide Resident #1 with adequate supervision and assistance on 07/10/25 when CNA A began to transfer Resident #1 when using a mechanical lift (specialized device designed to safely transfer individuals with limited mobility). CNA A was conducting a mechanical lift transfer without the required two (2) staff members and stopped the transfer to call for assistance from another staff member while CNA A left Resident #1 suspended in the air in the mechanical lift sling. This failure could place all residents who require mechanical lift assistance at risk for serious injury and accidents. Findings include: Record review of Resident #1's admission record, dated 6/23/25, indicated she was an [AGE] year-old female…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-21 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 facility reviewed for a clean and homelike environment. The facility failed to ensure hall 100 and hall 200 floors were swept and maintained. These failures could place residents at risk of living in an uncomfortable and unsafe environment, decreased feelings of self-worth, and a diminished quality of life. Findings included: Observation on 03/21/2025 at 10:09 AM on hall 100 revealed a dried sticky substance throughout the 100 hall and the floor was not swept. Hall 100 appeared with little styrofoam pieces from a cup on the floor. Observation on 03/21/2025 at 10:15 AM on hall 200 revealed throughout the hall the floor was not swept. Hall 200 appeared with little pieces of paper on the floor. During an interview with the Housekeeping Supervisor on 03/21/2025 at 5:04 PM, the Housekeeping Supervisor stated that it was expected that all hall floors were kept swept and not sticky. The Housekeeping Supervisor stated there was always…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two(Resident #2 Resident #3) of 5 residents reviewed for care plans. The facility failed to revise Resident #2's care plan to reflect Resident #2 no longer required monitoring when smoking cigarettes. The facility failed to revise Resident #3's care plan to reflect Resident #3 no longer had to return cigarettes to the nursing station. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: Review of Resident #2's face sheet dated 03/21/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acute kidney…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-21 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, 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 one (Resident #1) of 5 residents reviewed for medications and pharmacy services The facility failed to ensure Resident #1's physician ordered medication Neurontin was administered on 03/05/2025 at 2:00 PM. The facility failed to monitor Resident # 1 for pain every shift according to physician orders. This failure could place residents at risk of not receiving necessary medical care and hospitalization. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication or care to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of Resident #1's face sheet dated 03/21/2025 reflected a [AGE] year-old male who was admitted to the facility on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-21 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff and residents for 1 of 1 facility reviewed for medication storage. The facility failed to secure one over-the-counter Tylenol 500 MG tablet that was observed on 03/21/2025 at 10:15 AM in the shower room on the 500 hall. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication or care to maintain their highest practicable physical, mental, and psychosocial well-being. Findings include: Observation of the shower room on 03/21/2025 at 10:00 AM on hall 500 revealed one over-the counter Tylenol 500 MG was lying on a folding chair that was up against the wall. During an interview with the NP on 03/21/2025 at 1:26 PM, the NP stated Over- the -counter Tylenol is used for pain and has no adverse effect if taken. During an interview with the DON on 03/21/2025 at 6:29 PM, the DON stated that an over-the-counter Tylenol just laying around was not normal for the facility.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on 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 1 of 1 facility reviewed for infection control practices. The facility failed to ensure the ice scoopers on hall 100 and hall 600 were not exposed and not covered. This failure placed residents at risk of cross contamination. Findings included: Observation on 03/21/2025 at 10:09 AM on hall 100 revealed an ice scooper was lying on a rolling cart exposed and not covered. Observation on 03/21/2025 at 10:20 AM on hall 600 revealed an ice scooper was lying on a rolling cart exposed and not covered. During an interview with CNA C on 03/21/2025 at 4:42 PM, CNA C stated all CNAs were responsible for making sure the ice scoopers were in the plastic covers. CNA C stated it was expected for the ice scoopers to be covered. CNA C stated if the ice scoopers are exposed, cross contamination could…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 7 citations
  • Potential for harm · Fcited before2025-02-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based 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 1 of 1 kitchen reviewed for dietary services. 1. The facility failed to ensure that the dry storage items were free from expired foods. 2. The facility failed to ensure kitchen staff followed proper hand hygiene during meal preparations. 3. The facility failed to ensure that the puree blender was cleaned between menu items. These failures could place residents at risk for food contamination and foodborne illness. Findings included: An observation was made on 02/24/25 at 10:49 AM in the kitchen. The observation in the kitchen's dry storage area revealed expired food. Sysco Imperial thickened orange juice from concentrate had a date labeled and expiration of 02/23/2025. An observation was made of 4 boxes of thickened dairy drink that did not have an expiration date on them. An observation was made on 02/25/2025 at 11:15AM in the kitchen for the process of hand washing. During this observation Ck #1…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-26 · tag F0926 — failed to keep the home smoke-free / fire-safe — pattern
