Cycle 1
Health 2025-03-13 · Fire 2025-03-13
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Mesquite, TX
Christian Care Communities and Services Mesquite
4-star overall rating with 3-star inspections with $36,753 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1000 Wiggins Pkwy, Mesquite, TX
(972) 686-3000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
180
Certified beds
Average residents
84
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Boncrest Resource Group
Operator or chain grouping
Approved since
1985-12-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 health / 4 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
0.57
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.93
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,946
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.78% · Performance 21.50% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.23
Baseline 7.11% · Performance 6.87% · Measure score 3.23 · Achievement 3.23 · Improvement 0.64
Total nurse turnover
5.49
Baseline 17.86% · Performance 41.25% · Measure score 5.49 · Achievement 5.49 · Improvement 0
Adjusted total nurse staffing
3.78
Baseline 4.30 hours · Performance 4.15 hours · Measure score 3.78 · Achievement 3.78 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.16% |
10.72%
3.4 pts worse
|
Worse than the National Rate · Eligible stays 219 · Observed rate 15.53% · Lower 95% interval 11.41% |
| Discharge to community | 69.55% |
50.57%
19 pts better
|
Better than the National Rate · Eligible stays 181 · Observed rate 65.19% · Lower 95% interval 61.12% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.31% |
95.27%
4 pts better
|
Numerator 144 · Denominator 145 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 145 |
| Discharge self-care score | 65.22% |
53.69%
11.5 pts better
|
Numerator 60 · Denominator 92 |
| Discharge mobility score | 38.04% |
50.94%
12.9 pts worse
|
Numerator 35 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 0.69% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 145 · Adjusted rate 0.68% |
| Healthcare-associated infections requiring hospitalization | 6.87% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 5.74% · Lower 95% interval 3.85% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 20.18% |
42%
21.8 pts worse
|
Numerator 44 · Denominator 218 |
| Discharge function score | 42.39% |
56.45%
14.1 pts worse
|
Numerator 39 · Denominator 92 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 99.04% |
96.28%
2.8 pts better
|
Numerator 103 · Denominator 104 |
| Resident COVID-19 vaccinations up to date | 8.64% |
25.2%
16.6 pts worse
|
Numerator 7 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.7 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.1
1.7 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
97.1%
1.3 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.9% · Q3 98.0% · Q4 98.0% · 4Q avg 98.4% |
| 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 | 6.7% |
3.3%
3.4 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 8.3% · Q3 6.1% · Q4 5.9% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
2.7%
1.6 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
3.3%
2.5 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 17.1% · Q4 5.6% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.3% |
18.9%
6.4 pts worse
|
19.6%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 27.8% · Q3 18.9% · Q4 26.3% · 4Q avg 25.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.0% |
10.8%
1.2 pts worse
|
16.7%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 15.2% · Q3 13.3% · Q4 6.2% · 4Q avg 12.0% · 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 | 27.3% |
15.4%
11.9 pts worse
|
16.3%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.8% |
16.1%
11.7 pts worse
|
14.9%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.4% · Q2 23.1% · Q3 17.2% · Q4 25.0% · 4Q avg 27.8% · 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 | 0.0% |
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 | 25.4% |
15.0%
10.4 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 20.9% · Q3 27.6% · Q4 31.1% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.2%
0.2 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.6% · Q3 4.3% · Q4 4.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
89.7%
6.8 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 98.6% · Q3 94.9% · Q4 95.7% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
12.0%
0.4 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 11.2% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
88.0%
11.1 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
25.9%
7.6 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 16.1% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-01-05 · Fire 2023-01-05
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
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 2025-03-27
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 2025-04-04
E · Potential for more than minimal harm
2024-02-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-02-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-06
E · Potential for more than minimal harm
2023-01-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-02-18
E · Potential for more than minimal harm
2023-01-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-18
E · Potential for more than minimal harm
2023-01-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-10
D · Potential for more than minimal harm
2023-01-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-08-16
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 2025-08-26
J · Immediate jeopardy
2025-08-13
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 2025-05-02
D · Potential for more than minimal harm
2025-08-13
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 2025-09-11
J · Immediate jeopardy
2025-06-18
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 2025-06-16
E · Potential for more than minimal harm
2025-03-13
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 2025-03-27
D · 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 2025-03-27
E · Potential for more than minimal harm
2025-02-19
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-12-30
K · Immediate jeopardy
2024-12-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-10-19
J · Immediate jeopardy
2024-12-18
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 2024-10-19
D · Potential for more than minimal harm
2024-09-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-19
E · Potential for more than minimal harm
2024-02-08
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-02-08
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 2024-03-06
E · Potential for more than minimal harm
2024-02-08
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 2024-03-06
D · Potential for more than minimal harm
2024-02-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-06
Penalties and ownership
What sits behind the stars
$22,320
2025-08-13
Fine
Fine · fine $22,320
Fine
$14,433
2024-12-18
Fine
Fine · fine $14,433
Fine
Ownership
Baker, Amelia
Operational/Managerial Control · Individual
Beck, Kari
Operational/Managerial Control · Individual
Ccc Mesquite Management LLC
Operational/Managerial Control · Organization
Corrigan, Frank
Operational/Managerial Control · Individual
German, Todd
Operational/Managerial Control · Individual
Holt, Erin
Operational/Managerial Control · Individual
Johnson, Matthew
Operational/Managerial Control · Individual
Keeton, Wendy
Operational/Managerial Control · Individual
Kissling, Monica
Operational/Managerial Control · Individual
Langston, Karla
Operational/Managerial Control · Individual
Matheny, Cynthia
Operational/Managerial Control · Individual
Mcbean, Patricia
Operational/Managerial Control · Individual
Mcmullan, John
Operational/Managerial Control · Individual
Mesquite Senior Care LLC
Operational/Managerial Control · Organization
Oakdale Seniors Alliance, LLC
Operational/Managerial Control · Organization
Owens, Angela
Operational/Managerial Control · Individual
Rosenbaum, Maurice
Operational/Managerial Control · Individual
Sanderson, Clark
Operational/Managerial Control · Individual
Thompson, Joyce
Operational/Managerial Control · Individual
Trompler, Kelly
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Town East Rehabilitation and Healthcare Center
Mesquite, TX
2-star overall rating with 1-star inspections with abuse icon flag with $38,860 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Palomino Place
Mesquite, TX
2-star overall rating with 1-star inspections with $248,987 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Advanced Health & Rehab Center of Garland
Garland, TX
2-star overall rating with 1-star inspections with $236,424 in total fines with 21 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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