Mesa Hills Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 1 of 3 residents (Resident #1) reviewed for unnecessary medications. The facility failed to ensure LVN A correctly documented Resident #1's ordered medications outcome for Haloperidol and Invega on July 20, 21, 24, 25, 26, 2026 during the 7:00 a.m. to 7:00 p.m. shift. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents reviewed for resident rights. The facility failed to ensure LVN A and LVN B notified the physician and the resident representative when there were reported scratches to Resident #1's arm and face on [DATE]. This deficient practice could affect residents with a change of condition and result in not receiving adequate and timely invention and decline in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #1) of five residents reviewed for ADL care. The facility failed to ensure Resident #1's nails were cleaned and did not have rough edges on 7/01/2026. These failures could place residents at risk of not receiving services or care, diminishing quality of life, and decreased self-esteem.

Inspectors wroteBased on interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of six residents reviewed for infection control practices. The facility failed to ensure isolation protocols were followed when Resident #2 was newly admitted to the facility and roomed with a resident who was under droplet precautions. This failure could place residents at risk for the transmission of communicable diseases and infections.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 6 resident (Resident #4, Resident #56, Resident #73, Resident #82, Resident #104, and Resident #109) of 17 residents reviewed for consent for antipsychotic medications.1. The facility failed to ensure Resident #4's Consent for Antipsychotic or Neuroleptic Medication Treatment HHSC Form 3713 was correctly completed for Seroquel (an antipsychotic) as evidenced by there was no date or signature for the practitioner and there was no date after the resident's signature. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 5 (Resident #9, Resident #56, Resident #73, Resident #82, and Resident #104) of 11 residents reviewed for unnecessary medications. 1. The facility failed to have an adequate indication for the use of the medication olanzapine (Zyprexa) (an antipsychotic) for Resident #9 with a diagnosis of dementia.2. The facility failed to have an adequate indication for the use of the medication risperidone (Risperdal) (an antipsychotic) for Resident #56 with a diagnosis of dementia.3. The facility failed to have an adequate indication for the use of the medication olanzapine (Zyprexa) (an antipsychotic) for Resident #73 with a diagnosis of dementia.4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASSR) program to the maximum extent practicable to avoid duplicative testing and effort for 4 (Resident #4, Resident #9, Resident #13, and Resident #28) of 12 residents reviewed for PASSR. 1. The facility failed to refer Resident #4 and Resident #28 for PASSR Level I when the facility incorrectly completed Form 1012. 2. The facility failed to refer Resident #9 and Resident #13 for PASRR Level II assessment when the resident were newly diagnosed with a mental illness. These failures could place residents at risk of not receiving a needed assessment, individualized care, or specialized services to meet their needs.

