Cycle 1
Health 2025-01-30 · Fire 2025-01-30
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Mckinney, TX
Baybrooke Village Care And Rehab Center
4-star overall rating with 3-star inspections with $15,642 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
8300 Eldorado Parkway West, Mckinney, TX
(972) 548-9339
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
98
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stonegate Senior Living
Operator or chain grouping
Approved since
2006-04-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
24 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,546
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.79% · Performance 21.26% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.22
Baseline 6.97% · Performance 6.57% · Measure score 4.22 · Achievement 4.22 · Improvement 1.50
Total nurse turnover
3.49
Baseline 54.44% · Performance 49.41% · Measure score 3.49 · Achievement 3.49 · Improvement 1.2
Adjusted total nurse staffing
1.62
Baseline 3.16 hours · Performance 3.54 hours · Measure score 1.62 · Achievement 1.62 · Improvement 0.94
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 265 · Observed rate 10.57% · Lower 95% interval 8.31% |
| Discharge to community | 46.64% |
50.57%
3.9 pts worse
|
No Different than the National Rate · Eligible stays 243 · Observed rate 40.33% · Lower 95% interval 40.68% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.66% |
95.27%
1.6 pts worse
|
Numerator 133 · Denominator 142 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 142 |
| Discharge self-care score | 75.82% |
53.69%
22.1 pts better
|
Numerator 69 · Denominator 91 |
| Discharge mobility score | 50.55% |
50.94%
0.4 pts worse
|
Numerator 46 · Denominator 91 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 142 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.57% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 6.02% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 0.8% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 125 |
| Staff flu vaccination coverage | 47.37% |
42%
5.4 pts better
|
Numerator 63 · Denominator 133 |
| Discharge function score | 69.23% |
56.45%
12.8 pts better
|
Numerator 63 · Denominator 91 |
| Transfer of health information to provider | 89.77% |
95.95%
6.2 pts worse
|
Numerator 79 · Denominator 88 |
| Transfer of health information to patient | 37.93% |
96.28%
58.4 pts worse
|
Numerator 11 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 10.77% |
25.2%
14.4 pts worse
|
Numerator 7 · Denominator 65 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.1
0.5 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
97.1%
0.4 pts worse
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 98.5% · Q4 89.1% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
97.9%
0.5 pts worse
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.3%
1.1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 1.4% · Q3 0.0% · Q4 1.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
3.3%
2 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
18.9%
4.7 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 17.2% · Q3 14.5% · Q4 12.3% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
10.8%
4.6 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 7.5% · Q3 6.0% · Q4 8.3% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.5% |
15.4%
6.9 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 11.7% · Q3 0.0% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
16.1%
5.7 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 12.7% · Q3 2.1% · Q4 18.4% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.5%
0.6 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.3% |
15.0%
6.7 pts better
|
19.8%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 12.4% · Q3 1.7% · Q4 6.6% · 4Q avg 8.3% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.2%
1.4 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.1% · Q3 1.3% · Q4 1.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.0% |
89.7%
4.7 pts worse
|
81.7%
3.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 84.0% · Q3 90.6% · Q4 74.9% · 4Q avg 85.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.2% |
12.0%
0.8 pts better
|
12.0%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.2% · Observed 11.4% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.7% · Q3 0.7% · Q4 0.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.3% |
88.0%
2.7 pts worse
|
79.7%
5.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
25.9%
2.3 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 23.7% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-07 · Fire 2023-12-07
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-10-07 · Fire 2022-10-07
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-05
F · Potential for more than minimal harm
2025-01-30
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-01-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-05
E · Potential for more than minimal harm
2023-12-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-02
E · Potential for more than minimal harm
2023-12-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-02
C · Minimal harm
2023-12-07
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-01-02
F · Potential for more than minimal harm
2022-10-07
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-11-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-11-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-11-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-04-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-27
D · Potential for more than minimal harm
2025-04-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-27
E · Potential for more than minimal harm
2025-01-30
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-01-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-30
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-03-03
D · Potential for more than minimal harm
2025-01-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-03
E · Potential for more than minimal harm
2024-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-09-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-07-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-30
J · Immediate jeopardy
2024-02-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-04
F · Potential for more than minimal harm
2023-12-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-02
E · Potential for more than minimal harm
2023-12-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-02
E · Potential for more than minimal harm
2023-12-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-02
E · Potential for more than minimal harm
2023-12-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-02
E · Potential for more than minimal harm
2023-09-19
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-09-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-05-03
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-05-27
K · Immediate jeopardy
2022-10-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-10-28
J · Immediate jeopardy
2022-10-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-10-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-28
E · Potential for more than minimal harm
2022-10-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-10-28
Penalties and ownership
What sits behind the stars
$15,642
2024-02-07
Fine
Fine · fine $15,642
Fine
Ownership
South Limestone Hospital District
5% Or Greater Direct Ownership Interest · Organization
Major, Samuel
Operational/Managerial Control · Individual
Pf Baybrooke SNF Ops, LLC
Operational/Managerial Control · Organization
Price, Larry
Corporate Officer · Individual
Stonegate Senior Living, LP
Operational/Managerial Control · Organization
Umb Bank Na
5% Or Greater Mortgage Interest · Organization
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4-star overall rating with 4-star inspections with $23,546 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
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Frisco, TX
4-star overall rating with 4-star inspections with 5 recent health deficiencies
#3
Belterra Health & Rehab
Mckinney, TX
5-star overall rating with 4-star inspections with 5 recent health deficiencies
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