Mesa Vista Inn Health Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 (Resident #2) residents reviewed for resident rights: The facility failed to have Resident #2's call light within reach while he was in bed. This deficient practice could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' medical, nursing, and mental and psychosocial needs for 1of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated with the facility's new interventions for his wandering behaviors. This failure could place residents at risk of not having their needs met and not receiving appropriate care.

Inspectors wroteBased on interviews, and record reviews, the facility failed to develop and implement a comprehensiveperson-centered care plan for each resident, consistent with the resident rights, which includes measurable objective andtimes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in thecomprehensive assessment for 1 Resident (Resident #1) of 5 residents reviewed for comprehensive person-centered. care plans. The facility failed to ensure Resident #1's comprehensive care plan addressed the active diagnosis of osteoporosis. This deficient practice could place residents at risk of missed or miscommunicated care.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the comprehensive care plan for 1 (Residents #1) oof 5 residents reviewed for comprehensive care plans, in that: Resident #1's comprehensive care plan was not revised to reflect that she no longer took antipsychotic and antianxiety medications. This deficient practice could result in substandard level of care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 8 residents (Resident #2, Resident #72, and Resident #89) whose rooms were observed for personal refrigerators. The facility failed to assist in maintaining personal refrigerator logs, in fridge thermometers, and/or discarding spoiled food for Residents #2, #72, and #89. These deficient practices could place residents at risk of food-bone illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accidents and hazards as was possible for 3 of 18 residents (Resident #29, Resident #41, and Resident #52) reviewed for quality of care. 1. The facility failed to ensure Resident #41 did not have scissors stored openly on top of the nightstand. 2. The facility failed to ensure Resident #52 did not have a bottle of mouth wash in a shared room with Resident #11. 3. The facility failed to ensure Resident #29 did not have mouth wash or tiger balm in her room. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs for 3 of 7 carts (700/800 hall nurse cart, 700/800 hall medication cart, and 100/400 nurse cart) reviewed for pharmacy services. 1. The facility failed to ensure the controlled substance reconciliation logs were signed for accuracy of medication quantities during shift change. 2. The facility failed to remove expired medications (Naproxen 220mg, and 5 insulins) from the medication cart. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 warming kitchen reviewed for sanitation in that: The DA (Dietary Aide) failed to wash her hands prior to plating food. CNA A entered the warming kitchen during meal service without a hair net and did not wash her hands prior to getting ice out of the ice machine to fill a glass. There were no paper towels in the paper towel dispenser by the handwashing sink in the warming kitchen. These failures could place residents at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 disease and infection for 4 of 32 residents reviewed (Resident #2, Resident #39, Resident #79, and Resident #94) and 3 of 4 (LNV E, RN G and MA H) facility staff observed for infection control. 1. The facility failed to ensure LVN E maintained proper hand hygiene during wound care for Resident #2. 2. The facility failed to ensure Resident #39's indwelling urinary catheter bag was not in a trash can with a dirty brief. 3. The facility failed to ensure Resident #79's indwelling urinary catheter bag was not touching the floor. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with dignity and respect in a manner and environment that enhances their quality of life for 1 of 6 residents (Resident #64) reviewed for dignity. Resident #64's catheter bag was not placed in a privacy bag and was visible from the hallway. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for 1 (Resident #2) of 13 residents reviewed for dignity. The facility failed to ensure Resident #2's shared bathroom door remained closed during wound care. This failure could cause a decrease in feelings of self-worth by being exposed during care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 of 33 residents (Residents #88 and #113) reviewed for assessments: Resident #88's Quarterly MDS dated [DATE] did not indicate she was receiving hospice services. Resident #113's Quarterly MDS dated [DATE] did not indicate she was receiving hospice services. These failures could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 1 residents with mental illness were provided with a PASRR Level II assessment accurately 1 of 6 residents (Resident #6) whose records were reviewed for PASRR services. The facility failed to conduct a Level 1 PASRR screening for Resident #6 after a diagnosis of PTSD and coordinate with the Local Authority to conduct a Level 2 PASRR evaluation to determine the need for specialized services. This deficient practice could place residents at risk of a diminished quality of life related to not receiving or benefiting from specialized PASRR services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care for 1 of 6 residents (Resident #128) whose medical records were reviewed for accuracy, in that: The facility failed to develop a baseline care plan within 48 hours of Resident #128's admission to the facility. This failure could place residents at risk of not receiving needed care and treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 1 resident (Resident #5) reviewed for quality of care. The facility failed to ensure Resident #5's sterile water was dated on the oxygen concentrator. This failure could place residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #9) reviewed for quality of care: The facility did not maintain communication, coordination, or collaboration with the dialysis facility for Resident #9. This failure could affect residents who received dialysis treatments and place them at risk of complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 7 medication carts (100/400 hall nurse cart) reviewed for medication storage and labeling. The facility failed to ensure all insulins located inside the 100/400 hall nurse cart were properly labeled with opened dates. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of their prescribed medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 residents (Resident #82) reviewed for accuracy of records: The facility failed to ensure Resident #82's hospice binder was accurate with their DNR status. These failures could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.

