Mesquite Tree Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to provide each resident with nourishing, palatable, well-balanced diet that meets the resident's nutritional needs for 2 of 5 residents (Resident #1 and Resident #2) reviewed for dietary needs. The facility's kitchen failed to prepare and serve 3 ounces of pork loin as stated on resident meal tickets on 06/24/2026. This failure places residents at risk of not meeting their daily nutritional needs and could result in weight loss or decline in overall quality of health.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure a bag of dry rolled oats were not sitting on the floor in the kitchen preparation area. The facility failed to ensure raw meat was being thawed properly. The facility failed to ensure food items were not in the same sink compartment as used dishes. These failures could place residents at risk for foodborne illness and foodborne intoxication.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 5 residents (Resident #1 and Resident #4) reviewed for resident assessments. The facility failed to accurately assess and document Resident #1's active medical diagnosis of depression. The facility failed to accurately assess Resident #4's antidepressant medication status. The facility failed to accurately document Resident #4's active medical diagnosis. These failures could place residents at risk of having inaccurate diagnoses and inappropriate identification of care needs.1. Record review of Resident #1's face sheet, dated 05/20/2026 revealed a [AGE] year-old male with a primary diagnosis of encephalopathy (abnormal brain function, lead to cognitive impairment). [...]

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 time frames to meet residents' mental and psychosocial needs, for three residents (Resident #1, Resident #2, and Resident #3) of 11 residents reviewed for care plans. The facility did not develop a comprehensive person-centered care plan to address the discharge plans of Resident #1, Resident #2, and Resident #3. This failure could place residents at risk of not having their discharge goals met.

Inspectors wroteBased on observation, interview, and record review, the facility to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure Dietary Aide A wore a hairnet. The facility failed to ensure two 32-ounce pitchers of dark red liquid were labeled with the name of the product and dated with the use by date. The facility failed to ensure that meat that was submerged in a bowl full of water in the sink was thawed out under running water. The facility failed to ensure on 03/03/26 1 of 2 drink pitchers that held a dark yellow orange liquid were labeled with the name of the product and dated with the use by date, in 1 of 2 stand-by refrigerators. The facility failed to ensure a 3.5-gallon tea urn was labeled with the name of the product and dated with the use by date. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the ombudsman of the transfer or discharge and the reason for the move in writing for 1 of 2 residents reviewed for discharge rights. The facility failed to ensure Resident #1 was notified in writing of the details of the transfer. The facility failed to notify the ombudsman of Resident 1's transfer. This failure could affect all residents who were transferred or discharged to another facility at risk of having their discharge rights violated.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care ,including tracheostomy care and tracheal suctioning, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #1) residents reviewed for respiratory care. The facility failed to ensure physician's orders were written for oxygen use via nasal canula for Resident #1 on readmission [DATE] to 09/16/2025. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, and Resident #2) of 11 residents reviewed for ADLs. The facility failed to ensure:- Resident #1 had his fingernails cleaned and trimmed.- Resident #2 had his fingernails trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to be adequately equipped to allow residents to call for assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 11 residents (Resident #1) reviewed for reasonable accommodations. The facility failed to ensure the call light in the resident room, used by Resident #1, was always within reach. This failure could place residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency. [...]

Inspectors wroteBased on interview and record review, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed for qualifications of Social Worker. 1. The facility, licensed for 144 beds, did not employ a full-time social worker from 3/26/25 to 6/11/25. This failure could place residents at risk of social service and psychosocial needs not being 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 time frames to meet residents' mental and psychosocial needs, for 1 (Resident #55) of 6 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #55 had a person-centered care plan to include significant advance directive code status change from full code to DNR code, when they received Resident#55 consent on [DATE]. This failure could place resident at risk of been resuscitated and not honoring her DNR wishes.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #35, Resident #45, Resident#24, and Resident#40) of 16 residents reviewed for ADLs. The facility failed to ensure: - Resident #35 had her fingernails cleaned and trimmed. - Resident #45 had her fingernails trimmed. - Resident #24 had her fingernails cleaned and trimmed. - Resident #40 had her fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

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 the facility's only kitchen. 1. The facility failed to ensure food items in the facility kitchen were covered. This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 residents (Resident #60) reviewed for reasonable accommodations. The facility failed to ensure the call light in resident room [ROOM NUMBER] A used by Resident #60 was always within reach. This failure could place resident at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 (Resident #51) of 6 residents observed for infection control. The facility failed to ensure: CNA E donned the appropriate PPE (Personal Protective Equipment) during the transfer of Resident #51 who was on enhanced barriers precautions r/t having an indwelling foley catheter. This failure could place residents at risk for infection and cross contamination of pathogens and illness.

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 receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for two of eight residents (Resident #3 and Resident #4) reviewed for ADL care. The facility failed to ensure Resident #3, and Resident #4 had her fingernails trimmed and cleaned. This failure could place residents at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #2) of four residents reviewed for abuse. The facility failed to protect Resident #2 from physical abuse by HA B. On 2/16/24 at 9:45 PM , HA B physically grabbed snacks from Resident #2, then proceeded to grab his arm and became involved in a physical interaction of tugging items back and forth with Resident #2 until Resident #2 fell on the ground without any physical injuries or harm. The noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 02/16/24 at 9:45 PM and ended on 02/23/24. The facility had corrected the noncompliance before the Incident investigation began on 10/22/24. [...]

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 one (Residents #1) of seven residents observed for infection control. CNA A failed to perform hand hygiene during incontinence care for Resident #1. This failure could place residents at risk for the development and/or worsening of urinary tract infections, cross contamination, and skin breakdown.

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 the facility's only kitchen. 1. The facility failed to ensure dish machine reached minimum of 120 degrees F for wash and rinse on 10/24/23. 2. The facility failed to ensure food in the kitchen's refrigerator and freezer were stored in sealed containers, labeled, and dated. The facility failed to ensure food item in refrigerator was not spoiled. 3. The facility failed to maintain cleanliness of the inside of the ice machine. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observations, interview and record review, the facility failed to provide a safe, clean, and homelike environment for 2 (Residents #188 and #84) of 24 residents reviewed for environment. The facility failed to provide Residents #188 and #84 a handwashing sink that was not loose and a paper towel dispenser that worked properly without cover coming off in resident bathroom. This failure could place residents at risk for living in an unsanitary and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #12 and Resident#30) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #12 had her fingernails cleaned and trimmed. 2- Resident #30 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, 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 one (Resident #80) of three residents reviewed for respiratory care. The facility failed to have Resident #80's oxygen humidifier replaced weekly as ordered. This failure could place residents at risk for infection.

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 2 (Nurses cart halls 200/300 and Med Aide cart hall 300) of 3 carts reviewed for pharmacy services. The facility failed to ensure: 1- MA E, responsible for Med Aide cart hall 300, counted controlled drugs every shift change. 2- Medications in unsecure containers were immediately removed from stock. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (200/500 hall Nurse Medication cart) of 3 medication carts reviewed for pharmacy services and 1 medication room of 1 reviewed for storage in that: The facility failed to ensure: 1- The 200/500 Hall Nurse Medication cart had a control solution expired. 2- Two vials of TB serum (used to test if you have a tuberculosis germs in the body) that were opened and used were dated in the medication room refrigerator. These failures could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.

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 one (Residents #238) of four residents reviewed for infection control. The facility failed to ensure CNA A wore an N95 facemask, gown, gloves, and goggles or a face shield upon entering Resident #238's room who was on droplet isolation (used to prevent the spread of pathogens that are passed through the respiratory secretions ). This failure could place residents at risk for the spread of infection through cross-contamination of pathogens and illness.