Mesquite, TX

Town East Rehabilitation and Healthcare Center

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

3617 O'Hare Dr, Mesquite, TX

(972) 284-8600

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

130

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Dallas County Hospital District

Operator or chain grouping

Approved since

2007-08-22

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 3 overall / 2 health / 3 staffing / 5 quality stars

Changed ownership

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

0.33

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.91

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.08

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.33

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.25

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.06

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.20

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.34

CMS adjusted RN staffing hours

Adjusted total hours

3.36

CMS adjusted total nurse staffing hours

Case-mix index

1.36

Higher values indicate more complex resident acuity

RN turnover

55%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,849

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.89

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 22.36% · Performance 23.63% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 9.37% · Performance 9.28% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

4.62

Baseline 74.16% · Performance 48.89% · Measure score 4.62 · Achievement 3.62 · Improvement 4.62

Adjusted total nurse staffing

2.93

Baseline 4.02 hours · Performance 3.91 hours · Measure score 2.93 · Achievement 2.93 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.65%	10.72% 0.9 pts worse	No Different than the National Rate · Eligible stays 111 · Observed rate 14.41% · Lower 95% interval 8.3%
Discharge to community	54.22%	50.57% 3.6 pts better	No Different than the National Rate · Eligible stays 106 · Observed rate 43.4% · Lower 95% interval 43.75%
Medicare spending per beneficiary	1.01	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 72 · Denominator 72
Falls with major injury	1.39%	0.77% 0.6 pts worse	Numerator 1 · Denominator 72
Discharge self-care score	85.71%	53.69% 32 pts better	Numerator 42 · Denominator 49
Discharge mobility score	93.88%	50.94% 42.9 pts better	Numerator 46 · Denominator 49
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 72 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	9.28%	7.12% 2.2 pts worse	No Different than the National Rate · Eligible stays 61 · Observed rate 14.75% · Lower 95% interval 5.36%
Staff COVID-19 vaccination coverage	74.83%	8.2% 66.6 pts better	Numerator 110 · Denominator 147
Staff flu vaccination coverage	63.57%	42% 21.6 pts better	Numerator 89 · Denominator 140
Discharge function score	95.92%	56.45% 39.5 pts better	Numerator 47 · Denominator 49
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 21 · Denominator 21
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 32 · Denominator 32
Resident COVID-19 vaccinations up to date	100%	25.2% 74.8 pts better	Numerator 29 · Denominator 29

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.0	2.1 1.1 pts better	1.9 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.4 · Expected 2.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.9	2.1 1.2 pts better	1.8 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.1 · Expected 1.9 · 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	1.6%	3.3% 1.7 pts better	3.3% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 0.0% · Q4 1.4% · 4Q avg 1.6% · 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 2.6% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0%
Percentage of long-stay residents who lose too much weight	1.5%	3.3% 1.8 pts better	5.4% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.2% · 4Q avg 1.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	13.1%	18.9% 5.8 pts better	19.6% 6.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 13.7% · Q3 9.7% · Q4 12.1% · 4Q avg 13.1%
Percentage of long-stay residents who received an antipsychotic medication	7.7%	10.8% 3.1 pts better	16.7% 9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 7.4% · Q3 10.3% · Q4 7.3% · 4Q avg 7.7% · 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	19.9%	15.4% 4.5 pts worse	16.3% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 78.7% · 4Q avg 19.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.7%	16.1% 3.6 pts worse	14.9% 4.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.5% · Q3 0.0% · Q4 79.3% · 4Q avg 19.7% · 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 1.3% · Q2 1.2% · Q3 1.0% · Q4 0.0% · 4Q avg 0.9% · 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 2.8% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	11.4%	15.0% 3.6 pts better	19.8% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 48.3% · 4Q avg 11.4%
Percentage of long-stay residents with pressure ulcers	4.7%	4.2% 0.5 pts worse	5.1% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.1% · Q3 6.6% · Q4 3.4% · 4Q avg 4.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	93.9%	89.7% 4.2 pts better	81.7% 12.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 79.4% · 4Q avg 93.9%
Percentage of short-stay residents who had an outpatient emergency department visit	4.5%	12.0% 7.5 pts better	12.0% 7.5 pts better	Short Stay · 20240701-20250630 · Adjusted 4.5% · Observed 4.8% · Expected 11.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.4%	1.5% 0.1 pts better	1.6% 0.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 1.5% · Q4 2.4% · 4Q avg 1.4% · 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	25.6%	25.9% 0.3 pts better	23.9% 1.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 25.4% · Expected 23.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-05 · Fire 2025-09-05

12 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2024-07-11 · Fire 2024-07-11

11 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2023-05-11 · Fire 2023-05-11

10 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

E · Potential for more than minimal harm 2025-09-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-09-06

E · Potential for more than minimal harm 2025-09-05

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-09-06

F · Potential for more than minimal harm 2024-07-11

K900 · Miscellaneous Deficiencies

Fire Safety

Meet Health Care Facilities Code mechanical requirements.

Corrected 2024-07-12

F · Potential for more than minimal harm 2024-07-11

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-07-27

E · Potential for more than minimal harm 2024-07-11

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-07-19

E · Potential for more than minimal harm 2023-05-11

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-06-01

Inspection history

Recent health citations

J · Immediate jeopardy 2025-12-06

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 2025-12-07

G · Actual harm 2025-12-06

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 2025-12-07

F · Potential for more than minimal harm 2025-12-02

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 2025-12-03

E · Potential for more than minimal harm 2025-12-02

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 2025-12-03

J · Immediate jeopardy 2025-09-05

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 2025-09-08

E · Potential for more than minimal harm 2025-09-05

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 2025-09-08

E · Potential for more than minimal harm 2025-09-05

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 2025-09-08

E · Potential for more than minimal harm 2025-09-05

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-09-08

D · Potential for more than minimal harm 2025-09-05

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 2025-09-08

D · Potential for more than minimal harm 2025-09-05

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 2025-09-08

D · Potential for more than minimal harm 2025-09-05

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-09-08

D · Potential for more than minimal harm 2025-09-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-08

D · Potential for more than minimal harm 2025-01-23

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-01-30

D · Potential for more than minimal harm 2025-01-23

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 2025-01-30

D · Potential for more than minimal harm 2025-01-23

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 2025-01-30

D · Potential for more than minimal harm 2025-01-23

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-01-30

E · Potential for more than minimal harm 2024-07-11

F576 · Resident Rights Deficiencies

Health

Ensure residents have reasonable access to and privacy in their use of communication methods.

Corrected 2024-07-20

E · Potential for more than minimal harm 2024-07-11

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-07-15

E · Potential for more than minimal harm 2024-07-11

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 2024-07-20

E · Potential for more than minimal harm 2024-07-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-25

D · Potential for more than minimal harm 2024-07-11

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 2024-07-19

D · Potential for more than minimal harm 2024-07-11

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 2024-07-30

D · Potential for more than minimal harm 2024-04-20

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-05-03

E · Potential for more than minimal harm 2023-05-11

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2023-07-14

E · Potential for more than minimal harm 2023-05-11

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 2023-07-14

E · Potential for more than minimal harm 2023-05-11

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 2023-07-14

E · Potential for more than minimal harm 2023-05-11