Inspectors wroteBased on observations, interview and record review the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 (4/21/26) of 4 days reviewed in that: The daily posted nurse staffing data was not posted in the facility on 4/21/26. This deficient practice could affect all residents and could result in residents and visitors being unaware of staffing levels in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 of 3 residents (Resident #3) reviewed for infection control in that: LVN A did not wash his hands between removing soiled gloves and putting on clean gloves when providing direct care to Resident #3 who had a skin tear and was on enhanced barrier precautions (EBP). The DON did not wash her hands after touching a window blind, bed controls, and bed linens prior to providing direct care to Resident #3 who had a skin tear and was on EBP. This deficient practice could affect residents who are receiving wound care or were on enhanced barrier precautions placing them at risk for infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made for 1 of 4 Residents (Resident #1) whose records were reviewed for suspicious injuries. The facility failed to report an injury of unknown injury to HHSC when Resident #1 was noted with bruising to right temple and was sent out to the hospital on 9/2/25 about 11:30 PM. This deficient practice could place the residents at risk for further abuse or neglect.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 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 3 of 5 residents (Resident #2, Resident #3, and Resident #4) reviewed for infection control. The facility failed to ensure staff wore PPE during wound care for Resident #2 who was on enhanced barrier precautions. The facility failed to ensure LVN A and ADON B appropriately doffed (removed) PPE after providing care to Resident #3 and Resident #4. This deficient practice could put residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect, 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 2 of 4 residents (Resident #2 and Resident #3) reviewed for dignity. The facility failed to ensure residents' privacy/dignity was maintained during wound observations/care on (2) occasions. These failures could affect residents by contributing to poor self-esteem, decreased self-worth and quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of 12 residents (Resident #6), in that: Resident #6's care plan did not include a focus area or interventions for Resident #6's ordered hospice care diagnosis. This failure placed residents at risk of not receiving appropriate end of life care, a decreased quality of life, mismanagement of medications, and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 2 physicians (Physician R) signed and dated resident physician orders for physicians reviewed for physician visits. The facility failed to have Physician R electronically sign physician orders. The Medical Records Director was instructed by Administrator O to electronically sign Physician R orders in the EMR using Physician R's username and password. This failure could place residents assigned to Physician R at risk for not receiving appropriate physician ordered care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 11 (Resident #4) reviewed for care plans. 1. The facility failed to ensure a care plan was developed and interventions put in place to address Resident#4 physical and verbally aggressive behaviors toward others. This deficient practice could place residents with behaviors at risk for injury to themselves or others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 disease and infection for 1 of 3 residents (Resident #3) reviewed for infection control: The facility failed to ensure CNA A changed her gloves and washed or sanitized her hands after they became contaminated during incontinent care, before touching Resident #3's clean linen and clean brief. This failure could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 1 of 1 facility in that: The ADM did not follow the ANE policy and procedures by not reporting a serious injury of unknown source to HHSC when: Resident #1 fell, went to the hospital, and received 6 sutures to her forehead. This could affect all resident that had a fall and could result in further injuries.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 of 1 facility in that: Resident #1 had an unwitnessed fall, went to the emergency room, and received 6 sutures to her forehead. This was not reported by the ADM to HHSC. This deficient practice could result in the delay of investigating the residents' circumstances after sustaining a serious injury of unknown source.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 (Resident #2) residents in that: Resident #2's fall mat was not on the ground near her bed as specified in her care plan. Resident #2 had a fall and had behaviors and required a fall mat to prevent injury. This deficient practice could place residents at risk for not receiving proper care and services due to incomplete care plans.

Inspectors wroteBased on observation, interview and record review the facility must ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 7 residents (Resident #2) reviewed for pressure sores, in that: The facility failed to ensure Resident #2's air mattress was was dialed to the correct weight. This failure could affect residents with skin injures and wounds and could place the residents at risk for worsening of pressure ulcers.

