Mesquite Post Acute Care

Inspectors wroteBased on interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 2 of 5 (Resident #1 and Resident #2) residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC online portal for Resident #1 and Resident #2 within 20 business days after the IDT meeting held for Resident #1 on 04/30/2026 and Resident #2 on 04/09/2026. This failure could place residents who were PASRR positive at risk of not receiving PASRR services, which may enhance quality of life, and could lead to a decline in health.

Inspectors wroteBased on interview and record review the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 7 of 23 confidential residents reviewed . The facility failed to provide sufficient staffing to prevent long wait times to answer call lights. This failure could place residents at risk of injury, pain, hospitalization, skin breakdown, poor self-worth, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 15.38% based on 4 out of 26 opportunities, which involved 4 of 5 Residents (Residents #12, # 20, #24 and #31) reviewed for medication administration. 1. LVN A failed to give Resident #20's dose of the medication Escitalopram at the ordered time, due to not having the medication available, resulting in a late dose. 2. LVN A failed to give Resident #31's doses of the medications Oxybutynin and Hydrochlorothiazide at the ordered time, due to not having the medication available, resulting in a late dose of each medication. 3. LVN A failed to give Resident #12's dose of the medication Citalopram at the ordered time, due to not having the medication available, resulting in a late dose. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and stored in locked compartments for 3 of 3 medication carts (Hall 200 Nurse Medication Cart, Hall 200 Medication Aide Cart, and Hall 300 Medication Aide Cart) reviewed for medication storage. The facility failed to ensure the Hall 200 Nurse Medication Cart was secured when unattended. The facility failed to ensure the Hall 200 Medication Aide Cart did not contain loose pills. 3. The facility failed to ensure the Hall 300 Medication Aide Cart was secured when unattended and did not contain loose pills. These failures could place residents at risk of not receiving prescribed medications as ordered, having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversion.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable, attractive and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 2 (Breakfast) meal reviewed for food and nutrition services. The facility failed to provide food that was palatable for the breakfast meal on 05/20/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

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 reviewed for dietary services. The facility failed to ensure foods were properly stored in the refrigerator, freezer and pantry. The facility failed to ensure the oven doors, refrigerator handles and microwave were properly cleaned. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to respect the resident's right to personal privacy and confidentiality of his or her medical records on 1 of 2 medication carts (Hall 200 Nurse Medication Cart) reviewed for privacy in that: 1. LVN D left the computer screen unlocked with a resident's medication information visible on the Hall 200 Nurse Medication Cart when she left the medication cart unattended. 2. LVN D left a list of residents' vitals exposed on top of the Hall 200 Nurse Medication Cart. These failures could place residents at risk of having medical information or care instructions exposed to others and misuse of personal/medical information.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 17 Residents (Resident #54) and 1 of 2 Shower rooms (Shower Room A) reviewed. The facility failed to store Resident #54's portable oxygen tank properly when not in use. The facility failed to ensure Lemon disinfectant spray bottle was not stored properly in Shower Room A. These failures could place residents at risk for poisoning or chemical burns and avoidable injuries related to improperly storing a portable oxygen tank.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 meals (breakfast and lunch) observed for puree texture. The facility failed to provide pureed food in proper form for the breakfast and lunch meals observed on 05/20/26. This failure could place residents at risk of decreased food intake, choking and aspiration.

