Cycle 1
Health 2025-08-07 · Fire 2025-08-07
11 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Mesquite, TX
Mesquite Village Wellness & Rehabilitation
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
825 W. Kearney Street, Mesquite, TX
(972) 288-7668
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
149
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Opco Skilled Management
Operator or chain grouping
Approved since
2020-05-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 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
0.17
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.18
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,129
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.54
Baseline 22.58% · Performance 41.03% · Measure score 5.54 · Achievement 5.54 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.67 hours · Performance 2.96 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.08% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 11.76% · Lower 95% interval 6.43% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 89.29% |
95.27%
6 pts worse
|
Numerator 25 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 28 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 56 |
| Staff flu vaccination coverage | 32.14% |
42%
9.9 pts worse
|
Numerator 18 · Denominator 56 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 94.0% |
97.9%
3.9 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.3%
0.6 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 2.2% · Q4 6.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 who lose too much weight | 0.0% |
3.3%
3.3 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 17.6% |
18.9%
1.3 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 17.5% · Q3 16.2% · Q4 19.4% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.4% |
10.8%
7.4 pts better
|
16.7%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.2% · Q3 3.4% · Q4 3.3% · 4Q avg 3.4% · 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 | 28.0% |
15.4%
12.6 pts worse
|
16.3%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.7% |
16.1%
7.6 pts worse
|
14.9%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 11.1% · Q3 28.6% · Q4 28.1% · 4Q avg 23.7% · 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 | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
15.0%
2.6 pts worse
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 17.5% · Q3 13.2% · Q4 11.3% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.2%
1.2 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 8.5% · Q3 6.7% · Q4 1.5% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
89.7%
4.5 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 88.1% · Q3 95.1% · Q4 100.0% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.5% |
12.0%
3.5 pts better
|
12.0%
3.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.5% · Observed 11.1% · Expected 14.6% · 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 · 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 | 53.5% |
88.0%
34.5 pts worse
|
79.7%
26.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
25.9%
2.2 pts better
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 33.3% · Expected 33.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-03 · Fire 2023-05-03
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-07
F · Potential for more than minimal harm
2024-06-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-16
E · Potential for more than minimal harm
2024-06-27
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 2024-07-16
E · Potential for more than minimal harm
2024-06-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-16
F · Potential for more than minimal harm
2023-05-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-19
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-21
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 2025-08-22
E · Potential for more than minimal harm
2025-08-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-08-21
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-08-21
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 2025-08-22
E · Potential for more than minimal harm
2025-08-21
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 2025-08-22
E · Potential for more than minimal harm
2025-08-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-08
E · Potential for more than minimal harm
2025-08-07
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 2025-08-08
E · Potential for more than minimal harm
2025-08-07
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 2025-08-08
E · Potential for more than minimal harm
2025-08-07
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-08-11
D · Potential for more than minimal harm
2025-08-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-01-08
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 2025-01-31
J · Immediate jeopardy
2024-06-27
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 2024-05-10
D · Potential for more than minimal harm
2024-02-29
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-01-06
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-01-26
D · Potential for more than minimal harm
2023-05-30
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 2023-05-31
E · Potential for more than minimal harm
2023-05-03
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 2023-06-18
E · Potential for more than minimal harm
2023-05-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-18
E · Potential for more than minimal harm
2023-05-03
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 2023-06-18
D · Potential for more than minimal harm
2023-05-03
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 2023-06-18
D · Potential for more than minimal harm
2023-05-03
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 2023-06-18
Penalties and ownership
What sits behind the stars
$8,021
2024-06-27
Fine
Fine · fine $8,021
Fine
Ownership
Stratford Hospital District
5% Or Greater Direct Ownership Interest · Organization
Caraday Mesquite LLC
Operational/Managerial Control · Organization
Chumley, Richard
Corporate Officer · Individual
Moore, Gregory
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Edgewood Rehabilitation And Care Center
Mesquite, TX
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
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
#3
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
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