Cycle 1
Health 2025-05-06 · Fire 2025-05-06
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Mesquite, TX
Cheyenne Medical Lodge
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
750 Highway 352, Mesquite, TX
(972) 788-8900
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
139
Certified beds
Average residents
127
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Foursquare Healthcare
Operator or chain grouping
Approved since
2019-08-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 4 health / 1 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
0.36
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.99
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.08
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.64
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
2.43
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,264
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.08
Baseline 24.53% · Performance 21.09% · Measure score 4.08 · Achievement 0.73 · Improvement 4.08
Healthcare-associated infections
0
Baseline 7.13% · Performance 8.05% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.90
Baseline 55.96% · Performance 55.93% · Measure score 1.90 · Achievement 1.90 · Improvement 0
Adjusted total nurse staffing
1.01
Baseline 2.07 hours · Performance 2.63 hours · Measure score 1.01 · Achievement 0 · Improvement 1.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.48% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 125 · Observed rate 15.2% · Lower 95% interval 8.87% |
| Discharge to community | 49.73% |
50.57%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 44.07% · Lower 95% interval 41.92% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 115 · Denominator 115 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 115 |
| Discharge self-care score | 53.66% |
53.69%
About the same
|
Numerator 22 · Denominator 41 |
| Discharge mobility score | 53.66% |
50.94%
2.7 pts better
|
Numerator 22 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 1.74% |
2.29%
0.6 pts better
|
Numerator 2 · Denominator 115 · Adjusted rate 1.09% |
| Healthcare-associated infections requiring hospitalization | 8.06% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 78 · Observed rate 10.26% · Lower 95% interval 4.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 175 |
| Staff flu vaccination coverage | 42.18% |
42%
0.2 pts better
|
Numerator 62 · Denominator 147 |
| Discharge function score | 58.54% |
56.45%
2.1 pts better
|
Numerator 24 · Denominator 41 |
| Transfer of health information to provider | 85% |
95.95%
11 pts worse
|
Numerator 34 · Denominator 40 |
| Transfer of health information to patient | 93.75% |
96.28%
2.5 pts worse
|
Numerator 45 · Denominator 48 |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 5 · Denominator 55 |
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 3.7 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.8 · 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 | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 2.0% · Q4 2.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 58.2% |
2.7%
55.5 pts worse
|
11.4%
46.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.5% · Q2 59.8% · Q3 57.5% · Q4 61.3% · 4Q avg 58.2% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
3.3%
0.9 pts worse
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 3.6% · Q3 4.6% · Q4 1.0% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.1% |
18.9%
1.2 pts worse
|
19.6%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 19.4% · Q3 21.1% · Q4 23.8% · 4Q avg 20.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.2% |
10.8%
2.6 pts better
|
16.7%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 7.9% · Q3 9.1% · Q4 10.3% · 4Q avg 8.2% · 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 | 15.9% |
15.4%
0.5 pts worse
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 16.2% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
16.1%
1.9 pts worse
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 17.4% · Q3 22.4% · Q4 14.0% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.5%
0.4 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 1.0% · Q4 0.7% · 4Q avg 0.9% · 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 1.1% · Q3 0.0% · Q4 1.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
15.0%
7.1 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 16.9% · Q3 27.1% · Q4 18.5% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
4.2%
About the same
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.2% · Q3 4.1% · Q4 2.8% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
89.7%
7.5 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.2% · Q2 98.4% · Q3 99.3% · Q4 98.4% · 4Q avg 97.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
12.0%
4.6 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.1% · Expected 10.8% · 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 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.1% |
88.0%
0.9 pts worse
|
79.7%
7.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
25.9%
6.4 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 21.4% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-01-19 · Fire 2023-01-19
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-06
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 2025-05-20
F · Potential for more than minimal harm
2024-03-28
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 2024-04-08
F · Potential for more than minimal harm
2024-03-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-03-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-08
D · Potential for more than minimal harm
2024-03-28
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 2024-04-08
D · Potential for more than minimal harm
2024-03-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-06
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 2025-06-06
E · Potential for more than minimal harm
2025-05-06
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 2025-06-06
E · Potential for more than minimal harm
2025-05-06
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 2025-06-06
E · Potential for more than minimal harm
2025-05-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-06
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 2025-06-06
D · Potential for more than minimal harm
2025-05-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-06
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 2025-06-06
D · Potential for more than minimal harm
2025-05-06
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 2025-06-06
D · Potential for more than minimal harm
2024-03-28
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 2024-04-16
D · Potential for more than minimal harm
2024-01-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-10-12
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-10-13
D · Potential for more than minimal harm
2023-05-25
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-06-12
E · Potential for more than minimal harm
2023-01-19
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 2023-02-17
E · Potential for more than minimal harm
2023-01-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-01-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-01-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-02-17
D · Potential for more than minimal harm
2023-01-19
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 2023-02-17
D · Potential for more than minimal harm
2023-01-19
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 2023-02-17
D · Potential for more than minimal harm
2023-01-19
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 2023-02-17
D · Potential for more than minimal harm
2023-01-19
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 2023-02-17
D · Potential for more than minimal harm
2023-01-19
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 2023-02-17
Penalties and ownership
What sits behind the stars
Ownership
Boatler, Keith
Operational/Managerial Control · Individual
Campbell, John
Operational/Managerial Control · Individual
Campbell, Kenneth
Operational/Managerial Control · Individual
David W Miller Gs Trust
Operational/Managerial Control · Organization
Dwm 5x5 Trust
5% Or Greater Mortgage Interest · Organization
Fairbrook Partners, LP
5% Or Greater Mortgage Interest · Organization
Foursquare Texas 16 LLC
Operational/Managerial Control · Organization
Jec Gs Trust
Operational/Managerial Control · Organization
Jem 5x5 Trust
5% Or Greater Mortgage Interest · Organization
John E Miller Gs Trust
Operational/Managerial Control · Organization
Kingsbury Capital LLC Series F
Operational/Managerial Control · Organization
Kjc Gs Trust
Operational/Managerial Control · Organization
Lewis, Shane
Operational/Managerial Control · Individual
Lion Plaza LP
Operational/Managerial Control · Organization
Meekins, Greg
Corporate Director · Individual
Miller, David
Operational/Managerial Control · Individual
Miller, Don
5% Or Greater Mortgage Interest · Individual
Miller, John
Operational/Managerial Control · Individual
Miller, Richard
Operational/Managerial Control · Individual
Mnh-Inv Series LLC Series D
Operational/Managerial Control · Organization
Montague Nh, LP
5% Or Greater Mortgage Interest · Organization
Nocona Hospital District
5% Or Greater Mortgage Interest · Organization
Richard M Miller Gs Trust
Operational/Managerial Control · Organization
Rmm 5x5 Trust
5% Or Greater Mortgage Interest · Organization
Rockett, LP
5% Or Greater Mortgage Interest · Organization
Sdl Gs 5x5 Trust
5% Or Greater Mortgage Interest · Organization
Sv Nh Realty Ltd
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Mesquite Tree Nursing Center
Mesquite, TX
4-star overall rating with 3-star inspections with $26,046 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Mesquite Village Wellness & Rehabilitation
Mesquite, TX
3-star overall rating with 3-star inspections with $8,021 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Edgewood Rehabilitation And Care Center
Mesquite, TX
4-star overall rating with 4-star inspections with 4 recent health deficiencies
Jump out