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 3 of 19 residents (Residents #2, #4 and #26) reviewed for infection control. 1. CNA E failed to wear proper PPE (gown) when providing direct resident care for Resident #2 who was on EBP on 5/20/26. 2. CNA E failed to wear proper PPE (gown) when providing direct resident care between Residents #2 and #4 when Resident #2 was on EBP on 5/20/26. 3. CNA F failed to wear proper PPE (gown and gloves) when providing direct resident care for Resident #26 who was on EBP on 5/20/26. These failures could place residents at risk for the spread of infection and cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 4 (Rooms #407, 602, 604 and 611) of 48 semi-private rooms reviewed for physical environment. The facility failed to ensure resident Rooms #s 407, 602, 604 and 611 met the required minimum of 80 square feet per resident. This failure could place residents at risk of crowding and cause difficulty in providing resident 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 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 3 (Resident #1, Resident #2, and Resident #3) of 9 residents reviewed for comprehensive care plans. The facility failed to update or add interventions to Resident #1's care plan regarding aggressive and physical behaviors toward one other resident that occurred on 09/03/25. The facility failed to update or add interventions to Resident #2's care plan regarding aggressive and physical behaviors toward one other resident that occurred on 09/06/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances for 12 of 20 confidential residents. The facility failed to ensure 12 of 20 confidential residents were provided, through postings in prominent locations; the grievance procedures, were provided access to the Grievance form, information regarding who the facility grievance officer was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. These failures could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage areas and 1 of 2 medication carts (Med Cart A) reviewed for medication storage. 1. The facility failed to keep a record of a receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. 2. The facility failed to ensure expired medications were not kept in Med Cart A. These failures could place residents at risk of not receiving the therapeutic benefit of medications, loss of prescribed medications and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 20 residents (Residents #38) reviewed for advanced directives, in that: Residents #38's OOH-DNR form was missing required information. This failure could place residents at risk for not having their end of life wishes honored and incomplete records.

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 reviewed for dietary services, in that: The facility failed to seal foods stored in the refrigerator. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 2 of 20 residents (Resident #254 and Resident #5) reviewed for infection control. 1. LVN A failed to sanitize his hands between glove changes during wound care for Resident # 5. 2. CNA B failed to wear proper PPE when providing direct care for Resident #254 who was on Enhanced Barrier Precautions. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 4 (Rooms #407, 602, 604 and 611) of 48 semi-private rooms reviewed for physical environment. The facility failed to ensure resident Rooms #s 407, 602, 604 and 611, met the required minimum of 80 square feet per resident. This failure could place residents at risk of crowding and cause difficulty in providing resident care.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be free from abuse for 1 of 7 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1 when the SW witnessed CNA A slap Resident #1 on the arm. An Immediate Jeopardy (IJ) situation was determined to have existed on 07/15/24. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to beginning of the survey. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 residents (Residents #1 and #2) reviewed for infection control. 1. LVN A failed to change her gloves during wound care for Resident #1 after cleaning each wound. 2. LVN A failed to use proper handwashing technique for a minimum of 20 seconds during wound care for Resident #2. These failures could place residents at risk for infection and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 5 out of 30 days (02/02/24, 02/03/24, 02/04/24, 02/08/24, and 02/12/24) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 02/02/24, 02/03/24, 02/04/24, 02/08/24, and 02/12/24 This failure could place residents at risk for inconsistency in care and services.

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 two of two kitchens reviewed for dietary services. 1. The facility failed to ensure pureed foods were prepared under sanitary conditions in that the food processor was dried with paper towels and water from faucet of the 3-compartment sink was liquid used to in the puree. 2. The facility failed to ensure serving utensils were stored properly in that the ice scoop was not stored properly. 3. The facility failed to ensure prepared food was covered properly before serving in that desserts and drinks were not covered while sitting under shelving. 4. The facility failed to ensure refrigerator food items were stored and dated properly. 5. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents 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 option he or she preferred, for 11 of 24 residents (Residents #6, 16, #25, #26, #28, #33, #34, #35, #39, #47, #52) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #6, #16, #25, #26, #28, #33, #34, #35, #39, #47, #52) prior to administering psychotropic medications (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 4 of 18 residents (Resident #19, Resident #32, Resident #35, and Resident #45) reviewed for Respiratory Care. 1. The facility failed to follow MD orders for initial and dating oxygen supplies/equipment for Resident #19 and Resident #32. 2. The facility failed to implement procedures that ensure the safe and sanitary use and storage of oxygen supplies/equipment for Resident #19, Resident #32, Resident #35, and Resident #45. 3. The facility failed to obtain MD orders for oxygen use for Resident #32, Resident #35, and Resident #45. These failures could affect residents by placing them at an increased risk of respiratory compromise, infections, pneumonia, respiratory distress, and sepsis.

