Cycle 1
Health 2025-05-08 · Fire 2025-05-08
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mckinney, TX
Mckinney Healthcare And Rehabilitation Center
4-star overall rating with 4-star inspections with 6 recent health deficiencies
253 Enterprise Dr, Mckinney, TX
(972) 542-2695
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
80
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1992-02-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 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
0.57
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.77
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.09
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.11
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,793
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9866
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.94
Baseline 20.64% · Performance 21.00% · Measure score 0.94 · Achievement 0.94 · Improvement 0
Healthcare-associated infections
7.37
Baseline 8.08% · Performance 5.65% · Measure score 7.37 · Achievement 7.30 · Improvement 7.37
Total nurse turnover
4.36
Baseline 67.31% · Performance 46.67% · Measure score 4.36 · Achievement 4.16 · Improvement 4.36
Adjusted total nurse staffing
0
Baseline 3.47 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.97% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 138 · Observed rate 13.04% · Lower 95% interval 7.64% |
| Discharge to community | 47.14% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 39.37% · Lower 95% interval 39.44% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 97.3% |
95.27%
2 pts better
|
Numerator 108 · Denominator 111 |
| Falls with major injury | 0.9% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 111 |
| Discharge self-care score | 36.92% |
53.69%
16.8 pts worse
|
Numerator 24 · Denominator 65 |
| Discharge mobility score | 41.54% |
50.94%
9.4 pts worse
|
Numerator 27 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 0.9% |
2.29%
1.4 pts better
|
Numerator 1 · Denominator 111 · Adjusted rate 0.8% |
| Healthcare-associated infections requiring hospitalization | 5.65% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 2.91% · Lower 95% interval 3.17% |
| Staff COVID-19 vaccination coverage | 0.85% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 117 |
| Staff flu vaccination coverage | 13.19% |
42%
28.8 pts worse
|
Numerator 24 · Denominator 182 |
| Discharge function score | 52.31% |
56.45%
4.1 pts worse
|
Numerator 34 · Denominator 65 |
| Transfer of health information to provider | 70.37% |
95.95%
25.6 pts worse
|
Numerator 38 · Denominator 54 |
| Transfer of health information to patient | 97.14% |
96.28%
0.9 pts better
|
Numerator 34 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 4.55% |
25.2%
20.6 pts worse
|
Numerator 3 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.1
About the same
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · 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 100.0% · Q2 98.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
97.9%
1.1 pts worse
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.8% · Q4 3.4% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
2.7%
1 pts worse
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.1% · Q3 6.4% · Q4 2.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
3.3%
2.3 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.8% |
18.9%
7.9 pts worse
|
19.6%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 26.9% · Q3 25.9% · Q4 26.3% · 4Q avg 26.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.3% |
10.8%
6.5 pts better
|
16.7%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.4% · Q3 0.0% · Q4 4.5% · 4Q avg 4.3% · 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 | 22.5% |
15.4%
7.1 pts worse
|
16.3%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 8.7% · Q3 26.7% · Q4 18.8% · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.9% |
16.1%
10.8 pts worse
|
14.9%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 17.4% · Q3 20.4% · Q4 41.5% · 4Q avg 26.9% · 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 | 0.0% |
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 | 20.9% |
15.0%
5.9 pts worse
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 20.1% · Q3 17.0% · Q4 14.5% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
4.2%
2.6 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.3% · Q3 2.2% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
89.7%
2 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 91.1% · Q3 92.6% · Q4 92.1% · 4Q avg 91.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.2% |
12.0%
5.8 pts better
|
12.0%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.2% · Observed 6.4% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.9% |
88.0%
11.1 pts worse
|
79.7%
2.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
25.9%
2.5 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 28.7% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-11 · Fire 2024-04-11
11 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-09 · Fire 2023-03-09
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-03-09
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-03-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-25
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 2025-11-26
D · Potential for more than minimal harm
2025-05-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-05-08
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-05-01
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 2025-05-02
D · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
E · Potential for more than minimal harm
2024-04-11
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 2024-05-03
E · Potential for more than minimal harm
2024-04-11
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 2024-04-30
E · Potential for more than minimal harm
2024-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-04-11
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 2024-04-30
D · Potential for more than minimal harm
2024-04-11
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 2024-05-03
D · Potential for more than minimal harm
2024-04-11
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 2024-04-12
D · Potential for more than minimal harm
2024-04-11
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-11
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 2024-04-12
D · Potential for more than minimal harm
2023-05-15
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 2023-05-19
D · Potential for more than minimal harm
2023-05-15
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 2023-05-19
E · Potential for more than minimal harm
2023-03-09
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 2023-04-06
D · Potential for more than minimal harm
2023-03-09
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 2023-04-06
D · Potential for more than minimal harm
2023-03-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-06
Penalties and ownership
What sits behind the stars
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Doshi, Dipauni
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Moonflower Healthcare, Inc.
Operational/Managerial Control · Organization
Wilson, Edward
Operational/Managerial Control · Individual
Wright, Laban
Corporate Officer · 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
Belterra Health & Rehab
Mckinney, TX
5-star overall rating with 4-star inspections with 5 recent health deficiencies
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