Inspectors wroteBased on observation, interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #23) of 5 residents and 1 (100 hall medication room) of 2 medications storage rooms reviewed for infection control.1. The facility failed to ensure RN C disinfected the blood pressure cuff before use for Resident #23 on [DATE].2. The facility failed to ensure RN C wore a gown to give gastric tube medications to Resident #23 on [DATE].3. The facility failed to dispose of an expired COVID test that was in a cabinet in the medication room. 4. The facility failed to dispose of expired IV supplies stored on the counter and in cabinet in the medication room. 5. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a PASRR evaluation was completed on newly admitted residents prior to admission or after admission for 1 resident (Resident #25) out of 6 residents reviewed for Preadmission Screening and Resident Review screenings. The facility failed to ensure Resident #25's PASRR L1 screening dated 03/07/25 accurately reflected her diagnoses of mental illness. There was no evidence that Resident #25 was referred to a Level 2 PASRR Screening and Evaluation having a primary diagnosis of mental illness. This failure could affect residents by placing them at risk for not receiving needed treatments and services.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #7 and Resident #116) of 5 residents reviewed for care plans. 1. The facility failed to ensure Resident #7's comprehensive care plan was updated to reflect he was on hemodialysis. 2. The facility failed to ensure Resident #116's comprehensive care plan was completed. These failures could place residents at risk of not receiving individualized care and services to attain or maintain the residents' highest practicable physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team, for 2 (Resident #11 and Resident #104) of 12 residents reviewed for comprehensive care plan revisions. 1. The facility failed to review and revise Resident #11's care plan to reflect his current diet (regular texture with thin liquids) and to reflect he had weight gain.2. The facility failed to review and revise Resident #104's care plan to reflect eating with her fingers and refusing assistance with eating. These failures could place the residents at risk of not receiving appropriate interventions and care to meet their current needs.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 5 residents (Resident #23) reviewed for enteral feeding tubes. The facility failed to ensure RN C followed physician ordered water flushes before and after medication administration given via the enteral feeding tube for Resident #23 on 06/17/26. This failure could place residents at risk of feeding tube obstruction and a decrease in nutrition and hydration.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure residents were free of significant medication errors for 1 (Resident #76)of 5 residents reviewed for medication errors. 1. The facility failed to ensure LVN A did not administer Resident #76's 9:00 pm dose of Diltiazem (blood pressure lowering medication) on 06/09/26 when her blood pressure was not within parameters for administration. The facility failed to ensure LVN A did not administer Resident #76's 9:00 pm dose of Metoprolol Tartrate (blood pressure lowering medication) on 06/09/26 when her blood pressure was not within parameters for administration. The facility failed to ensure LVN B did not administer Resident #76's 3:00 pm dose of Diltiazem (blood pressure lowering medication) on 06/14/26 when her blood pressure was not within parameters for administration. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food additives in accordance with professional standards for food service safety for 1 of 2 medication storage rooms (100 hall medication room) reviewed for storage of medications and food additives. The facility failed to label an opened container of food thickener stored in a cabinet with the date it was opened. This failure could place residents at risk of receiving medications and food additives that were expired.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 6 residents (Resident #6 and Resident #76) reviewed for medical records. 1. The facility failed to ensure RN C failed to remove contact precautions from the MAR for Resident #6 after receiving verbal orders from the physician to discontinue contact precautions. 2. The facility failed to ensure LVN B and LVN D documented Resident #76's information accurately on her pre-dialysis forms in the facility's electronic medical record. This failure could place residents at risk of errors in care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #2) of 5 residents reviewed for abuse. The facility failed to protect Resident #2 from Resident #1's physical abuse on 04/13/26 at around 11:00 PM. This failure could lead to residents suffering physical injuries and fear.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures to report and investigate abuse of residents for 2 of 4 residents (Resident #1 and Resident #2) reviewed for incident reporting and investigating. The facility failed to follow their abuse policy when they did not report and have evidence of a thorough investigation of an allegation of abuse when Resident #1 hit Resident #2 on 04/03/26. The facility failed to follow their abuse policy when they did not report and have evidence of a thorough investigation of an allegation of abuse when Resident #1 alleged a doctor or the DON hit his left leg on the bed frame on 04/03/26, resulting in a 1 centimeter skin tear. These failures could place residents at risk of abuse and/or continued abuse and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, for 2 of 4 residents (Resident #1 and Resident #2) reviewed for abuse/neglect. The facility failed to report an allegation of abuse to the State Survey Agency within two hours, when Resident #1 hit Resident #2 on 04/03/26. The facility failed to report an allegation of abuse to the State Survey Agency within two hours, when Resident #1 alleged a doctor or the DON hit his left leg on the bed frame on 04/03/26, resulting in a 1 centimeter skin tear. These failures could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to have evidence that all alleged violations involving abuse, neglect, or mistreatment, were thoroughly investigated for 2 of 4 residents (Resident #1 and Resident #2) reviewed for abuse/neglect. The facility failed to have evidence of a thorough investigation regarding an allegation of abuse when Resident #1 hit Resident #2 on 04/03/26. The facility failed to have evidence of a thorough investigation regarding an allegation of abuse when Resident #1 alleged a doctor or the DON hit his left leg on the bed frame on 04/03/26, resulting in a 1 centimeter skin tear. These failures could place all residents at increased risk for potential abuse due to uninvestigated allegations of abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 4 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's care plan reflected his diagnosis of diabetes, major depressive disorder, and ADLs with assistance needed. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #1 and Resident #2) observed for infection control. The facility failed to ensure CNA A performed hand hygiene when she was feeding Resident #1 and Resident# 2 at the same time, on 3/10/2026. This failure could place residents at risk of cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the PASRR program, including incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's care planning for two (Resident #1 and Resident #2) of seventeen residents positive for PASRR. The facility failed to ensure the service request form was sent to the state PASRR unit, within 30 days of the IDT meeting, to assist Resident #1 and Resident #2 with receiving services identified in the meeting plan. This failure could affect PASRR positive residents by placing them at risk of their specialized needs not being met.