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 7 of 18 residents (Residents #7, #29, #39, #41, #45, #46, #47) and 4 of 4 staff (CMA A, CMA B, CNA C, CNA B) reviewed for infection control. 1. CMA A failed to properly clean multi-use equipment between each resident. 2. CMA A failed to sanitize hands between residents during medication administration for Resident #29 and Resident # 46. 3. CMA B failed to properly clean multi-use equipment between each resident. 4. CNA C failed to change gloves when providing incontinent care for Resident #39. 5. CNA B failed to perform hand hygiene before and after incontinent care for Resident #45 and Resident #47. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 18 residents (Residents #39) reviewed for advanced directives, in that: Residents #39 was listed as a DNR but had OOH-DNR forms that were incorrectly filled out or missing required information. These failures could place residents at risk for not having their end of life wishes honored and incomplete records.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for 2 of 18 residents (Resident #3 and #25) reviewed in that: Residents #3 and #25 continued to have a PRN order for Lorazepam 0.5mg after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 1 of 2 medication carts (medication cart for hall 100-200), and 1 of 1 medication storage rooms. 1. The medication cart assigned to hall 100-200 had loose pills. 2. An expired medication was stored in the refrigerator in the medication storage room. These failures could place residents at risk of not receiving prescribed medications as ordered, receiving medications that are less effective or have altered composition, and drug diversions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 4 (Rooms #407, 602, 604 and 611) of 48 semi-private rooms reviewed for physical environment. The facility failed to ensure resident Rooms #s 407, 602, 604 and 611 met the required minimum of 80 square feet per resident. This failure could place residents at risk of crowding and cause difficulty in providing resident care.

Inspectors wroteBased on interview and record review, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for the care and treatment of 1 of 1 facilities reviewed. The facility failed to employ a DON. This failure had the potential to place residents in the facility at risk by leaving staff without supervisory coverage and could place residents at risk for inconsistency in care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 2 of 3 residents reviewed for misappropriation of property. (Resident #2 and 3) The facility failed to prevent a diversion (misappropriation) by RN of Resident #2's Hydrocodone-Acetaminophen (Norco) 5-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) on 1/11/24, 1/23/24 and 1/31/24. The facility failed to prevent a diversion (misappropriation) by LVN B of Resident #2's Hydrocodone-Acetaminophen (Norco) 5-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) on 1/11/24, 1/23/24 and 1/31/24. The facility failed to prevent a diversion (misappropriation) by RN of Resident #3's Hydrocodone-Acetaminophen (Norco) 7.25-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) on 1/25/24. [...]

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all medications for 2/4 medication carts reviewed for pharmaceutical services in that: LVN A failed to sign the narcotic count sheets for 2/4 medication carts (North 3 Medication aide and North 3) reviewed for change of custody at shift change. MA failed to sign the narcotic count sheet for 1 of 2 (North 3 Medication aide) carts reviewed for change of custody at shift change from LVN A. The facility failed to ensure LVN B, LVN C, RN followed the physician's orders for Resident #2's PRN pain medication administration for Norco 5-325 mg. These failures could place residents at risk of having their medications diverted or missing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the notice of discharge or transfer was made by the facility at least 30 days before the residents transfer or discharge for 1 (Resident #1) of 2 residents reviewed for transfers/discharges. The facility failed to provide at least 30 days' notice before transferring Resident #1's to an unlicensed facility. This failure could affect residents at the facility by placing them at risk of being transferred/discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 2 of 2 residents (Resident #2 and #3) whose records were reviewed for medication administration. The facility failed to completely and accurately document administration of a PRN pain medication to Resident #2 by not documenting Hydrocodone-Acetaminophen (Norco) 5-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) in the MAR. The facility failed to completely and accurately document administration of medication to Resident #3's Hydrocodone-Acetaminophen (Norco) 7.25-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever). This failure could place residents at risk of having incomplete or inaccurate records and inadequate care. [...]

