Mesa Springs Healthcare Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident, who needed respiratory care, was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1's respiratory status was assessed before and after administering a nebulized breathing treatment on 07/01/2026, per physician's order. 2. The facility failed to ensure CNA-A notified LVN B of Resident #1's racing breathing on 07/02/2026. These failures could place residents at risk for respiratory distress and not having their respiratory needs met. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement their written policies and procedures regarding allegations of abuse/neglect for one (Resident #1) of seven residents reviewed for abuse/neglect. The facility did not report an incident of neglect to the state agency within the given time frame. These failures could place all residents that access the facility van.

Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, for 1 of 1 (FY Quarter 4 2025) reviewed for Staffing Data Report. The facility failed to submit staffing information to CMS for FY Quarter 4 2025 (October 1- December 31). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 3 (Resident #19, Resident#24 and Resident#31) of 12 residents reviewed for quality of care. The facility failed to ensure Resident #19 and #24's nasal canula was properly stored while oxygen was not in use on 03/17/2026. The facility failed to ensure Resident #31's nebulizer mask was properly stored while not in use on 03/17/2026. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to review the risks and benefits of bed rails with the resident or a resident representative and obtain informed consent prior to installation for 3 of 5 residents (Resident #2, Resident #3, and Resident #6) reviewed for bed rail consents. 1. The facility failed to obtain informed consent, or maintain evidence that, Resident #2 and Resident #3 or their representative had been provided with sufficient information so that they could make an informed decision prior to installing bed rails.2. The facility failed to obtain informed consent from Resident #6 when bed rails were installed on his bed. Informed consent was obtained 17 days after bed rail safety evaluation was performed and 23 days after physician order was obtained. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food and drink that was palatable, attractive, and at safe and appetizing temperatures for reviewed food and nutrition services. The facility failed to adhere to their policy for acceptable serving temperatures on 03/17/26. This failure could place residents at risk of food-borne illnesses, decreased appetite, and overall meal dissatisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen in the facility.1. The facility failed to date a tray of covered cups of milk and fruit cups on 03/17/26.2. The facility failed to keep 2 boxes of Vanilla pudding cups off the floor in the walk-in pantry on 03/17/26.3. The facility failed to ensure the steam table was clean and free from food particles on 03/17/26.4. The facility failed to ensure cookware was properly rinsed and sanitized in adherence to professional standards for food service safety on 03/17/26. These failures could place residents at risk of food-borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 16 residents (Resident #2 and Resident #3) reviewed for care plans. The facility failed to ensure Resident #2, and Resident #3 had a care plan in place for bed rails. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide training to their staff that at a minimum educates staff on dementia management for all new and existing staff for 1 of 18 (CNA F) staff reviewed for dementia management. The facility failed to ensure CNA F was educated on dementia management upon hire. This failure could place residents with dementia diagnosis at risk of being inappropriately cared for by uninformed staff.

Inspectors wroteBased on interviews and record review, the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff on the elements and goals of the facility QAPI program for all new and existing staff for 1 of 18 (CNA F) staff reviewed for training on QAPI. The facility failed to ensure CNA F was educated on the facility's QAPI program upon hire. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program.

Inspectors wroteBased on interviews and record reviews, the facility failed to include as part of its compliance and ethics program (1) an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program; (2) annual training if the operating organization operates 5 or more facilities for all new and existing staff for 1 of 18 (CNA F) reviewed for training on compliance and ethics. The facility failed to ensure that CNA F was educated on compliance and ethics upon hire. This failure could affect residents and place them at risk of being uninformed of compliance and ethics program due to lack of staff training.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 5 residents (Resident #312) reviewed for grievances. The facility failed to ensure a grievance was completed for Resident #312's complaint of LVN A. This failure could place residents at risk for not having their grievances resolved.

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 5 residents (Resident #312) reviewed for developing and implementing neglect policies. The facility failed to follow its policy to investigate and report to the Texas Health and Human Services Commission (HHSC) when Resident #312's family member alleged that LVN A neglected Resident #312. This failure could place residents at risk of not having allegations thoroughly investigated per policy.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of the residents for 1 of 1 medication room and 1 of 3 (treatment cart) medication carts reviewed for drugs and biologicals. 1. The facility failed to ensure 1 vancomycin IV bag (antibiotic medication in bag for IV) had been removed from the medication room when it had expired on December 2024. 2. The facility failed to ensure 6 boxes of lancets (needles used to obtain small blood samples) were removed from the medication room when they had expired on or after 08/27/2020. 3. The facility failed to ensure 12 IV start kits (used to start IVs) were removed from the medication room when they had expired on 12/10/2024. 4. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the quality of laboratory services in the facility for 1 of 1 medication room reviewed for drugs and biologicals. The facility failed to ensure 2 boxes of COVID testing kits (used for COVID testing) were removed from the medication room when they had expired on 12/15/2023. The facility failed to ensure 1 box and 4 packages of influenza A & B Tests (used for Flu testing) were removed from the medication room when they had expired on 11/30/2024. These failures could place residents at risk of inaccurate testing results.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization. The facility failed to ensure foods in Refrigerator #1, Refrigerator #2, and the freezer were not sealed and/or labeled properly. The facility failed to ensure food that left the kitchen was covered. This failure could place residents that eat out of the kitchen at risk for contamination and food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed implement its policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 3 (Resident #23, Resident #36, and Resident #65) of 18 residents reviewed for food and nutrition services. 1. The facility failed to ensure that Resident #36's personal refrigerator did not have expired goods stored and failed to log refrigerator's temperature after 01/01/2025. 2. The facility failed to ensure that Resident #65's personal refrigerator did not have expired goods stored and failed to have a thermometer inside to check temperature. 3. The facility failed to ensure that Resident #23's personal refrigerator had a thermometer inside to check temperature and failed to keep temperature log during the month of January 2025. [...]

