Cycle 1
Health 2025-05-15 · Fire 2025-05-15
4 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mesquite, TX
Edgewood Rehabilitation And Care Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies
1101 Windbell Dr, Mesquite, TX
(972) 288-8800
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
142
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
2012-10-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
69 facilities
Chain averages 2 overall / 2 health / 2 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
0.37
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
2.81
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,471
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.88
Baseline 24.10% · Performance 20.29% · Measure score 4.88 · Achievement 2.46 · Improvement 4.88
Healthcare-associated infections
0
Baseline 6.61% · Performance 7.89% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.79
Baseline 70.91% · Performance 60.38% · Measure score 1.79 · Achievement 0.81 · Improvement 1.79
Adjusted total nurse staffing
0
Baseline 3.36 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.45% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 16.22% · Lower 95% interval 7.65% |
| Discharge to community | 50.17% |
50.57%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 42% · Lower 95% interval 35.52% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 72.97% |
53.69%
19.3 pts better
|
Numerator 27 · Denominator 37 |
| Discharge mobility score | 56.76% |
50.94%
5.8 pts better
|
Numerator 21 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 54 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.89% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 11.9% · Lower 95% interval 5.01% |
| Staff COVID-19 vaccination coverage | 10.45% |
8.2%
2.2 pts better
|
Numerator 7 · Denominator 67 |
| Staff flu vaccination coverage | 22.86% |
42%
19.1 pts worse
|
Numerator 16 · Denominator 70 |
| Discharge function score | 75.68% |
56.45%
19.2 pts better
|
Numerator 28 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 4.35% |
25.2%
20.9 pts worse
|
Numerator 1 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.1%
2.4 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.1% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 1.8% |
3.3%
1.5 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 1.9% · Q4 3.5% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
2.7%
1.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 0.6% |
3.3%
2.7 pts better
|
5.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
18.9%
10.3 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 6.5% · Q3 7.0% · Q4 10.6% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.4% |
10.8%
9.4 pts better
|
16.7%
15.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 3.1% · Q4 0.0% · 4Q avg 1.4% · 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 | 3.8% |
15.4%
11.6 pts better
|
16.3%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
16.1%
1.9 pts better
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 14.3% · Q3 7.7% · Q4 32.6% · 4Q avg 14.2% · 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 | 0.5% |
15.0%
14.5 pts better
|
19.8%
19.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
4.2%
3 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
89.7%
9.8 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.1% · Q4 99.2% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.7% |
12.0%
7.3 pts better
|
12.0%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.7% · Observed 5.1% · Expected 12.1% · 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 | 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 | 29.3% |
25.9%
3.4 pts worse
|
23.9%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 33.9% · Expected 27.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-12 · Fire 2024-04-12
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-12
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-05-10
F · Potential for more than minimal harm
2024-04-12
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 2024-05-10
E · Potential for more than minimal harm
2024-04-12
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-10
D · Potential for more than minimal harm
2023-02-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-30
E · Potential for more than minimal harm
2025-05-15
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 2025-06-03
E · Potential for more than minimal harm
2025-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-15
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 2025-06-03
E · Potential for more than minimal harm
2024-10-21
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-21
E · Potential for more than minimal harm
2024-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-10-21
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 2024-11-21
D · Potential for more than minimal harm
2024-10-21
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-11-21
D · Potential for more than minimal harm
2024-04-25
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 2024-05-25
E · Potential for more than minimal harm
2024-04-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-10
E · Potential for more than minimal harm
2024-04-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-04-12
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 2024-05-10
D · Potential for more than minimal harm
2024-04-12
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-05-10
D · Potential for more than minimal harm
2023-06-02
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 2023-06-30
G · Actual harm
2023-04-04
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 2023-05-16
G · Actual harm
2023-04-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-16
E · Potential for more than minimal harm
2023-02-16
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 2023-03-17
E · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-16
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 2023-03-17
D · Potential for more than minimal harm
2023-02-16
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 2023-03-17
Penalties and ownership
What sits behind the stars
Ownership
Dallas County Hospital District
5% Or Greater Direct Ownership Interest · Organization
Care Inn Of Edna LLC
Operational/Managerial Control · Organization
Castaneda, Edmundo
Corporate Officer · Individual
Cerise, Frederick
Corporate Director · Individual
Yates, Timothy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#2
Willowbend Nursing And Rehabilitation Center
Mesquite, TX
2-star overall rating with 2-star inspections with $94,394 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
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
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