Cycle 1
Health 2025-02-13 · Fire 2025-02-13
5 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mckinney, TX
Belterra Health & Rehab
5-star overall rating with 4-star inspections with 5 recent health deficiencies
2170 North Lake Forest Drive, Mckinney, TX
(972) 542-5500
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Priority Management
Operator or chain grouping
Approved since
2014-08-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 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
0.71
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
2.82
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,087
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9942
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.14
Baseline 20.86% · Performance 19.98% · Measure score 3.14 · Achievement 3.14 · Improvement 1.81
Healthcare-associated infections
6.76
Baseline 7.40% · Performance 5.81% · Measure score 6.76 · Achievement 6.76 · Improvement 6.10
Total nurse turnover
5.94
Baseline 85.22% · Performance 46.34% · Measure score 5.94 · Achievement 4.24 · Improvement 5.94
Adjusted total nurse staffing
0.69
Baseline 2.66 hours · Performance 3.03 hours · Measure score 0.69 · Achievement 0 · Improvement 0.69
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.43% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 186 · Observed rate 12.37% · Lower 95% interval 8.72% |
| Discharge to community | 46.23% |
50.57%
4.3 pts worse
|
No Different than the National Rate · Eligible stays 171 · Observed rate 38.6% · Lower 95% interval 38.4% |
| Medicare spending per beneficiary | 1.52 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 97.7% |
95.27%
2.4 pts better
|
Numerator 170 · Denominator 174 |
| Falls with major injury | 1.72% |
0.77%
0.9 pts worse
|
Numerator 3 · Denominator 174 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 72 · Denominator 126 |
| Discharge mobility score | 41.27% |
50.94%
9.7 pts worse
|
Numerator 52 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 0.57% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 174 · Adjusted rate 0.52% |
| Healthcare-associated infections requiring hospitalization | 5.81% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 161 · Observed rate 4.35% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 77 |
| Staff flu vaccination coverage | 98.36% |
42%
56.4 pts better
|
Numerator 120 · Denominator 122 |
| Discharge function score | 59.52% |
56.45%
3.1 pts better
|
Numerator 75 · Denominator 126 |
| Transfer of health information to provider | 98.11% |
95.95%
2.2 pts better
|
Numerator 52 · Denominator 53 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 82 · Denominator 82 |
| Resident COVID-19 vaccinations up to date | 6.74% |
25.2%
18.5 pts worse
|
Numerator 6 · Denominator 89 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.1%
2.5 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
97.9%
0.7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 1.4% · Q3 2.7% · Q4 2.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.1% |
2.7%
17.4 pts worse
|
11.4%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 31.8% · Q3 13.9% · Q4 6.1% · 4Q avg 20.1% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
3.3%
1.6 pts worse
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.8% · Q3 5.4% · Q4 8.5% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.8% |
18.9%
3.9 pts worse
|
19.6%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 22.4% · Q3 25.0% · Q4 18.8% · 4Q avg 22.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
10.8%
2.5 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.1% · Q3 8.3% · Q4 5.7% · 4Q avg 8.3% · 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 | 14.8% |
15.4%
0.6 pts better
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 13.4% · Q3 11.3% · Q4 12.5% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
16.1%
0.2 pts worse
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 20.4% · Q3 6.0% · Q4 8.9% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
0.8%
About the same
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.7% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.1% |
15.0%
6.1 pts worse
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 31.2% · Q3 10.1% · Q4 11.6% · 4Q avg 21.1% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.2%
1.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 3.6% · Q4 2.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
89.7%
10 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.4% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
12.0%
4.7 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 7.5% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.9% · Q3 0.8% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.3% |
88.0%
10.3 pts better
|
79.7%
18.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.1% |
25.9%
6.8 pts better
|
23.9%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 18.3% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-13
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 2025-03-03
E · Potential for more than minimal harm
2025-02-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-03
E · Potential for more than minimal harm
2025-02-13
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 2025-03-03
E · Potential for more than minimal harm
2025-02-13
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
D · Potential for more than minimal harm
2025-02-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-03
E · Potential for more than minimal harm
2024-01-11
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 2024-01-15
E · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-15
D · Potential for more than minimal harm
2024-01-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-15
Penalties and ownership
What sits behind the stars
Ownership
Fannin County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Bauder Family Investments, LLC
5% Or Greater Mortgage Interest · Organization
Bauder, Kelly
5% Or Greater Mortgage Interest · Individual
Bauder, Madison
5% Or Greater Mortgage Interest · Individual
Bauder, Parker
5% Or Greater Mortgage Interest · Individual
Bauder, William
Operational/Managerial Control · Individual
Bauder, William
5% Or Greater Mortgage Interest · Individual
Boulware St James LLC
5% Or Greater Mortgage Interest · Organization
Boulware, Douglas
5% Or Greater Mortgage Interest · Individual
Boulware, Sandra
5% Or Greater Mortgage Interest · Individual
Boulware, Steven
Operational/Managerial Control · Individual
Boulware, Steven
5% Or Greater Mortgage Interest · Individual
Boulware, Thomas
5% Or Greater Mortgage Interest · Individual
Pmg Opco - Mckinney LLC
Operational/Managerial Control · Organization
Pmg Realco-Mckinney, LLC
5% Or Greater Mortgage Interest · Organization
Sanderson, Clark
Corporate Director · Individual
Walker, Katie
5% Or Greater Mortgage Interest · Individual
Nearby options
Other facilities in reach
#1
Park Manor Of Mckinney
Mckinney, TX
2-star overall rating with 3-star inspections with $29,426 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
North Park Health And Rehabilitation Center
Mckinney, TX
4-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#3
Mckinney Healthcare And Rehabilitation Center
Mckinney, TX
4-star overall rating with 4-star inspections with 6 recent health deficiencies
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