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 2 (CMA J and CMA K) of 6 staff observed for infection control practices. The facility failed to ensure CMA J wore the required PPE in a Resident #17's room while providing medication and eye drops for Resident #17. The facility failed to ensure CMA K sanitized face shield per infection control protocols and procedures. These failures place residents at risk for cross contamination and spreading of infections while in facility.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure residents had the right to voice grievances to the facility with respect to care and treatment which had been furnished as well as that which had not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay for 1 of 18 residents (Resident #171) reviewed for grievances. The facility failed to investigate and respond to a grievance made by Resident #171's representative who made a grievance to RN A. This failure could place residents and their representatives at risk of not having their grievances heard and or resolved.

Inspectors wroteBased on interviews and record review, the facility failed to refer residents with newly evident or possible serious mental illness or a related condition for PASSR evaluation for 2 of 18 residents (Resident #27, and Resident #29) reviewed for PASRR. The facility failed to refer Resident #27 & Resident #29 for a PASSR evaluation after diagnoses reflected serious mental disorders. This failure placed residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assistance devises to prevent accidents for 1 of 29 residents (Resident #12) whose records were reviewed for quality of care. The facility failed to ensure that Resident #12's wheelchair was placed at Resident #12's bedside as care planned to prevent falls. This failure could place residents at risk of being injured.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 1 of 29 (Resident #12) reviewed for respiratory care. The facility failed to ensure that Resident #12's oxygen tubing had been changed weekly per physician order. This failure places residents that use oxygen at risk of respiratory complications and/or possible respiratory infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments and to permit only authorized personnel to have access to 1 (treatment cart) of 5 medication carts reviewed for security. The facility failed to ensure treatment cart with prescription medications and biologicals were not left unlocked, unsecured, and unattended. These failures could place residents at risk of misappropriation of medications, drug diversions, or accidental ingestion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 3 (Residents #1 and Resident #2) residents observed for dignity. CNA A and CNA B failed to provide Resident #1 with full privacy while providing incontinent care on 10/29/24. Facility failed to provide Resident #2 with a privacy curtain installed in her room on 11/19/2024. These failures could place residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse and neglect for 1 (Resident #1) of 7 residents reviewed. The facility did not have evidence that a thorough investigation was completed for Resident #1 allegation of being verbally abused. This failure could place residents at risk of incidents not being thoroughly investigated and subject to further abuse.

Inspectors wroteBased on interview, and record review the facility failed review and revise the comprehensive plan of care to meet a resident's needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #3) reviewed for comprehensive person-centered care plans. The facility failed to address Resident #3's 04/29/24 fall in her plan of care. This deficient practice could place residents at risk for injury with falls and not having personalized plans developed to address their needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that food was discarded after its use by date. The facility failed to ensure food temperatures were taken and recorded prior to service. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 4 medication carts reviewed for storage in that: The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion.

Inspectors wroteBased on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 1 (Resident #6) of 3 residents reviewed for care plans. The care plan for Resident #6 did not adequately address his interventions to describe how to meet his needs when transferring resulting in a fracture to right arm. This deficient practice placed residents at risk of not having care needs met, which could cause a decline in physical and psychosocial health and serious injury.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and injuries of unknown source, to include identifying and investigating any such allegations for 1 (Resident #1) of 4 residents reviewed for abuse and neglect. The facility failed to conduct an investigation and report an injury of unknown origin to the appropriate State agency when notified Resident #1 had an injury of unknow origin of a large purple and yellow bruise on the right side of her forehead. This failure could place residents at risk of repeated injuries and abuse and/or neglect.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency, one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to report an alleged injury of unknown origin to the State Survey Agency when Resident #1 was discovered with a purple and yellow bruise on the right side of her forehead approximately two inches in diameter This failure could place residents residing in the facility at risk of abuse/neglect not being reported.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, including injury of unknown origin, were thoroughly investigated for 1 (Resident #1) of 4 residents reviewed for abuse and neglect. The facility failed to investigate when Resident #1's family reported a large purple and yellow bruise on the right side of her forehead that was unknown how the injury occurred. This failure could place residents residing in the facility at risk of not being protected or having a thorough investigation.

Inspectors wroteBased on interviews and records reviews, the facility failed to maintain complete, accurately documented and readily accessible medical records, in accordance with accepted professional standards and practices, on each resident for 2 out of 3 (Resident #1 and Resident #6) reviewed for clinical records 1. The facility failed to document in Resident #1's clinical record the details involved around the incident when Resident #1's family member reported a large bruise on the right side of her forehead. 2. The facility failed to document in Resident #6's clinical record the details involved in the incident when Resident #6 was picked up to be transferred from his wheelchair to his bed and sustained 2 fractures in his right arm. This failure could place residents at risk for inaccurate or incomplete clinical records.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain infection control protocols to prevent infections for 1 of 1 resident (Resident #6) observed for catheter care needs. CNA-A used a peri-care cleaning wipe and cleaned catheter tubing toward the resident and not away from toward catheter bag to clean catheter tubing. These failures place residents at risk for unnecessary infections while in the facility.