Cycle 1
Health 2025-02-26 · Fire 2025-02-26
10 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Ennis, TX
Bluebonnet Rehab At Ennis
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
2300 South Oak Grove Rd, Ennis, TX
(972) 875-8643
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
136
Certified beds
Average residents
67
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Caring Healthcare Group
Operator or chain grouping
Approved since
1993-05-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 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
0.49
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.75
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.05
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,902
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.00% · Performance 22.47% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.75% · Performance 7.92% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.80
Baseline 58.67% · Performance 56.34% · Measure score 1.80 · Achievement 1.80 · Improvement 0.19
Adjusted total nurse staffing
5.68
Baseline 3.76 hours · Performance 4.69 hours · Measure score 5.68 · Achievement 5.68 · Improvement 4.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.37% |
10.72%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 20.51% · Lower 95% interval 9.62% |
| Discharge to community | 42.34% |
50.57%
8.2 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 32.73% · Lower 95% interval 32.76% |
| Medicare spending per beneficiary | 1.34 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 95.31% |
95.27%
About the same
|
Numerator 61 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 41.38% |
53.69%
12.3 pts worse
|
Numerator 12 · Denominator 29 |
| Discharge mobility score | 44.83% |
50.94%
6.1 pts worse
|
Numerator 13 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 64 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.93% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 9.8% · Lower 95% interval 4.62% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 140 |
| Staff flu vaccination coverage | 67.46% |
42%
25.5 pts better
|
Numerator 85 · Denominator 126 |
| Discharge function score | 48.28% |
56.45%
8.2 pts worse
|
Numerator 14 · Denominator 29 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 77.14% |
25.2%
51.9 pts better
|
Numerator 27 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.3%
2.9 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
2.7%
0.2 pts worse
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.7% · Q3 3.2% · Q4 3.2% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
3.3%
0.9 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 7.3% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.5% |
18.9%
2.4 pts better
|
19.6%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 18.0% · Q3 12.7% · Q4 16.1% · 4Q avg 16.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
10.8%
3.6 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.3% · Q3 9.8% · Q4 5.3% · 4Q avg 7.2% · 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 | 25.4% |
15.4%
10 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 32.4% · Q3 16.9% · Q4 24.3% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
16.1%
3.7 pts worse
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 22.9% · Q3 22.2% · Q4 24.1% · 4Q avg 19.8% · 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 | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.9% |
15.0%
10.1 pts better
|
19.8%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 3.7% · Q3 2.9% · Q4 4.4% · 4Q avg 4.9% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.2%
1.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 5.0% · Q3 1.5% · Q4 2.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
89.7%
9.7 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.2% |
12.0%
9.2 pts worse
|
12.0%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 20.9% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.5%
1.2 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 4.3% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
88.0%
9.7 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 39.3% |
25.9%
13.4 pts worse
|
23.9%
15.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 39.3% · Observed 41.9% · Expected 25.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-04 · Fire 2024-01-04
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-10-22 · Fire 2022-10-22
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 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
2025-02-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-02-26
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-04-16
D · Potential for more than minimal harm
2024-01-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-01-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-01-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-18
F · Potential for more than minimal harm
2022-10-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-23
E · Potential for more than minimal harm
2022-10-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-23
E · Potential for more than minimal harm
2022-10-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-29
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 2025-07-30
D · Potential for more than minimal harm
2025-03-21
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 2025-03-22
D · Potential for more than minimal harm
2025-03-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-22
D · Potential for more than minimal harm
2025-03-21
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 2025-03-22
D · Potential for more than minimal harm
2025-03-21
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 2025-03-22
D · Potential for more than minimal harm
2025-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-22
F · Potential for more than minimal harm
2025-02-26
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 2025-02-27
E · Potential for more than minimal harm
2025-02-26
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-26
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-02-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-02-27
F · Potential for more than minimal harm
2024-01-04
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 2024-01-05
E · Potential for more than minimal harm
2024-01-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-05
D · Potential for more than minimal harm
2024-01-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-05
K · Immediate jeopardy
2022-10-22
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 2022-10-24
F · Potential for more than minimal harm
2022-10-22
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 2022-10-24
E · Potential for more than minimal harm
2022-10-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-10-24
Penalties and ownership
What sits behind the stars
Ownership
Coryell County Memorial Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Byrom, David
Corporate Officer · Individual
Ennis SNF, LLC
Operational/Managerial Control · Organization
Ray, Vincent
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Ennis Care Center
Ennis, TX
1-star overall rating with 2-star inspections with $187,220 in total fines with 8 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Legend Oaks Healthcare And Rehabilitation - Ennis
Ennis, TX
5-star overall rating with 5-star inspections with $13,275 in total fines with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Pleasant Manor Healthcare Rehabilitation
Waxahachie, TX
3-star overall rating with 3-star inspections with $14,996 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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