Inspectors wroteBased on 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, for 1 resident (Resident #1) of 5 residents reviewed for abuse/neglect, The facility did not report the allegation of resident abuse to the State Survey Agency within the allotted time frame for Resident #1 who family member alleged abuse. This failure could place all residents at risk for injuries, abuse, and/or neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 1 of 5 allegations reviewed for resident abuse (Resident #1). The facility failed to ensure an allegation of abuse between Resident #1 and LVN A was thoroughly investigated. This failure placed residents at risk of unidentified abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be free from abuse for 4 of 6 residents (Resident #1, Resident #2, Resident #3, and Resident #5), reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1 when CNA A was witnessed by CNA B, by using force to hold down combative residents (Resident #1, and Resident #5). The facility failed to ensure a safe environment free from abuse for Resident #2 and Resident #3 when Resident stated that CNA A physically and verbally abused her. An Immediate Jeopardy was identified on 09/08/2023 at 4:30 p.m. The IJ Template was provided to the facility on [DATE]. [...]

Inspectors wroteBased on Interview and Record Review the facility failed to ensure that residents are free from physical or chemical restraints imposed for purpose of discipline or convenience and that are required to treat the resident's medical symptoms. The facility failed to ensure that Resident #1, Resident #2, Resident #3, and Resident #5 was free from the use of restraints when CNA A was witnessed restraining residents by holding them down by crossing their arms across their chest and holding them down. An Immediate Jeopardy was identified on 09/08/2023 at 4:30 p.m. The IJ Template was provided to the facility on [DATE]. While the IJ was removed on 09/11/2023, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on Interview and Record Review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility failed to ensure that Resident #1, Resident #2, Resident #3, and Resident #5 was free from abuse when CNA A was witnessed holding residents by holding them down by crossing their arms across their chest and holding them down. The facility failed to implement polikcies by not reporting, investigating allegations of abuse. The facility failed to implement policies by allowing CNA A to continue working with residents with allegations of abuse. (Resident #2 and Resident #3) An Immediate Jeopardy was identified on 09/08/2023 at 4:30 p.m. The IJ Template was provided to the facility on [DATE]. [...]

Inspectors wroteBased on Interview and Record Review the facility failed to thoroughly investigated, prevent further potential abuse, neglect, exploitation, or mistreatment, while the investigation is in progress, report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State Law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. Residents affected by allegations of abuse were 4 out of 6 residents reviewed for abuse and neglect. (Resident #1, Resident #2, Resident #3 and Resident #5). The facility failed to investigate and report allegations of abuse for Resident #1, Resident #2, and Resident #3 and Resident #5. An Immediate Jeopardy was identified on 09/08/2023 at 4:30 p.m. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The facility failed to maintain clean lint traps for both dryer #1 and #2. Staff admitted to only cleaning lint traps once a day. Dryers #1 and #2 had excessive buildup of lint. Dryer #2 had a broken on/off switch with plastic strap hanging out of it to keep it propped to the on cycle. This failure could place residents and staff at risk due to the possibility of fire hazards and placing all residents and staff at risk for fire, and for laundry not dry quickly fast putting residents on hold to obtain their clean laundry. Findings Include: [...]

Inspectors wroteBased on Interview and Record Review the facility failed to ensure allegations of abuse, neglect or mistreatment, including injuries of unknown origin was reported immediately but not later than 24 hours after the allegations was made for 4 out of 6 residents reviewed for reporting alleged abuse and neglect. (Resident #1, Resident #2, Resident #3, Resident #5). The Facility failed to report to HHSC allegations of abuse made from staff members RN, CNA B, and CNA C to the ADON for Residents #1, #2, #3, and #5. The facility failed to report abuse for Resident #2 and Resident #3 when Resident stated that CNA A verbally and physically abused her. The facility failed to report abuse of Resident #1 and Resident #5 when CNA B witnessed CNA A holding down residents and being rough. [...]