Inspectors wroteBased on the observations, interviews, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 1 (Resident #60) of 2 residents reviewed for accidents. The facility failed to make sure Resident #60's environment was free of sharp devices that could harm the resident such as a pair of nail clippers. This failure could place the resident at risk of self-injury and complications with resident's diabetic condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #31) reviewed for incontinent care: The facility failed to ensure CNA A and CNA B properly cleaned Resident #31's vaginal and buttock area after an incontinent episode. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 8 residents (Resident #31) reviewed for medical records: The facility failed to ensure staff obtained a written order for Resident #31's use of a left arm sling. This failure could result in residents not having an accurate overall view of their care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 or 4 residents (Residents #31 & #33) reviewed for infection control. 1. The facility failed to identify and implement interventions for Resident #33 on Enhanced Barrier Precaution who had a colostomy. 2. The facility failed to ensure CNA A and CNA B used appropriate infection control principles including during catheter care, incontinent/peri care, and hand hygiene/glove changes for Resident #31. These deficient practices could affect residents who were on EBP and required assistance with incontinent/peri care and could place residents at risk for cross contamination and infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside, toilet, and bathing facilities, for 1 of 2 residents (Resident #41) reviewed for call light accessibility and functionality. On 01/28/25 at 10:05 am, Resident #41 was observed to have utilized his call light which did not illuminate the nurse call light directly outside and above his room door. This failure could place residents at risk for harm by not receiving care and attention when their nurse call light system malfunctioned and/or was out of reach.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from accidents and hazards for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. On 04/09/24, Resident #1, who resided in the Memory Care wing of the facility, managed to undo the lock on the window of his room, kick out the screen and climb out the window. Resident #1 then left the property and was not located until the morning of 04/10/24. The non-compliance was identified as past noncompliance. The IJ began on 04/09/24 and ended on 04/10/24. The facility had corrected the noncompliance before the investigation began on 12/15/24. This failure could place residents at risk of harm, serious injury, or death.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for 1 (Resident #1) of 5 reviewed for resident rights. 1. The facility failed to obtain a signed consent for antipsychotic medication, Escitalopram Oxalate (Lexapro) which was administered to Resident #1. 2. The facility failed to provide Resident #1's Responsible Party with the benefits, risks, and options available after a Psychiatric Nurse Practitioner's recommendation of an increase in Escitalopram Oxalate (Lexapro) on 03/01/2024. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' had the right to formulate an advanced directive for 1 of 24 residents (Resident #5) reviewed for advance directives. Resident #5's OOH-DNR form was invalid because the attending physician's license number, physician's date signed, and physician's printed name were missing from the form. This failure could result in a resident's DNR not being executed.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents' mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 20 residents (Resident #20 and #57) reviewed for care plans in that: The facility failed to develop a comprehensive care plan that addressed Resident #20 and #57's need to want to sleep in each other's bed when residing in the memory/secure care unit. This failure could place residents at risk of not receiving appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 2 Residents (Resident #69) reviewed for quality of care. The facility failed to obtain medical information needed to monitor the parameters of the cardiac pacemaker for Resident #69. This failure could place residents with cardiac pacemakers at risk for not having care and services provided to meet their needs.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 24 residents (Resident #17) reviewed for respiratory care, in that: Resident #17 did not have sufficient oxygen flow based on the physician's order. This failure could place residents at-risk of inadequate oxygen availability.

Inspectors wroteBased on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA C) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide in that: The facility failed to ensure CNA C had a current nurse aide certification while employed at the facility while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 3 Residents (Resident #78) reviewed for medication administration. LVN L administered insulin to Resident #78 without cleaning the rubber seal on the insulin pen prior to injection. These deficient practices could affect residents who received medication and place them at risk of an adverse reaction or a decline in health.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were given psychotropic medications to treat specific diagnoses for 1 (Resident #31) of 24 Residents, reviewed for unnecessary psychotropic medications in that: The facility failed to ensure the medication (Seroquel) was administered to treat a specific diagnosis for Resident #31. This failure could affect residents who received psychotropics in the facility and put them at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 19 residents (Resident #85) reviewed for accuracy of medical records. The facility failed to accurately document the implementation of the physician's orders for Resident #85. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview, 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 infections for 1 of 3 staff (LVN L) reviewed for infection control. LVN L administered insulin to Resident #78 without cleaning the rubber seal on the insulin pen prior to injection. These deficient practices could place residents who received care at-risk for infections.