    Have policies on smoking.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 5 (Residents #4, #27, #35, #48, and #50) of 8 residents reviewed for smoking. 1. The facility failed to ensure that Residents #4, #48, and #50 did not keep their personal cigarette lighters in their rooms per facility policy. 2. The facility failed to ensure that Resident #35 only used his e-cigarettes inside the designated smoking areas. 3. The facility failed to address where e-cigarettes should be stored, how to handle the devices, batteries, and refill cartridges. This failure could place residents at risk of an unsafe smoking environment and injury. Findings included: Review of the facility's Smoking Residents updated 02/21/2025, provided by the facility, identified Resident #4, #27, #35, #48, and #50 as smokers. Review of Resident #4's quarterly MDS assessment dated [DATE] revealed she was a [AGE] year-old female who initially admitted to the facility on [DATE]. Her diagnoses…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-26 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change of condition for 1 of 6 (Resident #3) residents reviewed for comprehensive assessments. The facility did not complete a significant change MDS for Resident #3 after she was admitted to hospice services. This failure could place residents at risk of not having their individual needs met when a significant change in condition occurs. Findings included: Review of Resident #3's comprehensive MDS, dated [DATE], reflected an [AGE] year-old female originally admitted to the facility on [DATE]. Her diagnoses included unspecified dementia (memory loss), anxiety (a feeling of fear, tension, or worry), depression (persistent feelings of sadness), hypothyroidism (when the thyroid gland does not produce enough thyroid hormone), and diabetes mellitus (increased blood sugar levels). Resident #3 had a BIMS score of 00, indicating severe cognitive impairment. Review…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-26 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 (Resident #31) of 6 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #31's significant change MDS accurately reflected his hospice status. This failure could place residents at risk of not having their individual needs met when a significant change in condition occurs. Findings included: Review of Resident #31's closed record significant change MDS dated [DATE] revealed he was a [AGE] year-old male who initially admitted to the facility on [DATE] with a re-admit date of 10/13/2024. His diagnoses included: cancer, malnutrition, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), adult failure to thrive, lack of coordination, and acute pain due to trauma. His BIMS was 03, which indicated severe cognitive impairment. In Section O - Special Treatments, Procedures, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-01-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 for the facility's only kitchen, which was observed for dietary services. The facility failed to: 1. Clean and sanitize kitchen surfaces and kitchen equipment to reduce food-borne pathogens. 2. Ensure snack refrigerators and individual resident refrigerators maintained adequate temperature to reduce food borne pathogens. This failure placed residents at risk for ingesting food-borne pathogens. Finding included: Observation and interview on 1/2/2024 at 9:10 AM reflected [NAME] A removing items from the exiting side of the facility's dishwasher and drying them with a towel before placing them in their respective locations. [NAME] A stated that she learned to wipe items, that came out of the dishwasher, from other people in the kitchen. She stated that having dried the equipment, there was less water spilled on the floor, so people…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-04 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 3 of 6 residents (Resident #59, Resident #68, and Resident #39) who were reviewed for accommodation of needs. The facility failed to ensure Resident #59's, Resident #68's, and Resident #39's call lights were placed within their reach. This failure could place dependent residents at risk of injuries and unmet needs. Findings included: A) Review of Resident #59's face sheet, dated 1/04/24, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of Protein calorie malnutrition, Unspecified Dementia (loss of cognitive Functioning that affects reasoning and thinking), and Hypertension (elevated blood pressure). Review of Resident #59's Quarterly MDS Assessment, dated 10/27/23, reflected she had a BIMS score of 06 indicating severe cognitive impairment. Further review…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-04 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record review the facility failed to complete an assessment that accurately reflected the resident's status for 2 of 8 residents (Residents #'s 30 and 55) whose records were reviewed for MDS accuracy, in that: The facility failed to ensure that Resident #30's Annual MDS Assessment reflected shortness of breath and tobacco use. The facility failed to accurately assess RES #55 on her Quarterly MDS Assessment, for Section H0300., Urinary Continence, which created an MDS discrepancy. These failures by the facility placed residents at risk of not receiving the care and services to meet their needs. Findings included: A record review of Resident #30's face sheet reflected Resident #30 was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a disease that causes airflow blockage and breathing-related problems) end-stage renal disease (the last stage of long-term kidney disease), shortness of breath (unable to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CARING HEALTHCARE GROUP — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.0+1.0 vs chain
Health inspection 4 of 53.0+1.0 vs chain
Staffing 2 of 51.9+0.1 vs chain
Quality measures 3 of 53.8-0.8 vs chain
The other 13 homes this chain runs (chain average 3.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/17/2019
RAY, VINCENTIndividualW-2 MANAGING EMPLOYEEsince 03/17/2019
BYROM, DAVIDIndividualCORPORATE OFFICERsince 03/17/2019
ENNIS SNF, LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 03/17/2019

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$6.1M
Net patient revenuemost recent cost report
-4.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 66%Medicare 12%Other / private 22%

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$245per resident / day
operating cost
$7,458per month
≈ monthly operating cost
$234per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in TX

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Texas Medicaid page.

Typical monthly cost in Texas
$5,627/mo
Nursing home (semi-private)
$7,604/mo
Nursing home (private)
$5,666/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 675150. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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