Inspectors wroteBased on interviews, and record review, the facility failed to develop a comprehensive care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's medical, nursing, and mental and psychosocial needs for 3 (Resident #252, Resident #97 and Resident #72) of 8 residents reviewed for comprehensive care plans. 1. Resident #72's comprehensive care plan was not revised after he returned from being hospitalized on [DATE] for a recurrence of pneumonia. 2. The facility failed to develop a comprehensive person-centered care plan to address Resident #252's antibiotics for positive sputum culture. 3. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure all food products in walk-in freezer were labeled and dated. The facility failed to ensure employee medication and a soft drink cup were not stored in refrigerated. The facility failed to properly thaw raw chicken that was observed in the sink designated for vegetables only. The chicken was not under running water. There was raw ground beef on the sink counter next to the sink that contained the raw chicken. These failures could place residents at risk for food contamination and food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #62) of 8 residents reviewed for Advance Directives. The facility failed to ensure Resident #62's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #36) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #36 was coded in the MDS for falls. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 Resident (Resident #91) of 8 residents reviewed for foot care. The facility did not provide adequate foot care for Resident #91. Resident #91's nails were greyish/black, thick, and long. The nail of her right big toe was curving and growing toward her second toe. This failure could put residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents and failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 3 residents reviewed for accidents (Resident #97). The facility failed to provide adequate supervision to ensure Resident #97 did not obtain and keep cigarettes at his bedside. This failure could place residents who require supervision to prevent accidents and ensure their environment remains as free of accident hazards as possible, at risk for decreased quality of life or injury that could result in unnecessary hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 Resident out of 5 (Resident #42) reviewed for Enhanced Barrier Protections (EBP) for infection control practices. LVN A failed to follow Enhanced Barrier Precautions for an indwelling medical device (gastrostomy tube) for Resident #42. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for 1 of 3 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility on 04/12/2024 and was found by the police department approximately 4.3 miles away from the facility. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 04/12/2024 and ended on 04/25/2024. The facility had corrected the noncompliance before the survey began. This failure could prevent residents from receiving appropriate supervision which could lead to residents sustaining serious injury, harm, or death.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 4 of 10 (Resident #3, Resident #4, Resident #5, and Resident #6)) residents reviewed for environment. 1. The facility failed to ensure Resident #3's room was thoroughly cleaned, the walls and in good condition. 2. The facility failed to ensure Resident #4's room was thoroughly cleaned, and in good condition. 3. The facility failed to ensure Resident #5's room was thoroughly cleaned; and in good condition; and had privacy from the outside. 4. The facility failed to ensure Resident #6's door to bathroom did not have a hole and walls were painted and free from black spots. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, for one Resident (Resident #2) of two residents reviewed for feeding tubes, in that: Certified Nurse Aide (CNA) C was not competent in and did not follow facility protocols regarding feeding tube nutrition and care. CNA A adjusted Resident #2's feeding pump while providing Resident #2 with incontinent care. This failure could place residents with feeding tubes at risk for reflux, aspiration, nausea, vomiting, cramps, or diarrhea.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source were reported immediately to the State Survey Agency, within two hours, if the events that cause the allegation involve abuse or result in serious injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 1 resident (Resident #2) of 3 residents reviewed for abuse/neglect, The facility did not report the allegation of resident abuse to the State Survey Agency within the frame for Resident #1 who had been found with drug paraphernalia in his room. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #3) The facility did not ensure Resident # 3's smoking supplies were stored at Nurses' station. This failure could place 4 residents who require supervision, at risk for a decreased quality of life or injury that could lead to an unnecessary hospitalization.

Inspectors wroteBased on interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise for 1 of 17 residents reviewed for nutritional status (Resident #1). The facility failed to ensure Resident #1 did not have a significant weight loss in 3 months. The facility failed to follow the dietitian recommendations to Resident #1 who had experienced significant weight loss. These failures could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #72 ) of three residents reviewed for dignity. The facility failed to promote Resident #72's dignity by not covering his catheter's urinary collection bag with a privacy bag. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services with reasonable accommodation of resident needs and preferences, for 2 of 8 residents (Resident #11 and Resident # 35) reviewed for accommodation of needs. The facility staff did not provide Resident #11 and Resident #35 with a call light that was within reach. This failure could place residents who utilized call lights at risk for not having his/her needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 of 8 residents (Resident #11) reviewed for care plans in that: The facility failed to develop a care plan to address Resident #11's in-room activities. These failures could place residents at risk of not receiving individualized interventions for their care needs.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident who entered the facility with an indwelling catheter and is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one of 8 residents (Resident #72) reviewed for incontinent care and catheter care, in that. The facility failed to obtain documented MD orders from re-admission from hospital for catheter use which included catheter size, balloon inflation parameter and frequency of care for Resident #72. This deficient practice could place residents at-risk for infection due to improper catheter care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 2 of 4 residents (Resident #77 and Resident #81) reviewed for enteral nutrition, in that: The facility failed to follow physician's orders to ensure that Resident #77 and Resident #81 received the appropriate amount of enteral nutrition. This deficient practice could affect residents receiving optimal enteral nutrition and place them at risk of health complications and decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a prescribed medication was given for 1 of 5 residents (Residents # 25) reviewed for Medication Pass. The facility failed to prevent Resident #25 from missing his daily nose spray . These failures could place the residents at risk of not receiving the therapeutic dosage of medications prescribed by the physician.

Inspectors wroteBased on record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for one Resident (R#14) of nineteen residents whose medications were reviewed, in that: The facility's Pharmacy Consultant recommended that the physician review the use of duplicate antipsychotic therapy with Risperidone and Quetiapine. The facility failed to ensure the attending physician documented his rationale for making changes to Resident #14's antipsychotic therapy in Resident #14's medical record. These failures could place all residents receiving anti-psychotic medications at risk for adverse drug consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in 1 of 2 medication rooms (medication storage located in 100 hallway) reviewed for medication storage and labeling. The facility failed to ensure that all medical supplies in the medication storage room in the 100 hallway were not past their expiration date. The facility's failure could result in residents receiving expired medical supplies, such as formula, as well as those supplies not being maintained at their best therapeutic level.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to label and date frozen food items in one of one walk in freezers. These failures could residents at risk for food contamination and food-borne illness and impact the health and nutrition of residents.

Inspectors wroteBased on interview, and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #72 ) of 8 residents reviewed for accurate medical records. The facility failed to correctly transcribe the physician orders for Resident #72 related to indwelling catheter and document the treatment orders for catheter care. This failure could place resident at risk of not receiving needed care or treatments by misleading care providers regarding what care or treatment resident should receive.