Cycle 1
Health 2025-03-13 · Fire 2025-03-13
8 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Ennis, TX
Ennis Care Center
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
1200 S Hall St, Ennis, TX
(972) 875-9051
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
155
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eduro Healthcare
Operator or chain grouping
Approved since
1984-08-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 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
0.31
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.51
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.94
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.32
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.22
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
67%
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
5,099
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9906
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.45
Baseline 21.52% · Performance 18.91% · Measure score 5.45 · Achievement 5.45 · Improvement 5.32
Healthcare-associated infections
6.12
Baseline 10.01% · Performance 6.69% · Measure score 6.12 · Achievement 3.82 · Improvement 6.12
Total nurse turnover
3.39
Baseline 80.00% · Performance 58.54% · Measure score 3.39 · Achievement 1.26 · Improvement 3.39
Adjusted total nurse staffing
0
Baseline 2.93 hours · Performance 2.62 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.26% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 8.77% · Lower 95% interval 7.27% |
| Discharge to community | 49.53% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 44.83% · Lower 95% interval 35.9% |
| Medicare spending per beneficiary | 1.47 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 32 · Denominator 33 |
| Falls with major injury | 3.03% |
0.77%
2.3 pts worse
|
Numerator 1 · Denominator 33 |
| Discharge self-care score | 59.26% |
53.69%
5.6 pts better
|
Numerator 16 · Denominator 27 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 12 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 1.05% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 95 |
| Staff flu vaccination coverage | 29.51% |
42%
12.5 pts worse
|
Numerator 36 · Denominator 122 |
| Discharge function score | 40.74% |
56.45%
15.7 pts worse
|
Numerator 11 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · 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 | 4.2% |
3.3%
0.9 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 7.8% · Q3 1.9% · Q4 1.8% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
2.7%
1.2 pts worse
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.3% · Q3 3.9% · Q4 5.6% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
3.3%
1.7 pts worse
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 8.2% · Q3 2.5% · Q4 6.8% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.2% |
18.9%
3.3 pts worse
|
19.6%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 25.5% · Q3 20.9% · Q4 20.5% · 4Q avg 22.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
10.8%
0.9 pts worse
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 9.1% · Q3 10.0% · Q4 12.5% · 4Q avg 11.7% · 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 | 9.8% |
15.4%
5.6 pts better
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.5% · Q4 19.6% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.6% |
16.1%
2.5 pts worse
|
14.9%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 27.1% · Q3 13.9% · Q4 22.5% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.5%
0.1 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.8%
0.1 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.9% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.9% |
15.0%
9.1 pts better
|
19.8%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 13.3% · Q3 2.0% · Q4 5.5% · 4Q avg 5.9% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
4.2%
3.1 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 2.7% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
89.7%
7.4 pts better
|
81.7%
15.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.0% · Q4 95.2% · 4Q avg 97.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
12.0%
4.3 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 18.6% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.5%
0.9 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 3.6% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.9% |
25.9%
8 pts worse
|
23.9%
10 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.9% · Observed 41.9% · Expected 29.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-01 · Fire 2024-02-01
9 health deficiencies
Top issue: Environmental (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-11-22 · Fire 2022-11-22
4 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-27
F · Potential for more than minimal harm
2025-03-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-27
F · Potential for more than minimal harm
2025-03-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-27
F · Potential for more than minimal harm
2025-03-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-27
F · Potential for more than minimal harm
2025-03-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-27
F · Potential for more than minimal harm
2025-03-13
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-04-27
F · Potential for more than minimal harm
2025-03-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-27
E · Potential for more than minimal harm
2025-03-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-27
E · Potential for more than minimal harm
2025-03-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-27
E · Potential for more than minimal harm
2025-03-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-27
E · Potential for more than minimal harm
2025-03-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-27
E · Potential for more than minimal harm
2025-03-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-27
D · Potential for more than minimal harm
2025-03-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-27
C · Minimal harm
2025-03-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-14
F · Potential for more than minimal harm
2024-02-01
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-02-05
F · Potential for more than minimal harm
2024-02-01
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-07
F · Potential for more than minimal harm
2024-02-01
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 2024-02-05
F · Potential for more than minimal harm
2024-02-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-23
E · Potential for more than minimal harm
2024-02-01
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-07
E · Potential for more than minimal harm
2024-02-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-02
C · Minimal harm
2024-02-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-02
D · Potential for more than minimal harm
2022-11-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-22
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-01-03
D · Potential for more than minimal harm
2022-11-22
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-01-03
C · Minimal harm
2022-11-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-03
Inspection history
Recent health citations
J · Immediate jeopardy
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 2025-11-17
D · Potential for more than minimal harm
2025-05-19
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-03-13
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 2025-04-06
E · Potential for more than minimal harm
2025-03-13
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 2025-04-06
D · Potential for more than minimal harm
2025-03-13
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 2025-01-07
D · Potential for more than minimal harm
2025-03-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-13
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 2025-04-06
D · Potential for more than minimal harm
2025-03-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-06
D · Potential for more than minimal harm
2024-12-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-27
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-27
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 2025-01-17
K · Immediate jeopardy
2024-02-01
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 2024-02-03
E · Potential for more than minimal harm
2024-02-01
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-02-01
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 2024-02-03
E · Potential for more than minimal harm
2024-02-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-02-01
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-02-01
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-02-03
K · Immediate jeopardy
2023-08-11
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 2023-08-12
K · Immediate jeopardy
2023-08-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-25
F · Potential for more than minimal harm
2022-11-22
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 2022-11-23
E · Potential for more than minimal harm
2022-11-22
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 2022-11-23
Penalties and ownership
What sits behind the stars
$6,227
2025-05-19
Fine
Fine · fine $6,227
Fine
$30,684
2024-02-01
Fine
Fine · fine $30,684
Fine
$0
2024-02-01
Payment Denial
Payment Denial · denial start 2024-03-02 · 5 days
5 day denial
$150,309
2023-08-11
Fine
Fine · fine $150,309
Fine
Ownership
Fannin County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Ennis Nursing And Rehab Center LLC
Operational/Managerial Control · Organization
Ramos, Brian
Operational/Managerial Control · Individual
Sanderson, Clark
Corporate Director · Individual
Wyatt, Julie
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
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
#2
Bluebonnet Rehab At Ennis
Ennis, TX
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 2 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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